JOURNAL OF CHINESE MEDICINE NUMBER 66 JUNE 2001


equally divided amongst patients with involvement of either the feet alone, or the hands and feet together. Being an endogenous condition, the eruptions are almost always symmetrical. Although an asymmetrical presenta- tion may occur, the possibility of a fungal infection or a contact sensitivity should always then be considered. The vesicles tend to erupt on the sides of the fingers and palms, and often on the dorsal aspect of the distal fingers, where the skin is anatomically similar to that of the palms (absence of hair follicles). In more severe attacks the eczema spreads to the dorsum of the hands. If the eruption is particularly virulent, the eczema may extend upwards to involve the arms, neck and even the face. In a minority of cases, a generalised eczema of the entire body may also occur. When the feet are involved, the same pattern will emerge


as is seen on the fingers and palms, with an increased tendency for the vesicles to become confluent, and merge into bullae. As with the hands, in more persistent cases the eruption will affect the dorsal aspect of the feet, and may spread up the legs.


Natural history and clinical features


Pompholyx eczema is most often seen in 20-40 year olds, and only rarely in the elderly or prepubescent. It occurs slightly more frequently in females, and accounts for up to 20% of eczema cases seen in the clinic. There are several factors that are regularly associated


with initial eruptions, or subsequent relapses. Frequently the first attack is triggered by hot weather, appearing in late spring or summer; indeed a proportion of patients tend to get eruption only at these times, the eczema spontaneously subsiding once the weather turns cooler. Alternatively an initial attack, or exacerbation, may follow intense emo- tional upset, frustration, grief or unremitting stress. Com- monly excessive hand washing in new mothers, or the use of detergents, or other chemicals without proper protection will be sufficient to irritate the hands and precipitate an attack. The symmetrical outbreak of vesicles may either start on


the inner aspects of the fingers, on the palms themselves, or in both areas at once. In mild cases only the sides of the fingers may be affected. The patient usually reports a prickly, burning hot sensation before the appearance of the vesicles, followed rapidly by intense itching once the vesicles emerge. The palms and the area between the fingers typically glisten with sweat, drawing attention to the common finding of excessive sweating from affected areas. At the early stages, erythema is conspicuous by its ab-


sence, developing either only slightly as the condition develops, or more intensely only after it has progressed. Erythema is more likely to be present if, as can often happen, the vesicles spread up the sides of the fingers, to occupy the dorsal aspects of the fingers and hands. If the nail beds are affected repeatedly, a characteristic irregular transverse ridging, discoloration and pitting of the nails will also be evident.


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Once the vesicles have reached their height, there are two possible outcomes. They may grow tense and rupture, in which case there is discharge of fluid, erosion and eventu- ally the formation of yellow and white, often blood tinged crusts. This situation is more often associated with infection and the formation of pustules, in which case lymphangitis and lymphadenopathy may complicate the picture. Alter- natively and more commonly the vesicles become dry, shrink and are reabsorbed without a break in the skin. Whatever the outcome of the vesicular stage, which typi-


cally lasts 7-12 days, it is superseded by dry, scaling or fissured skin. The itching is characteristically replaced by soreness and pain. Once the “attack” has reached the end of its cycle, it is either replaced by another eruption, or the lesions will subside, and the skin return to normal. The cyclic nature of this condition is sometimes a striking feature, with regular eruptions occurring at an almost pre- dictable rate; the vesicular phase being followed closely by the dry, desquamating phase in wave-like oscillations. In other cases the two phases intertwine, vesicles are superim- posed on dry, scaly skin, so that there is no clear-cut pattern. In a minority, when reoccurring attacks have continued for years, the vesicular phase disappears for the most part, and is replaced by chronic dry, scaly, lichenified eczema, with a greater or lesser degree of erythema, and fissures of the palms and finger flexures. This form is also often accompa- nied by eczematous changes of the dorsal aspect of the hands or feet A remarkable attribute of this disorder is the excessive sweating (hyperhidrosis) that often occurs on the palms, fingers, soles and toes of sufferers. Over the years many clinicians postulated that the vesicles form as a conse- quence of the sweat being trapped under the skin. This has now been shown not to be the case, although it is interesting to note in regard to the excessive sweating that the distribu- tion of a typical eruption of pompholyx eczema signifi- cantly corresponds to the distribution of the emotionally activated sweat glands of the palms and soles. At least one study1


has shown that when patients were trained to con-


trol excessive sweating by biofeedback, there was improve- ment in their condition. This confirms the common finding in practice, of attacks being triggered by emotionally stress- ful situations. Pompholyx eczema can lead to significant morbidity.


Due to denudation of the fingers and palms, regular erup- tions on the hands can make the simplest tasks such as cutting vegetables, peeling fruit or handling paper a major problem, whereas pronounced eruptions on the feet can lead to incapacity and even inability to walk.


Diagnosis


Pompholyx eczema is a straightforward condition to diag- nose, and tends not to be mimicked by other conditions. However care should be taken not to confuse it with the following common conditions: Fungal infection. Fungal infection is much more common on


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