Pompholyx
A Review of Clinical Features, Differential Diagnosis, and Management
Uwe Wollina
Department of Dermatology and Allergology, Academic Teaching Hospital Dresden Friedrichstadt, Dresden, Germany
Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
1. Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
2. Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
3. Differential Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
4. Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
4.1 Topical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
4.1.1 Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
4.1.2 Calcineurin Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
4.1.3 Bexarotene Gel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
4.2 Systemic Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
4.2.1 Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
4.2.2 Immunosuppressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
4.2.3 Retinoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
4.2.4 Biologics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
4.2.5 Antihistamines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
4.3 Botulinum Toxin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
4.4 Phototherapy and Photochemotherapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
4.5 Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
4.6 Tap Water Ionotophoresis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Abstract Pompholyx is a vesicobullous disorder of the palms and soles. The condition is hard to treat because of
the peculiarities of the affected skin, namely the thick horny layer and richness of the sweat glands. In this
article, we review the available therapies, and score the treatments according to the level of evidence.
The cornerstones of topical therapy are corticosteroids, although calcineurin inhibitors also seem to be
effective. Topical photochemotherapy with methoxsalen (8-methoxypsoralen) is as effective as systemic
photochemotherapy or high-dose UVA-1 irradiation.
Systemic therapy is often necessary in bullous pompholyx. Corticosteroids are commonly used although
no controlled study has been published to date. For recalcitrant cases, corticosteroids are combined with
immunosuppressants. Alitretinoin has efficacy in chronic hand dermatitis including pompholyx. Another
evolving treatment seems to be the intradermal injection of botulinum toxin. Radiotherapy might be an
option for selected patients not responding to conventional treatment. In practice, patients benefit most
from a combination of treatments.
306 Wollina
The aim of this article is to review the clinical features, dif- Patients with pompholyx show highly significant differences
ferential diagnosis, and management of pompholyx. A litera- in autonomic vagal modulation under deep respiration (in-
ture search was conducted using the MEDLINE database and spiration and expiration), but cardiac autonomic modulation
the terms pompholyx and dyshidrotic eczema from January
2000 to April 2010.
a
1. Clinical Features
2. Pathogenesis
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Pompholyx 307
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308 Wollina
Table II. Differential diagnoses of pompholyx vesicles per square centimeter, erythema, desquamation, itch,
Disease Reference and the extension of the affected area.[53] The DASI can also be
Acropustulosis of infancy 33 used to monitor treatment effects.
Adult T-cell leukemia/lymphoma 34 Management needs to be adapted to etiopathogenesis. In
Bullous impetigo 35
patients with tinea pedis, antifungal therapy is necessary.
Patients with contact allergies should avoid identified allergens.
Bullous T-cell lymphoma 36
Dyshidrosiform pemphigoid 37
a
Linear IgA disease with (hemorrhagic) pompholyx 38
Epidermolysis bullosa 39
Erythema multiforme 40
Hand-foot-and-mouth disease 41
Herpes infection 42
HTLV-1 infection (adult cutaneous T-cell lymphoma) 43
Fixed drug eruption 44
Friction blisters 45
Pemphigus vulgaris 46
Polymorphic dermatitis in pregnancy 47
Psoriasis pustulosa 48
SAPHO syndrome 49
b
Scabies 33
Subcorneal pustular dermatosis 50
Vasculitis allergica (cutaneous small vessel vasculitis) 6
HTLV-1 = human T-lymphotrophic virus (human T-cell leukemia virus)-1;
SAPHO = synovitis, acne, pustulosis, hyperostosis, and osteitis.
