Desquamating Palmar Lesions

A 16-year-old male presents with 3 weeks of painful, pruritic, peeling hands. He first experienced this last year when he was playing football and wearing gloves. The peeling started at his wrist and expanded to the palms of both hands (Figures 1 and 2). His past medical history is remarkable only for patches of dry skin around his elbows and knees. No family members have these symptoms.

The patient has bilateral areas of epidermal desquamation on his hands with some underlying lichenification. The skin overlying the blisters does not desquamate with contact. The rest of the examination is unremarkable.

The patient was treated with high strength topical steroids and educated about avoiding potential triggers and use of emollients. He continued to use gloves and experienced 1 episode of cellulitis, which resolved with a course of oral cephalosporin.

Acute palmoplantar eczema encompasses all recurrent, pruritic, vesicular eruptions involving the hands (mainly the palms) and the feet (usually the soles). It is more common in young adults and affects males and females equally. It typically presents with pruritis followed by the appearance of symmetrical vesicles that occasionally coalesce into larger bullae. Within several weeks, the vesicles and bullae desquamate. Recurrence is a hallmark of diagnosis. The exact etiology is unknown but the disease is associated with atopy, allergic exposure to metals, smoking and stress.^{1, 2}

Clinical manifestations. Diagnosis of acute palmoplantar eczema is largely clinical. Biopsy is rarely indicated; patch testing to explore a possible allergic dermatitis component can be indicated. 

Differential diagnosis. The differential includes bullous tinea, contact dermatitis, herpes simplex, and palmoplantar pustulosis. Vesciulobullous tinea is more commonly unilateral and diagnosed based on characteristic microscopic fungal elements on potassium hydroxide scrapings.³ Occasionally, tinea causes dermatophytid reactions with pruritic vesicles at distant sites which rapidly resolve with resolution of the acute inflammation.⁴

Allergic contact dermatitis tends to have more distinct borders and involve more than just the palms or soles.⁵  Herpetic whitlow presents with grouped vesicles on an erythematous base, usually found unilaterally on the lateral aspect of the thumb or other finger.⁶

Palmoplantar pustulosis is a bilateral and symmetrical type of psoriasis. It presents as erythematous patches with pin-head sized intraepidermal pustules that enlarge and coalesce into lakes of pus. As the lesions resolve, denuded areas, crusts or hyperkeratosis persists. There is a strong association with thyroid disorders and smoking.⁷

Complications. Most cases do not interfere with a patient’s quality of life. Complications include bullae large enough to impede the use of the hands, intolerable pain or itching, bacterial super-infection, and rarely, lymphedema.⁸

Management. Treatment goals are to suppress blister formation, relieve itch, prevent infection and prevent recurrence. Avoiding irritants and use of emollients with short courses of high potency topical corticosteroids is sufficient for most cases. For more severe cases, systemic corticosteroids can be added. In refractory cases, psolaren plus ultraviolet A (PUVA) has been shown to be effective. ² Unfortunately, even with treatment, the majority of cases relapse and persist for years. ■

References:

1.Klein NK. Acute and recurrent vesicular hand dermatitis. Dermatol Clin. 2009;27:337-353.

2.Wollina U. Pompholyx: A review of clinical features, differential diagnosis, and management. Am J Dermatol. 2010;11:306-314.

3.Dawson AL, Dellavalle RP, Elston DM. Infectious skin diseases: A review and needs assessment. Dermatol Clin. 2012;30:141-151.

4.Habif TP. Clinical dermatology: A Color Guide to Diagnosis and Therapy. 5th ed. New York, NY: Mosby; 2010.

5. Ustane RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Phys. 2010;82:249-255.

6.Hoff NP. Herpetic whitlow. CMAJ. 2012;184(17):E924. 

7.James WD, Berger TG, Elston DM. Andrews’ diseases of the skin clinical dermatology. 11th ed. Philadelphia, PA: Elsevier; 2011.

8.Pearce VJ, Mortimer PS. Hand dermatitis and lymphoedema. Br J Dermatol. 2009;16:177-80.