Pompholyx and hand eczema

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Acute pompholyx may begin with burning then crops of tiny tapioca-like vesicles, which can be less obvious against deeply pigmented palmar skin but are palpable and intensely itchy. Chronic hand eczema becomes dry, hyperkeratotic and fissured, and the original vesicular pattern may disappear.

Functional assessment is essential: washing, cooking, clinical duties, fastening clothes, sleep and pain. Exposure reduction must be feasible. Occlusive gloves protect from some irritants but trap sweat; glove chemicals themselves can cause allergy. Occupational-health advice should specify tasks and substitutes rather than simply declaring unfit for work.

Pompholyx and hand eczema care should combine visible inflammation with itch, pain, sleep, occupation and treatment burden. Agree where each product goes, how much is used and when response will be reviewed; explain urgent features separately so normal fluctuation is not confused with infection or treatment failure.

Key points

Pompholyx causes intensely itchy deep-seated vesicles on palms and finger sides, followed by peeling, fissures and sometimes secondary infection.
Hand-eczema shape does not reveal cause; atopy, wet work, allergic contact and dermatophyte infection frequently overlap.
Ask about every task, hand-wash, sanitiser, glove material, hobby and product, plus improvement away from work and foot or nail fungus.
Use frequent emollient and soap substitution, reduce wet work, and select protective gloves for the actual chemical with cotton liners for prolonged wear.
Palmar skin often needs a potent topical corticosteroid for a defined course; very-potent treatment or occlusion should be supervised and short.
Unilateral scale, grouped painful digit vesicles or loss of movement should trigger tinea, herpes or deep infection assessment.
For Pompholyx and hand eczema, document body sites, severity, sleep and function, recent treatment, infection features and what the patient can realistically apply each day.
In Pompholyx and hand eczema, reassess the diagnosis when a well-used, correctly potent regimen fails rather than repeatedly intensifying treatment without examining adherence, exposure and mimics.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Atopic and barrier susceptibility

Previous atopic eczema and constitutional dry skin increase hand-eczema risk, especially when repeated washing and irritant work challenge the barrier.

Wet work and irritants

Water, detergents, solvents, friction and prolonged glove occlusion are major cumulative causes across healthcare, cleaning, catering, hairdressing and manual work.

Contact allergy

Rubber accelerators, preservatives, fragrances, metals, acrylates and occupational chemicals can add delayed allergic inflammation to irritant or atopic disease.

Vesicular triggers

Pompholyx flares may associate with sweating, stress, metals or remote dermatophyte infection, but many episodes have no single demonstrable trigger.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Palmar barrier stress
Thick stratum corneum tolerates friction but develops deep painful fissures once repeated wetting, detergent and inflammation disrupt its lipid structure.
2
Spongiotic vesiculation
Epidermal intercellular oedema creates intensely itchy deep-seated vesicles along palms and finger sides, which coalesce and later peel.
3
Itch-fissure cycle
Scratching and gripping rupture vesicles, thicken skin and repeatedly reopen fissures, amplifying pain and reducing hand dexterity.
4
Mixed-cause persistence
Atopy, irritancy, allergy and infection frequently coexist, explaining why morphology alone cannot identify one cause of chronic hand eczema.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Deep lateral vesicles

Tiny firm intensely itchy vesicles cluster on finger sides and palms, sometimes coalescing into larger blisters before peeling.

Hyperkeratotic phase

Thick dry palmar scale and painful fissures can dominate between vesicular crops and obscure the original pompholyx.

Occupational distribution

Finger webs and dorsal hands exposed to wet work may coexist with palmar disease from friction, sweat and glove occlusion.

Tinea clue

One scaly palm plus both feet or dystrophic nails supports dermatophyte infection rather than symmetrical endogenous pompholyx.

Deep infection warningRed flag

Progressive pain, swelling, limited movement, lymphangitis or fever requires urgent assessment beyond superficial eczema care.

Red flags requiring action

Severe pain, reduced movement, fever, spreading cellulitis, clustered painful erosions, extensive bullae, occupational incapacity or persistent unilateral disease requires urgent or specialist review.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Structured task and glove historyFirst step
Why
Quantify wet work, chemical contact, occlusion and periods of improvement.
Interpretation and limitations
Record exact glove material and accelerator content; job title alone does not reveal exposure.
02
Skin and nail mycology
Why
Exclude tinea manuum, tinea pedis and onychomycosis as a mimic or vesicular trigger.
Interpretation and limitations
Sample active scale or diseased nail before antifungal treatment; one negative low-volume sample may be insufficient.
03
Patch testing
Why
Identify allergic contact contribution in chronic, recurrent or occupational hand eczema.
Interpretation and limitations
Include baseline, glove, product and occupation series as appropriate; sensitisation must be linked to real exposure.
04
Bacterial swab for selected infection
Why
Guide treatment after failure, recurrence or severe infection.
Interpretation and limitations
Crust and ooze do not routinely require a swab or antibiotic; systemic illness and cellulitis are clinical decisions.
05
HSV PCR from a fresh digit vesicle
Why
Confirm suspected herpetic whitlow while avoiding incision.
Interpretation and limitations
Sample early, but isolate and treat clinically important infection without waiting when the phenotype and risk are convincing.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Tinea manuum

Unilateral diffuse palmar scale with bilateral tinea pedis or abnormal nails supports dermatophyte infection and requires scraping before stronger steroid.

