Images in Emergency Medicine
Article Outline
An 11-year-old boy presented to the emergency department with a bullous eruption on both hands and feet. The itchy rash started on the left index finger as blisters about 1 month earlier, gradually progressing to involve both hands and then about 10 days earlier spread to the feet. It hurt to walk, but otherwise the rash was not painful. There was no history of fever or exposure to plants or to any kind of toxins. The patient had been treated by multiple providers throughout the last month and had used over-the-counter soothing creams, antifungal creams, and oral acyclovir, without benefit. There was history of mild intermittent asthma and allergic rhinitis. On examination, his vital signs were normal. His body mass index was on the 85th percentile. His hands and feet were swollen and erythematous, with crusting and weeping, and had multiple blisters and bullae filled with clear-to straw-colored fluid (Figure). Some of the bullae had ruptured, leaving denuded areas of skin. There was full range of motion at all finger and toe joints and no neurovascular involvement. The remainder of the examination was normal.
Figure.
Rash on hands. Used with permission of Manoj K. Mittal, MD, MRCP(UK), Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, and the Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA.
Diagnosis
Dyshidrotic eczema
Dyshidrotic eczema, also known as pompholyx, is a chronic relapsing form of vesiculobullous dermatitis involving palms and soles. It is equally common in male and female individuals. The exact cause is unknown. Various factors, including atopy, atopic dermatitis, contact dermatitis, ingested heavy metals, fungal or dermatophyte infection, hyperhidrosis, smoking, and intravenous immunoglobulin, have been implicated in its causation or aggravation.1, 2 Bacterial infection, when it occurs, is considered to be a result of itching and is a complication rather than the cause. The differential diagnosis of dyshidrotic eczema includes pustular psoriasis, bullous impetigo, dyshidrosiform pemphigoid, epidermolysis bullosa, hand-foot-mouth disease, herpes infection, and acrodermatitis enteropathica. Treatment is difficult. It includes local or systemic steroids, plus antimicrobials as needed for secondary infection. Topical tacrolimus or pimecrolimus may also be used instead of local steroids.3, 4 Moisturizers and antihistaminic agents are used to control itching.
Our patient was also treated by the dermatology team. Bacterial cultures from the involved area grew methicillin-resistant Staphylococcus aureus. Fungal and dermatophyte cultures were negative, as were the polymerase chain reaction tests for herpes simplex and varicella zoster viruses. The patient was discharged home and received a 2-week tapering course of prednisolone, clindamycin, and wet soaks with aluminium acetate. This resulted in significant improvement, but cessation of treatment led to a relapse. Prednisolone was continued for another 2 weeks, along with local application of a low-potency steroid cream.
References
- . Adjuvant botulinum toxin A in dyshidrotic hand eczema: a controlled prospective pilot study with left-right comparison. J Eur Acad Dermatol Venereol. 2002;16:40–42
- . Factors associated with palmoplantar or plantar pompholyx: a case-control study. Ann Dermatol Venereol. 2006;133:139–143
- Topical tacrolimus (FK506) and mometasone furoate in treatment of dyshidrotic palmar eczema: a randomized, observer-blinded trial. J Am Acad Dermatol. 2002;46:73–77
- . Long-term efficacy of occlusive therapy with topical pimecrolimus in severe dyshidrosiform hand and foot eczema. Dermatology. 2007;214:99–100
For the diagnosis and teaching points, see page 21.
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PII: S0196-0644(07)01659-9
doi:10.1016/j.annemergmed.2007.10.004
© 2008 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
