1. What essential question does one still need to ask to help make the diagnosis?
2. What is the tentative diagnosis?
3. Can you list at least three differential diagnoses?
4. What features of this condition differentiate it from other conditions in your differential?
5. What is the suitable treatment of this condition?
Treating A Patient With Blisters And Papules On The Soles
A 29-year-old Caucasian female patient presented in consultation in the foot and ankle clinic regarding a six-week history of erythematous vesicles and papules on the soles. She reported intense pruritus. Her primary care physician told her that she had a case of “athlete’s feet” and that she should use an over-the-counter (OTC) antifungal cream. After two weeks of treatment with antifungal cream, the patient had no improvement.
The "www.consultant360.com>primary care physician then prescribed a first-generation cephalosporin but after two weeks, the condition became worse. The patient stated that she had no known exposures to any new chemicals, paints, toxins, irritants or other potential allergens. She was taking birth control pills but denied taking any other medications, vitamins or supplements. No one else in her household or within her family had any similar conditions.
What The Exam Revealed
Upon examination, the patient demonstrated small tense vesicular lesions and small papules on the lateral aspects of the digits of both feet and hands, and also on the plantar non-weightbearing surfaces of both feet. The vesicles did not involve the ankles or wrists, and there was little involvement of the dorsal acral surfaces. There were no targetoid lesions or other distinctive skin lesions. There were also no color changes or inflammation involving the eyes or ears. There were no tongue or oral lesions or discolorations. The patient’s vital signs were normal and there was no elevation of the oral temperature. The remaining portion of the physical examination was within normal limits and the patient had no other clinically significant skin conditions.
A Closer Look At Dyshidrotic Dermatitis
The most likely diagnosis is dyshidrotic dermatitis/pompholyx. Fox first described dyshidrotic dermatitis in 1873. Characteristically, dyshidrotic dermatitis produces chronic foot and hand dermatitis, frequently with the formation of small vesicles on the outer
aspects of the digits. Sometimes, clinicians refer to these vesicles as “tapioca pearls.” The term dyshidrotic eczema is a misnomer since abnormal sweat gland function is not implicated in this condition nor is it a specific eczematous disorder.
In 1876, Hutchinson described a much more severe form of the same condition, which he called “cheiropompholyx.” Several experts favor using the term “pompholyx” in reference to abrupt, primarily vesicular disease. Others continue to use the terms “dyshidrotic dermatitis,” “dyshidrotic eczema” and “pompholyx” interchangeably.
In general, hand and foot dermatitis is more common in women but dyshidrotic dermatitis may afflict men or women of any age equally. Previously, it has been said that dyshidrotic dermatitis is more prevalent among those with atopy and that over half of all patients with atopic dermatitis also have dyshidrotic dermatitis. Some authorities now dispute the relationship of atopy to dyshidrotic dermatitis.
Dyshidrotic dermatitis is a clinical diagnosis that clinicians may make via the history and clinical characteristics. It is characterized by symmetric vesicular eruptions on the soles, palms or lateral aspects of the digits, which eventually become dry and crusted. However, both surfaces of the palms and the soles may be involved simultaneously. Sharp demarcation at the wrists or ankles is common. Associated pruritus is intense in most reported cases. A clinical course of exacerbation and remission is common. This is sometimes associated with weather changes and, in other cases, may be associated with emotional stress.
It is usually not necessary to perform a biopsy in order to make the diagnosis. However, if one obtains a biopsy, the primary pathologic process identified is that of spongiotic dermatitis with an associated superficial perivascular lymphocytic infiltrate. The vesicular nature of the eruption is merely the phenotypic expression of severe spongiosis (epidermal edema) on acral skin with a thickened stratum corneum.