Pompholyx eczema is a type of dermatitis that specifically affects the hands and feet. The name itself offers clues to its appearance:

• Pompholyx is derived from the Greek word for “bubble,” referring to the characteristic blisters.
• Dyshidrotic eczema is an older, historical name that means “bad sweating.” It was once believed that the condition was caused by a sweat gland disorder, but this theory has since been disproven. Today, healthcare professionals prefer the term pompholyx eczema or acute palmoplantar eczema.

Pompholyx is considered an endogenous eczema, meaning the primary cause of the skin reactivity is internal, related to a person’s genetic predisposition and immune system. However, this internal predisposition is often “switched on” or flared by a variety of external or internal triggers.

To understand how the blisters form, it can be helpful to use an analogy.

• Think of the skin on your hands and feet as a unique type of terrain, and your immune system as its groundskeeper.
• In a person prone to pompholyx, this terrain is highly reactive. When it encounters a trigger be it internal stress, an external allergen, or excess moisture, the groundskeeper overreacts.
• This is like a sudden, underground water pipe bursting in a localized area. This “burst” of inflammation from the immune system creates small, deep, pressurized pockets of fluid (the vesicles) under the surface of the “terrain.”
• These fluid-filled “sinkholes” are what cause the intense itch and the feeling of pressure. Eventually, these bubbles rise to the surface, and after they resolve, the terrain becomes dry, cracked, and peels as it attempts to repair itself.

In my experience, patients often present with itchy, fluid-filled blisters on their hands or feet and are surprised to learn it’s a form of eczema, not an infection or allergy.

The exact, underlying cause of why some people develop pompholyx eczema is unknown. It is believed to be a multifactorial condition, meaning it likely results from a complex interplay of a person’s genetics and their exposure to specific triggers. It is not a single disease with a single cause, but rather a specific reaction pattern of the skin on the hands and feet. The immune system becomes over-activated, leading to the cycle of inflammation, blistering, and peeling.

In my experience, patients often develop it during periods of high stress or repeated hand washing, especially healthcare workers or individuals in humid environments.

A person develops pompholyx eczema because they have an underlying predisposition to this type of skin reaction, which is then ignited by a trigger. It is not contagious, and you cannot “catch” it from another person or give it to someone else.

Identifying and avoiding personal triggers is a cornerstone of managing the condition. Common triggers and risk factors include:

• Contact with Allergens: Exposure to certain metals is a well-known trigger, particularly:
  • Nickel, found in costume jewelry, coins, and some foods.
  • Cobalt and Chromates (used in leather tanning and cement).
• Hyperhidrosis (Excessive Sweating): This is a very strong trigger. The hands and feet are areas with a high concentration of sweat glands, and excessive moisture can irritate the skin and provoke a flare.
• Weather: Hot, humid weather that promotes sweating often worsens the condition. For some people, seasonal changes, especially spring and summer, can trigger flares.
• Stress: Periods of high emotional or psychological stress are a very common and well-documented trigger for eczema flare-ups, including pompholyx.
• “Id Reaction”: Sometimes, pompholyx can be triggered by a fungal infection elsewhere on the body, most commonly athlete’s foot (tinea pedis). The immune system’s reaction to the fungus on the feet can cause a “sympathy” or reactive eczematous rash to appear on the hands.
• Atopic Dermatitis: Individuals with a personal or family history of atopic eczema, asthma, or hay fever are more likely to develop pompholyx eczema.

In my experience, flare-ups often follow emotional stress or hot weather, particularly in patients with a personal or family history of atopic dermatitis.

Symptoms of pompholyx typically occur in flares that can last two to four weeks. The condition follows a characteristic cyclical pattern.

The Acute (Blistering) Phase

• Sudden Eruption of Vesicles: The condition begins with the sudden appearance of crops of small, deep-seated blisters (vesicles). They are often described as looking like “tapioca pudding” embedded in the skin.
• Intense Itching (Pruritus): This is the hallmark symptom. The itching can be severe, maddening, and is often accompanied by a burning sensation. The urge to scratch can be overwhelming.
• Location: The blisters appear almost exclusively on the palms of the hands, the sides of the fingers, the soles of the feet, and the sides of the toes.
• Large Blisters (Bullae): The small vesicles can sometimes merge together to form larger, more painful blisters.

The Chronic (Peeling) Phase

• After approximately one to three weeks, the fluid in the blisters is reabsorbed, and they begin to dry up.
• The affected skin then becomes red, dry, and scaly.
• Painful Fissures: Deep, painful cracks or fissures can develop in the dry skin, which can be very uncomfortable and can make using one’s hands difficult.
• Peeling: The affected skin then typically peels off in sheets, revealing new, tender, pink skin underneath.

A major risk during both phases is the development of a secondary bacterial infection. The intense scratching can create breaks in the skin, allowing bacteria like Staphylococcus aureus to enter, leading to increased pain, swelling, crusting, and the need for antibiotics.