3. Differential Diagnosis
4. Management
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Pompholyx 309
4.1 Topical Therapy tene alone, in 38% of patients treated with bexarotene and
mometasone furoate, and in 14% of patients with the combi-
4.1.1 Corticosteroids
nation of bexarotene and hydrocortisone. In a subgroup of
Topical corticosteroids are the cornerstone of treatment. other types of eczema/dyshidrotic eczema, the clearance rate
However, published evidence is limited. Veien et al.[54] reported with bexarotene gel monotherapy was 50%. Adverse effects
on 120 patients with chronic hand eczema, including 13 with related to bexarotene gel included burning, stinging, irritation,
recurrent vesicular hand dermatitis who were using mometa- and flare of dermatitis.[60] This study reveals that the combi-
sone furoate fatty cream in a randomized, open-label, pro- nation of bexarotene gel with a topical mid-potency cortico-
spective trial. They noted that dorsal hand eczema was steroid such as mometasone furoate is beneficial, whereas
controlled more rapidly than palmar or dorsal and palmar. weaker corticosteroids do not add any benefit in such a com-
Vesiculation at the beginning had no significant effect on the bination. It has not been evaluated systematically whether more
time it took to control the dermatitis.[54] Improvement has been potent corticosteroids in combination with bexarotene gel
achieved with clobetasol propionate in combination with a would further improve the outcome in pompholyx.
hydrocolloid dressing for a limited time.[55,56]
4.2 Systemic Therapy
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310 Wollina
retinoids are strictly contraindicated in premenopausal women pholyx. Sodium cromoglicate (disodium cromoglycate) was
who are not using sufficient contraception.[65] found to be more effective in the treatment and prevention of
In a European, randomized, double-blind, placebo- nickel-sensitive pompholyx than a low-nickel diet by dimin-
controlled, multicenter trial, 319 patients with chronic hand ishing the intestinal nickel uptake.[69] The use of sodium cromo-
dermatitis refractory to standard therapy were evaluated.[66] glicate raises several questions. First, since only a propor-
In a four-armed study design, patients received either placebo tion of pompholyx patients are nickel sensitized, would this
or alitretinoin at dosages of 10 mg, 20 mg, or 40 mg once daily drug be ineffective in the other patients? Second, how long
for 12 weeks. Responders were followed up for another should sodium cromoglicate be used for secondary prevention
3 months. Alitretinoin led to a significant, dose-dependent in nickel-sensitized patients? Probably as a life-long treatment,
improvement of the disease status in up to 53% of patients, with but there are no scientific data to support long-term prevention.
an up to 70% reduction in disease symptoms and signs. In this
trial, a group of 70 patients with pompholyx was included; the 4.3 Botulinum Toxin
response rate in this subgroup was not statistically different
between placebo and alitretinoin.[66] Botulinum toxin A (BTXA) shows potent anhidrotic ac-
A recent paper reported the results of a randomized, double- tivity, and sweating is an aggravating factor in pompholyx. In a
blind, placebo-controlled, multicenter trial in ten European pilot study with left-right comparison, intracutaneous injection
countries and in Canada.[67] A total of 1032 patients with of BTXA (100 U of Botox [Allergan, Inc., Irvine, CA, USA] in
refractory chronic hand dermatitis (eczema) were included. The one palm on day 1) was used in addition to topical cortico-
treatment was organized in three arms, i.e. alitretinoin 10 mg or steroids. Among the six patients who completed the 8-week
30 mg or placebo once a day for 24 weeks. Clear or almost clear trial, the DASI was significantly lower, and itching and vesicu-
hands were achieved in 48% of alitretinoin-treated patients lation disappeared earlier in the hand treated with BTXA.[70]
versus 17% of placebo recipients. There were more responses in Another study involving ten patients compared the effect of
the 30 mg group compared with the 10 mg group. The study BTXA alone (mean dose of 162 U of Botox per palm on one
included a group of 377 patients with pompholyx. In this group, hand) with the untreated side as control. Seven of ten patients
the response rate was 16% in the placebo recipients, 23% in the experienced a good to very good effect on vesicular pompholyx
patients receiving alitretinoin 10 mg/day, and 33% in the group and a decrease in itching.[71] Other reports also mentioned the
receiving alitretinoin 30 mg/day.[67] ability of BTXA to improve itch, vesiculation, and ery-
In conclusion, although oral alitretinoin is effective in re- thema.[72,73] Pain on injection is a common adverse effect that
calcitrant hand eczema in general, it is of limited efficacy in limits the use of BTXA in general.
pompholyx. A combination therapy with topical cortico-
steroids could achieve higher response rates; however, this has 4.4 Phototherapy and Photochemotherapy
yet not been evaluated in a controlled clinical trial.
