Dyshidrosis, pompholix in children and adults

Diseases of the group of palmar-plantar dermatitis of a non-infectious nature include lesions of the skin of the hands and feet, defined by such synonymous names as dyshidrosis, pompholyx, dyshidrotic eczema, endogenous vesicular (or blistering) eczema of the hands and feet, as well as acute vesicular-bullous eczema dermatitis) of the hands. [1]

In ICD-10, this chronic relapsing disease is coded L30.1 in the dermatitis section.

Epidemiology

According to some reports, at least 20% of cases of palmoplantar dermatitis are caused by pompholix (dyshidrotic eczema), which is most often detected in adults under 40, with a slight predominance of women. [2]

It is noticed that in regions with a warm climate there are more patients with dyshidrosis than in countries with moderate climatic conditions.

In clinical practice, hand dyshidrosis occurs four to five times more often than leg dyshidrosis (plantar side of the feet), and in most cases, symptoms appear on both hands or feet.

Causes of the dyshidrosis

Now the name "dyshidrosis", introduced by the British dermatologist William Tilbury Fox in the last quarter of the 19th century, is recognized as inaccurate, since no obvious violations of sweating in vesicular-bullous eczema of the hands and feet have been identified, and this pathology is associated with dysfunction of the eccrine sweat glands (that is their occlusion and perspiration retention) has not been proven. However, this definition has not disappeared from dermatological terminology.[3]

And pompholix is the most pronounced form of dyshidrotic dermatitis, in which vesicles (small bubbles) merge to form larger bubbles (bulls).

Despite numerous studies, it has not yet been possible to find out the exact causes of dyshidrosis. [4]And possible etiological factors can be:

• allergic contact dermatitis  (including some metals);
• contact  eczema of the palms ;
• skin sensitization associated with a change in certain genes, which increases the response of the cellular immunity of the epidermis to environmental factors, as well as to irritants and allergens.

Risk factors

Hypothetical risk factors for the development of dyshidrosis (dyshidrotic eczema or pompholix) are: stress; genetically determined predisposition; increased sweating (hyperhidrosis) of the palms and soles; a history (including family history) of seasonal allergies or atopic dermatitis (eczema).

According to the latest studies by foreign dermatologists and immunologists, the risk of developing dyshidrosis and pompholix is increased in the presence of autoimmune diseases (chronic glomerulonephritis, Sjogren's syndrome, SLE, Crohn's disease, etc.), as well as  Wiskott-Aldrich syndrome (WAS) and selective deficiency syndromes associated with  primary immunodeficiency. IgA.[5]

The first two factors (stress and an inherited tendency to develop allergic reactions) are most often caused by dyshidrosis in children.

Pathogenesis

The mechanisms responsible for the pathogenesis of dyshidrotic dermatoses are not entirely clear, although the involvement of the immune system of the skin, which includes epidermal dendritic cells (Langerhans cells), keratinocytes, fibroblasts, mast cells, macrophages (phagocytes), T-lymphocytes ( including T-helpers), as well as inflammatory mediators (cytokines, chemokines), antimicrobial sweat peptides, dermicidin. [6]

To date, it is known that diffuse intraepidermal vesicles (vesicles), which are formed in this pathology, are the result of intercellular edema in the epidermis (spongiosis) - with the expansion of the spaces between keratinocytes and subsequent ruptures of the dermosomes (intercellular adhesions).

It should be noted that spongiosis can be acrosirngial. Acrosiringium is an epidermal section of the duct, especially numerous on the palms and soles of eccrine sweat glands, the secretory part of which is located deep in the dermis, and the straight duct leads to the surface of the skin and exits into the slit-like pore.[7]

Researchers put forward such versions of the formation of vesicles in dyshidrosis, such as: lowering the threshold of skin irritation; distorted recognition of autologous skin antigens by immune cells; development of a secondary response to the spread of latent infection antigens; abnormalities in skin cells that cause an inadequate response of antigen-recognizing receptors and induce the activity of T-lymphocytes, etc.

Thus, dyshidrosis is a spongiotic dermatitis of an atopic nature, characteristic of the skin of the palms and soles with a thicker stratum corneum, consisting of compacted keratinocytes, and containing a greater number of other immunocompetent cells. [8]

A metaphysical interpretation of the origins of the disease or psychosomatics associates most skin problems with excessive self-control, unwillingness to show one's feelings and, at the same time, a great dependence on someone else's opinion.

Symptoms of the dyshidrosis

Often the first signs of dyshidrosis are manifested by sudden itching of the palms, lateral surfaces of the fingers or soles of the feet.

If this is a true dyshidrosis, the bubbles - transparent, filled with a colorless liquid - begin to appear in groups, which causes increased itching and even some soreness.

Dyshidrosis after pregnancy is manifested by the same vesicles on the palms and feet, causing itchy skin.

Often these symptoms appear sporadically: about once a month for a long time. As a result, dyshidrosis of the palms or dyshidrosis of the feet from the sole - especially advanced dyshidrosis - is transformed into pompholix. This is a bubbly form of palmar-plantar eczema, in severe cases of which there is exfoliation (peeling of the skin), painful cracks, and sometimes lichenification (thickening of the skin).

