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Differential Diagnosis Eczema
Information About Dyshidrotic Eczema
Diagnostic Hallmarks
Distribution - sides and tips of the digits, palms and soles
History of preceding noninflammatory vesicles (dyshidrosis)
Clinical Presentation
Dyshidrosis is a disease of noninflammatory vesiculatio. Eczematization of dyshidrosis develops under two conditions. The first occurs when itching leads to uncontrolled scratching. This superimposition of the itch-scratch cycle leads to vesicle roof disruption and causes excoriations in surrounding, previously normal skin. Weeping and crusting are present because of the broken epithelium. The second condition occurs when closely set vesicles appear fast enough to form fragile multilocular bullae. These break easily, leading to profuse weeping and crusting. New vesicles develop before reepithelialization has occurred, and the process continues indefinitely even without superimposition of the itch-scratch cycle.
In either set of circumstances, eczematous lesions may spread onto the previously uninvolved dorsal surface of the fingers and hands through the process known as autoeczematization. Moreover, the eczematization obscures the noninflammatory nature of the original underlying vesicles. Because of these two changes, the clinician may miss the correct diagnosis unless information is obtained about the very first lesions noted by the patient.
The diagnosis of dyshidrotic eczema is made on a clinical basis. Biopsy is usually not helpful. The differential diagnoses of hand and foot eczema are considered in greater detail in.
Course and Prognosis
Either the superim position of the itch-scratch cycle or the development of closely set repeated episodes of dyshidrosis converts an intermittently active process into one that is chronically troublesome. New crops of vesicles continue to appear on the skin that is already eczematized; this triggers new bouts of scratching and further skin damage. Moreover, mild irritation from exposure to soap and water, which might have been insufficient to harm normal skin, tends to aggravate the condition further. Essentially, a single disease, dyshidrosis, becomes a multifactorial process with additional elements of atopic dermatitis and irritant contact dermatitis.
Pathogenesis
The development of dyshidrotic eczema occurs in only about 10% of patients with dyshidrosis. In some instances, dyshidrotic eczema is simply an extension in severity of dyshidrosis. New vesicles appear more rapidly than old ones heal. In most instances, however, the eczematous appearance occurs as a result of the superim position of the itch-scratch cycle (atopic dermatitis) directly over the noninflammatory vesiculation of dyshidrosis. Not surprisingly, dyshidrotic eczema (as opposed to dyshidrosis itself) preferentially occurs in those who are genetically atopic.
Therapy
In general, the approach to treatment of dyshidrotic eczema is similar to that for dyshidrosis and atopic dermatitis. Soaks, sedatives, and application of mid- to high-potency topical steroids may clear mild cases of dyshidrotic eczema. Patients with more severe disease will require a "burst" of systemic steroids. PUVA therapy, usually topical rather than systemic can be used effectively in cases resistant to more conventional theory. Because of the importance of psychologic factors in both dyshidrosis and dyshidrotic eczema, it is sometimes necessary to consider counseling, behavior modification, and the use of psychotropic medication.
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Diseases of Hands-skin Disorders
Allergic contact dermatitis, like atopic dermatitis, almost always begins on the dorsal surface of the fingers and hands. This predilection is most likely due to the protective effect of the thick keratin found on the palmar aspect of the fingers and hands. Allergic contact dermatitis differs from atopic dermatitis in that excoriations are less prominent and a visible eruption precedes the scratching. Before a diagnosis of allergic contact dermatitis can be proven, however, several things must occur: a suspected contactant must be identified; a positive result to patch testing must be obtained; and the patient must demonstrate improvement when the contaclant is removed. The most readily identifiable type of allergic contact dermatitis is that of nickel allergy because the emplion occurs in such close proximity to the offending ring, bracelet, or watchband. Many industrial chemicals cause allergic contact dermatitis of the hands. The agents most commonly involved are chromates and epoxy resins. Cosmetics (cinnamates, lanolin, Peruvian balsam) are occasional offenders. Soaps and detergents cause irritant, rather than allergic, contact dermatitis.
Irritant contact dermatitis is characterized by the presence of chapping, cracking, and fissuring. Inflammation, weeping, crusting, and excoriations are considerably less prominent. The changes of irritant contact dermatitis occur most commonly on the volar aspects of the fingers, but the palms and dorsal surface of the hands, particularly over the knuckles, may also be involved. The skin is dull red and often has a shiny or glistening surface. Tingling or burning pain is present; pruritus is not prominent. The diagnosis is based on the clinical appearance and on the history of frequent exposure to soap, water, or other solvents. Irritant contact dermatitis is an occupational hazard for mothers, housewives, waitresses, bartenders, and those in the health professions. A second type of irritant contact dermatitis occurs because of moisture retention and maceration under wide rings. Thus, eczematous changes around rings may be either allergic or irritant in etiology. Patch testing to metals may be necessary to differentiate between these two possibilities.
Scabies is an infrequent cause of hand eczema. It is characterized by initial development of solitary vesicles or inflammatory vesicopapules in the web spaces. From there, eczematous changes can spread onto the dorsal surface of the hands and fingers. The diagnosis is based on this distribution pattern, evidence of contagion, recovery of the mite, and the presence of typical lesions at other body sites.
Autoeczematization (or autosensitization) is a reaction pattern in which eczematous disease elsewhere on the skin induces "metastatic" eczematous lesions at some distant site. The hands, particularly the palms and fingers, are frequently involved in this reaction. A vesicular component that resembles dyshidrosis is often present. A diagnosis of autoeczematization is likely: (1 ) if vesiculation is explosive in onset, (2) if there is minimal grouping of the vesicles, and most importantly, (3) when marked eczematous disease is found on the feet or elsewhere on the body.
The diagnosis and therapy for hand eczema are complicated because more than a single process is frequently involved. Thus, dyshidrotic eczema, allergic contact dermatitis,
and scabies are often complicated by the concomitant presence of either the itch-scratch cycle (atopic dermatitis) or irritant contact dermatitis resulting from soap and water exposure. With so many processes occurring at once, it is easy to see why many clinicians give up trying to sort out the individual processes responsible for the problem and simply label it "hand eczema." Nevertheless, since the treatment varies with each of the processes, it is important to identify them individually. As mentioned above, where this cannot be done on the basis of history and examination, it may be necessary to use a short course of systemic steroids so that the initial characteristic changes can be identified as they recur.
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