Photo Rounds

Severely painful vesicular rash

A 56-year-old woman sought care from her family physician for a severely painful rash on her hands that had been bothering her for the past 2 months. She said that it hurt to do anything with her hands and that she was unable to wash dishes or cook for her family without severe pain. She was a homemaker and had no exposure to chemicals.

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The family physician (FP) recognized the multiple vesicles on the patient’s hands as pompholyx, also known as dyshidrotic eczema. The term “pompholyx” means bubble, while the term “dyshidrotic” means "difficult sweating," as problems with sweating were once believed to be the cause of this condition. Some dermatologists prefer the name “vesicular hand dermatitis.” Regardless of the terminology, this can be a mild condition that is a minor nuisance or a severe chronic condition that impairs the patient's quality of life.

The FP prescribed 0.1% triamcinolone cream to be applied twice daily and gave the patient a referral to a dermatologist. While waiting for the dermatology appointment, the patient was not improving, so she went to an emergency room, where she received a prescription for oral prednisone.

When she arrived at the dermatology office, she stated that neither the topical cream nor the oral prednisone helped to improve the rash on her hands. The dermatologist performed patch testing and discovered that she had a contact allergy to topical steroids. He withdrew the steroids and started her on oral cyclosporine, which cleared the rash.

One major lesson from this case is that patients can actually be allergic to topical steroids. Referral to Dermatology was appropriate as the complexity of this case was beyond the scope of family medicine.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R. Hand eczema. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:597-602.

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