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
Key Insights On The Prevention And Treatment Of Dyshidrotic Dermatitis
Preventive measures include the identification of any aggravating factors such as secondary exposure to irritants. Wearing appropriate shoes or boots to prevent moisture from collecting in the shoes is important as is wearing wicking-material socks. Equally important is controlling localized hyperhidrosis. Decreasing emotional stress and stressful situations is also recommended.
In the initial stages of dyshidrotic dermatitis, when vesicles and blisters are present, foot soaks using weak solutions of Epsom salts (one cup in a basin of warm water) for 15 to 20 minutes twice a day will help to dry up blisters. A key component of treatment is using an emollient and a moisturizer, which the patient should apply together immediately after soaking or bathing. Effective moisturizers and emollients include products such as urea-based creams and lotions (Carmol or Keralac, Bradley Pharmaceuticals), petrolatum (Vaseline petroleum jelly) and mineral oil as well as products that contain ammonium lactate.
One should use topical corticosteroids as first-line treatment for dyshidrotic dermatitis. Use steroid creams when the skin is blistered or weeping, and use ointments for the chronic dry stage. Ointments are generally considered superior due to greater penetration and an absence of preservatives. When treating the thick skin of the palms and soles, utilizing potent or superpotent steroids is necessary, particularly early on, and then tapering to mid-potency agents as one achieves control. Clinicians may use occlusion initially to increase penetration of the topical agent but do not continue this for extended periods of time.
Topical immunomodulators, such as tacrolimus (Protopic, Astellas Pharma) and pimecrolimus (Elidel, Novartis), are reportedly successful in the treatment of mild to moderate recurrent dyshidrotic dermatitis. However, these agents may not be potent enough to treat severe cases.
Abrupt and severe eruptions, involving both feet and hands, classically referred to as pompholyx, may require oral corticosteroids. I like to use methylprednisolone 4 mg in a pre-measured tapering unit (Medrol Dosepak). Although one may often see dramatic improvement, use of oral steroids for prolonged therapy is limited by significant side effects.
While a nickel-free diet is still not consdered a primary treatment, it has been demonstrated to improve dyshidrotic dermatitis and decrease recurrences in some patients. However, a nickel-free diet is quite restrictive as no canned foods of any kind are permitted on such a diet and it requires a highly motivated patient to remain compliant.
Dr. Dockery is a Fellow of the American College of Foot and Ankle Surgeons, and a Fellow of the American Society of Podiatric Dermatology. He is board certified in foot and ankle surgery. He is the Chairman of the Board and Director of Scientific Affairs for Northwest Podiatric Foundation for Education and Research. Dr. Dockery is the author of Cutaneous Disorders of the Lower Extremity (Saunders, 1997) and Lower Extremity Soft Tissue & Cutaneous Plastic Surgery (Elsevier Science, 2006).