Palmoplantar psoriasis

Sharply bounded hyperkeratosis, pustules, nail pits and psoriasis elsewhere favour a psoriatic process, though overlap occurs.

Scabies

Nocturnal itch, finger-web burrows, wrist papules and affected close contacts distinguish scabies infestation from isolated vesicular pompholyx.

Herpetic whitlow

Grouped painful vesicles on one digit with tingling and marked tenderness require viral assessment and must not be incised.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01Acute vesicular flareSettle inflammation and preserve barrierFirst stepSymmetrical itchy palm or finger-side vesicles occur without fever, focal herpes or deep infection.

1Use cool wet compresses briefly for weeping, then a frequent bland emollient and soap substitute while protecting fissures.
2EscalationApply a potent palmar topical corticosteroid once or twice daily for a defined licensed course, using very-potent escalation only under supervision.
3Reduce wet work and sweat occlusion and review within two to four weeks for new vesicles, fissure closure and function.

02Chronic occupational diseaseRemove the repeated cause without disabling workHand eczema persists around wet work, gloves, products or hobbies and improves incompletely with treatment.

1Map tasks, substitute irritants, reduce repeated washing and select chemical-appropriate gloves with cotton liners and scheduled removal.
2Refer patch testing and occupational health when allergic exposure or work sustainability is uncertain.
3Provide sufficient emollient and anti-inflammatory treatment at work and home and document agreed modifications and review outcomes.

03Unilateral or painful diseaseTest tinea, herpes and bacterial infectionOne hand, one digit, marked pain, purulence, lymphangitis, reduced movement or fever departs from ordinary eczema.

1EscalationExamine feet and nails and collect mycology for unilateral scale before escalating corticosteroid.
2Do not incise suspected herpetic whitlow; obtain HSV sampling and urgent infection advice when severe or immunocompromised.
3Arrange same-day surgical or medical assessment for deep-space infection, cellulitis with systemic illness or threatened hand function.

Key medicines and prescribing safety2 treatments · regimens, roles and cautions

A potent topical corticosteroid suited to many palmar and dorsal hand flares alongside exposure control and regular emollient.

Betamethasone valerate 0.1% cream

Apply a thin film to active hand skin once or twice daily for up to four weeks, reducing or stopping when inflammation is controlled.

Avoid untreated infection and unplanned occlusion; review atrophy, total quantity and response, and investigate tinea or allergy when disease persists.

A very potent topical corticosteroid reserved for severe resistant thick hand disease when diagnosis, infection and safer potency have been reviewed.

Clobetasol propionate 0.05% ointment

Adults apply thinly once or twice daily only to resistant thick palmar plaques for a short specialist-directed course not exceeding four weeks or 50 g weekly.

Do not use on face, untreated infection or widespread skin; avoid prolonged occlusion, monitor local and systemic toxicity, and step down promptly with response.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Bacterial cellulitis

Deep fissures permit streptococcal or staphylococcal infection, causing increasing pain, warmth, swelling, lymphangitis and systemic illness.

Chronic occupational loss

Pain, bleeding and reduced dexterity impair hand hygiene, device use, food handling and manual work and can lead to absence or job change.

Treatment adverse effects

Continuous very-potent steroid, occlusion and repeated antibiotic exposure risk atrophy, systemic absorption, masking and antimicrobial resistance.

Sleep and psychological burden

Nocturnal vesicular itch, visible hands and recurrent treatment failure contribute to sleep loss, distress and avoidance of social touch.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Use a hand-eczema symptom and function record covering washing, sleep, pain, fissures, glove tolerance and work tasks.
Review the amount and site of potent or very-potent corticosteroid used and set a clear stop or step-down point.
After occupational changes, compare exposure days and flares to determine whether the modification is genuinely effective.
At review of Pompholyx and hand eczema, compare itch, sleep, fissuring or ooze, affected sites, function and treatment use with the agreed baseline.
For Pompholyx and hand eczema, record adverse effects, new contact exposures and the safety-net for pain, fever, rapidly spreading disease, eye symptoms or systemic illness.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Vesicles can be felt

On thick or deeply pigmented palmar skin, firm tiny blisters and itch may be clearer by side lighting and palpation than colour.

Feet can explain hands

Dermatophyte infection on both feet and one palm creates the classic two-feet–one-hand clue and can provoke vesicular reactions.

Glove chemistry matters

Nitrile, latex and other glove labels do not disclose every accelerator, and allergy may require a verified accelerator-free substitute.

Palms need adequate potency

Using a mild steroid on thick active palms can create apparent non-adherence and prolonged disease without reducing exposure.

Herpetic whitlow is not drained

Incision risks bacterial superinfection and does not treat HSV, so painful grouped digit vesicles need a different pathway.

11Common pitfallsFrequent interpretation and management errors.

01
Calling all palmar vesicles pompholyx without examining feet, nails and individual digits.
02
Recommending continuous glove wear and worsening sweat, friction and irritant exposure.
03
Repeating very-potent corticosteroid without patch testing or occupational assessment for persistent disease.
04
Incising a suspected herpetic whitlow because it resembles a bacterial abscess.
05
Ignoring work function and providing an avoidance plan that cannot be implemented.