Selective UVB phototherapy (300320 nm) combined with
balneotherapy was found to be more effective in palmoplantar
4.2.4 Biologics
dermatoses, including pompholyx, than broad-spectrum UVB
A 40-year-old woman with a 6-year history of recalcitrant
(280320 nm).[74] Narrow-band UVB (311 nm) and UVA-1
atopic cheiropompholyx was treated with subcutaneous inject-
(340400 nm) irradiation have been proven to be superior to
ions of the tumor necrosis factor-a inhibitor etanercept 25 mg
broad-band UVB for certain indications.[75]
twice weekly.[68] At a 6-week follow-up, the pompholyx had
Systemic photochemotherapy with PUVA (320400 nm) is
cleared. Remission was sustained for 4 months, after which
effective in vesicular pompholyx, although it has the dis-
time the patient experienced a flare-up. The dosage of etaner-
advantage of generalized photosensitivity and adverse effects
cept was doubled, but was ineffective and was, therefore,
on the gastrointestinal tract by the photosensitizer methoxsalen
eventually discontinued.[68] Further investigations are needed
(8-methoxypsoralen; 8-MOP). To reduce the risk of unwanted
with the use of biologics for pompholyx.
adverse effects, there have been modifications to the classical
systemic PUVA therapy, such as bath-PUVA and cream-
4.2.5 Antihistamines PUVA. For bath-PUVA, 8-MOP is used in a water bath prior
Antihistamines have been used to control accompanying to irradiation. Cream-PUVA employs a cream containing the
pruritus, although there is no proof of their efficacy in pom- photosensitizer applied 20 minutes prior to UV exposure.
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Pompholyx 311
Bath-PUVA is an effective treatment modality for palmo- Table IV. General advice for hand and foot care for patients with pompholyx
plantar eczema. However, smokers with vesicular pompholyx Wash hands and feet as infrequently as possible
are less sensitive to bath-PUVA than non-smokers, and a Avoid soaps, and direct contact with household cleansers, fresh fruits,
complete remission is less realistic as long as the patient con- and fresh meat
tinues to smoke.[30] Dry hands and feet carefully
Cream-PUVA is as effective as bath-PUVA in the treatment Use protective gloves for hair care, including shampooing
of palmoplantar dermatoses.[76] Use protective plastic gloves only with white cotton gloves beneath
Topical PUVA with 8-MOP has been compared with UVA Use cotton socks and change them regularly
in a randomized, double-blind, within-patient trial. Twelve Stop smoking
patients with vesicular pompholyx completed 8 weeks of
treatment. There was no statistical difference in the improve-
ment between topical PUVA and UVA alone.[77]
4.5 Radiotherapy
UVA-1 irradiation was found to be effective in vesicular
pompholyx of the palms in an uncontrolled trial.[78] UVA-1 Grenz rays and conventional superficial x-rays have been
irradiation (40 J/cm2) given five times a week was compared used either alone or in combination with topical corticosteroids
with placebo in a double-blind, controlled trial of vesicular for refractory hand dermatitis (eczema). In a double-blind
pompholyx. UVA was more effective than the placebo.[79] study, conventional x-rays (300 rad) were superior to Grenz
High-dose UVA-1 irradiation (maximum single dose of rays.[81] Complete remission of pompholyx is also possible with
130 J/cm2; cumulative dose of 1720 J/cm2) was as effective as low-dose external beam megavoltage radiation.[82]
cream-PUVA in a left-right study of 27 patients with vesicular
pompholyx as measured by the DASI.[80]
4.6 Tap Water Ionotophoresis
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312 Wollina
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Correspondence: Prof. Dr Uwe Wollina, Department of Dermatology
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Venereol 1996; 76 (6): 472-4 E-mail: wollina-uw@khdf.de
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