Clinically, I look for symmetrical vesicles on the lateral aspects of the fingers or feet, along with signs of chronicity like scaling or fissures in recurrent cases.

The diagnosis of pompholyx eczema is almost always clinically. This means a dermatologist or a primary care physician can confidently diagnose the condition based on:

• The Characteristic Clinical Appearance: The presence of the deep-seated, “tapioca-like” blisters.
• The Classic Location: The restriction of the rash to the hands and/or feet.
• The Patient’s History: A story of recurrent, intensely itchy flares is highly suggestive of the diagnosis.

Ruling Out Other Conditions

A key part of the diagnostic process is to rule out other conditions that can cause blisters on the hands and feet.

• Fungal Infection: A doctor will often perform a KOH test. This involves gently scraping a small sample of skin from a blister or a piece of scale. The sample is examined under a microscope with a potassium hydroxide (KOH) solution to look for the presence of fungus. This rules out a blistering tinea infection (“athlete’s foot”).
• Allergic Contact Dermatitis: The symptoms of pompholyx can be identical to those of an allergic reaction to a specific substance. If a contact allergy is suspected as a trigger, a dermatologist may recommend patch testing. This involves placing small patches containing common allergens (like nickel) on the person’s back to identify a specific trigger.
• Scabies: A doctor will examine the skin carefully, looking for the characteristic burrows of scabies mites to rule out this parasitic infestation.

In my experience, identifying the triggers (like allergens or irritants) is crucial. Patch testing is helpful in persistent or occupational cases.

There is no cure for pompholyx eczema, but it is a manageable condition. The goals of treatment are to heal the existing rash, relieve the intense itching, prevent secondary infections, and identify and avoid triggers to reduce the frequency of future flares.

1. Basic Skin Care and Home Remedies (Foundation of Care)

• Cool Compresses: Applying cool, wet compresses to the affected areas for 15 minutes at a time, several times a day, can provide significant relief from itching and burning.
• Soaks: Soaking the hands or feet in cool water or a Burow’s solution can also be very soothing.
• Gentle Cleansing: Wash hands with lukewarm water and a mild, fragrance-free, soap-free cleanser.
• Moisturizing: This is crucial, especially during the dry, peeling phase. Apply a thick, bland, hypoallergenic emollient or barrier cream frequently throughout the day and especially after washing hands to help heal the cracked skin.

2. Topical Treatments (First-Line Medical Therapy)

• Topical Corticosteroids: This is the mainstay of treatment for a flare-up. A doctor will prescribe a high-potency or super-potent steroid cream or ointment to be applied to the affected areas. This is highly effective at reducing the inflammation and relieving the itch.
• Topical Calcineurin Inhibitors: These are non-steroid anti-inflammatory creams (like tacrolimus or pimecrolimus) that can be used as an alternative to steroids, especially for maintenance therapy between flares.

3. Treatment for Severe Flares

• Draining Large Blisters: A doctor can safely drain large, painful blisters with a sterile needle to relieve the pressure and discomfort. This should not be done at home.
• Oral Corticosteroids: For a severe, widespread, or debilitating flare that is not responding to topical treatment, a doctor may prescribe a short course of oral steroids, like prednisone.
• Antibiotics: If the skin becomes secondarily infected with bacteria, a course of oral antibiotics will be necessary.

4. Treatment for Chronic, Refractory Cases

For the small number of people with very frequent, severe pompholyx that does not respond to standard care, a dermatologist may consider:

• Phototherapy: Controlled exposure to ultraviolet (UV) light in a medical setting can be very effective.
• Systemic Immunosuppressants: Powerful oral medications that suppress the immune system, such as methotrexate, may be used.

Clinically, I emphasize trigger avoidance and frequent emollient use, patients who use barrier creams regularly often see fewer flare-ups.

Pompholyx eczema, or dyshidrotic eczema, is a common but often miserable skin condition that causes recurrent episodes of intensely itchy blisters on the hands and feet. While its sudden and uncomfortable flares can be disruptive to daily life, it is important to remember that it is not contagious and is a manageable condition. The key to living well with pompholyx is a proactive partnership with your doctor or dermatologist. By identifying and avoiding your personal triggers such as stress, sweat, or specific allergens, practicing gentle skin care, and using effective topical corticosteroid ointments to quickly control flare-ups, you can significantly reduce the frequency of the episodes and minimize the impact of this challenging condition on your life.

National Eczema Association. (n.d.). Dyshidrotic Eczema. Retrieved from https://nationaleczema.org/eczema/types-of-eczema/dyshidrotic-eczema/

American Academy of Dermatology (AAD). (n.d.). Eczema types: Dyshidrotic eczema overview. Retrieved from https://www.aad.org/public/diseases/eczema/types/dyshidrotic-eczema

DermNet NZ. (n.d.). Pompholyx. Retrieved from https://dermnetnz.org/topics/pompholyx