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InflammatoryHand / foot vesicularICD-10 L30.1

Pompholyx (dyshidrotic eczema)

Dyshidrotic eczema · cheiropompholyx (palms) · podopompholyx (soles)

Pompholyx is a chronic-relapsing vesicular eczema of the lateral fingers, palms and / or soles, characterised by sago-grain vesicles on a non-inflamed base. It affects ~5-20% of hand-dermatitis cases. Atopic background, stress, hyperhidrosis, contact allergy (especially nickel) and ingested allergens (id reaction to distant fungal infection or systemic nickel exposure) are recognised triggers. It is an important DDx for EGFRi-related hand-foot dermatitis, BRAFi reaction and ICI-related dyshidrotic eruption.

CurrentLast reviewed 16 May 2026
Clinical image of Pompholyx (dyshidrotic eczema)
Pompholyx (dyshidrotic eczema). Image sourced from DermNet New Zealand. Used under CC BY-NC-ND 4.0. No endorsement implied.

Pathogenesis

  • Multifactorial; not a sweat-gland disorder despite the historical name.
  • Triggers:
    • Atopic background.
    • Contact allergy — particularly nickel, balsam of Peru, fragrance.
    • Systemic nickel ingestion ("id reaction") — chocolate, tinned foods, nuts, legumes, soya.
    • Hyperhidrosis.
    • Stress, anxiety.
    • Fungal infection (id reaction to tinea pedis).
    • Drugs: aspirin, OCP, IVIG, oral retinoids.
  • Female > male; peak 3rd-5th decade.

Clinical features

  • Sudden onset crops of small (1-2 mm) clear "sago-grain" vesicles on a non-inflamed base.
  • Sites: lateral aspects of fingers, palms, sides of feet, soles.
  • Intense pruritus; burning sensation.
  • Vesicles coalesce, may form bullae, eventually rupture leading to desquamation, fissuring, painful erosions.
  • Chronic-relapsing; flares every few weeks to months.
  • May be secondarily impetiginised.
  • Nail dystrophy (ridging, pitting) may develop in chronic disease.

Differentials

  • Allergic contact dermatitis — pattern of exposure; patch testing.
  • Irritant contact dermatitis — chronic; less vesicular.
  • Tinea manuum / pedis — annular margin; KOH+.
  • Bullous tinea.
  • Pustular psoriasis of Barber — sterile pustules, well-demarcated, chronic.
  • Scabies — burrows in finger webs.
  • EGFRi / BRAFi reaction — drug history.
  • Hand-foot syndrome (chemo, multikinase inhibitor) — symmetric tender erythema; no vesicles typically.
  • Friction blisters.

Investigations

  • Clinical diagnosis usually.
  • KOH for tinea if any concern.
  • Patch testing — particularly nickel, balsam of Peru, fragrance series.
  • Bacterial swab if pustular / oozing.
  • Drug history (especially IVIG, OCP, aspirin).
  • Consider examination of feet for tinea pedis (id-reaction trigger).

Management

  • Avoidance:
    • Identify and avoid contact allergens (nickel, fragrance).
    • Low-nickel diet trial if positive nickel patch test.
    • Treat coexistent tinea pedis.
    • Stress management, sleep, mood support.
  • Topical:
    • Super-potent topical corticosteroid (clobetasol propionate) 2-3 weeks; taper.
    • Topical calcineurin inhibitors as steroid-sparing.
    • Potassium permanganate 1:10 000 soak for acute weeping phase.
  • Phototherapy: hand & foot NBUVB / PUVA for chronic disease.
  • Systemic:
    • Alitretinoin 30 mg OD (NICE TA177).
    • Methotrexate, ciclosporin, azathioprine, mycophenolate.
    • Dupilumab — case series support.
  • Hyperhidrosis treatment: aluminium chloride hexahydrate, iontophoresis, botulinum toxin.
  • Counsel: chronic, relapsing; long-term skin-care regime.

References

  1. Veien NK et al. Pompholyx: a clinical review. Acta Derm Venereol. 2009;89:431-435.
  2. Wollina U. Pompholyx: a review of clinical features, differential diagnosis, and management. Am J Clin Dermatol. 2010;11:305-314.
  3. NICE TA177. Alitretinoin for the treatment of severe chronic hand eczema. London: NICE; 2009.
  4. Stuckert J, Nedorost S. Low-cobalt diet for dyshidrotic eczema patients. Contact Dermatitis. 2008;59:361-365.

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