Read more -  Dyshidrotic eczema

Somewhat different from pompholix is dry lamellar dyshidrosis - lamellar dyshidrosis or exfoliative keratolysis of the palms. It is characterized by annular erythema on the palmar surface of the hands (less often on the soles of the feet) with bubbles that are filled not with liquid, but with air. The rash usually occurs in the warm season, does not cause itching and quickly enough turns into exfoliation zones - with keratin scales on the skin surface, which gradually expand along the periphery, leaving a tight-fitting rim. There are no signs of inflammation.

In most cases, dry lamellar dyshidrosis in a child goes away spontaneously - by gradual exfoliation, but in adults, cracking of the skin is possible.

Complications and consequences

The most common complications and consequences of pomfolix:

• thickening of the affected skin;
• secondary bacterial infection (usually strepto and staphylococcal), which leads to swelling, increased pain, pustule formation on the arms / legs (with possible suppuration).

If dyshidrosis and dyshidrotic eczema affect the fingertips, inflammation of the nail fold can develop - paronychia and degeneration of the nail plates. [9]

Diagnostics of the dyshidrosis

Diagnosis of dyshidrotic eczema includes examination of the rash, the study of anamnesis,  and skin examination .

Blood tests are required: general, for immunoglobulins (IgE), for leukocyte-T-lymphocyte index, for serum complement titer. A skin scraping is done (for infection), a skin test may be required.

Differential diagnosis

Differential diagnosis is carried out with scabies, pustular psoriasis, bullous pemphigoid and other dermatological conditions with similar symptoms. [10]

Treatment of the dyshidrosis

As a rule, the treatment of dyshidrosis is long-term, and the main clinical recommendations of dermatologists include the use of external agents and systemic drugs to relieve symptoms.

Ointments and creams are widely used to treat dyshidrosis, these are  ointments for eczema  and  creams for eczema . In particular, an ointment, cream or emulsion with a corticosteroid methylprednisolone  Advantan  for dyshidrosis is applied to the affected skin for one and a half to two months.

Other dermatotropic agents are also prescribed, including zinc ointment or Desitin ointment   (with zinc oxide); Akriderm,  Betasalik , Belosalik,  Celestoderm B  or Diprosalik (with betamethasone and salicylic acid).

And with dry lamellar dyshidrosis, keratolytic creams containing urea, lactic or salicylic acid should be used.

To relieve itching, antihistamines are used - Tavegil tablets   (Clemastine), Loratadin or Tsetrin for dyshidrosis. [11]

In case of exacerbations, short courses of systemic corticosteroids, either oral or injections, may be prescribed. So, in the form of tablets, Prednisolone preparations are taken, and treatment with injections is carried out with betamethasone GCS preparations, as a rule, Diprospan is used for dyshidrosis

In severe cases, the immunomodulatory drugs Methotrexate or Cyclosporin are indicated  . And if the skin becomes infected, antibiotics may be prescribed.

Physiotherapeutic treatment corresponding to the condition of the skin is prescribed, for example, phototherapy (controlled exposure to ultraviolet radiation). [12]Read more -  Physiotherapy for dermatitis and dermatosis .

The efficacy of the adjuvant botulinum toxin A in dyshidrotic hand eczema was investigated. [13]

Most patients are treated at home, following the instructions of the attending physician. In addition, for the hands and / or feet, it is recommended to do baths and cold compresses, for which potassium permanganate (a pale pink solution of potassium permanganate) or table vinegar (diluted with water in a ratio of 1:10) is used.

It is possible to carry out herbal treatment at home: make baths with cooled decoctions of horsetail herbs, a series of tripartite, knotweed, pharmacy chamomile flowers or medicinal calendula.

Also, patients are given recommendations regarding nutrition, in more detail the diet and diet menu for dyshidrosis are discussed in the materials:

• Diet for eczema
• Diet for dermatitis

Prevention

As a primary measure to prevent dyshidrosis, avoid contact with anything that can irritate the skin, including soaps, shampoos, and other household chemicals.

Forecast

Endogenous vesicular eczema of the hands and feet - dyshidrosis - may resolve spontaneously. But the prognosis regarding the impossibility of her relapse, which develops quickly and completely unexpectedly, is uncertain. In 75-85% of cases, this dermatological disease is chronic, reducing the quality of life of patients.

Most Frequently Asked Questions

Dermatologists answer patients' questions:

• How is dyshidrosis transmitted? Is it contagious or not?

This skin disease is not contagious and cannot be transmitted to others in any way.

• What to do if dyshidrosis persists?

It is necessary to consult a dermatologist about the use of an ointment or cream with a stronger GCS - mometasone furoate (Momederm, Avecort, Uniderm, Elokom) or, as an option, treatment with immunomodulatory drugs. [14]

• Is it possible to visit the gym with dyshidrosis?

In the stage of exacerbation it is impossible, but in remission it is possible, but hands should be protected: wear gloves for training.

• Dyshidrosis and the army

The decision on the possibility of military service for persons with atopic dermatitis (eczema), including dyshidrotic, is taken by the medical board on the basis of the conclusion of a specialist dermatologist after examining the conscript.