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“A diagnosis and classification is still difficult“
Professor Hölzle;© private
This can also be said of Dyshidrosis, which typically occurs on the palms of the hands or soles of the feet in the shape of clear blisters. MEDICA.de asked Professor Erhard Hölzle, Medical Director of the Clinical Center for Dermatology and Allergology in Oldenburg, about the causes that form the basis of this disease and how they can best be treated.
MEDICA.de: There are many different diseases that cause skin lesions or blisters on the skin. Some of them, for example “bullous pemphigoid“, are among the blistering autoimmune diseases. How does the clinical pattern of Dyshidrosis differ from these diseases?
Erhard Hölzle: A distinction at first can be made by the location of the disease. Dyshidrosis only occurs on the palm of the hand and the sole of the foot, where small water blisters are forming. Autoimmune blistering diseases primarily happen on the entire skin area or mucous membrane – and if it occurs on the palm of the hand or soles of the feet, it’s only secondary. If we distinguish it from this, we proceed based on distribution patterns, meaning the clinical picture, which admittedly can also always present itself somewhat differently. “Bullous pemphigoid“ for instance can mimic blisters which are very similar to Dyshidrosis –especially if it also affects the palm of the hands and soles of the feet which happens often. However, the overall picture is essential for the differential diagnosis. Mostly it is not exclusively Dyshidrosis, but oftentimes there is something more behind it. We are then looking for an autoimmune disease. To determine the type of autoimmune bullous dermatosis the patient is affected with needs to be verified by a skin explant sample and further examinations.
MEDICA.de: Is a dysfunction of the connective structures between cells also the underlying basis of Dyshidrosis?
Hölzle: This is not the case. A dysfunction of connective structures only reflects the autoimmune disease pattern. Here structural elements which connect the cells are being destroyed. In the case of Dyshidrosis the top dermal layer, which we call the epidermis and which is comprised of keratinocytes, is slightly swollen and separated by a perfusion, meaning an accumulation of fluids, the edema. And this results in what we call spongiosis. In this instance, the epidermis is saturated like a sponge. This is characteristic of Dyshidrosis.
MEDICA.de: The name Dyshidrosis is derived from the erroneous assumption that a dysfunction of the sweat glands is the trigger. Nevertheless, is there a connection between increased sweating (hyperhidrosis) and this disease?
Hölzle: Dyshidrosis is a historical misnomer. In the past it was assumed that sweat glands are getting blocked, the discharge ducts in the top dermal layers to be more precise, and these blisters then swell up as internal beads of sweat. However, that’s not correct. Dyshidrosis is an eczema reaction, which originates from a spongy edema of the epidermis, a spongiosis. The spongiotic blisters are caused by trapped moisture or intracellular fluid.
The disease however does have something to do with excessive sweating. Unfortunately, the cause is not yet known. This is a so-called black box, which needs to be decoded. But by now we know that such eruptions of Dyshidrosis occur more often in the summer. We also know that patients, who are prone to increased sweating on the palms of their hands and soles of their feet, that is to say hyperhidrosis, are more often being affected. How this is all connected is still not known.
MEDICA.de: Many causes for the normally small blisters on the hands and feet of patients are being discussed. What are the causes for most patients?
Hölzle: The most common is a so-called atopic dyshidrosis and it eventually displays neurodermatitis on the hands and feet. Atopic means that a person has the genetic predisposition to get sick from hay fever, asthma and neurodermatitis. Usually, family members are affected or exhibit a sensitization against aeroallergens, the allergens that swirl around in the air, like for example house dust mites, pollen or animal hair. An atopic person very often has Dyshidrosis as the only manifestation of his/her neurodermatitis or he/she has Dyshidrosis on the palms of the hands or the soles of the feet associated with a generalized neurodermatitis. However, a diagnosis and classification is still difficult.
At first patients are bothered by itching, later the blisters converge and form larger blisters and this gets painful; © panthermedia.net/Robert Byron
MEDICA.de: How do you reach a reliable diagnosis of this disease?
Hölzle: A diagnosis for Dyshidrosis is relatively easy. Blisters on the palms of the hands and soles of the feet which look like Dyshidrosis and otherwise have no recognizable causes, is Dyshidrosis. At first you don’t know where it comes from. If the physician now can verify atopic eczema or also a sensitization against a dog or birch pollen, he then knows that the patient is an atopic person. The classification of neurodermatitis then is certain. However, if the physician does not detect a sensitization, that is to say the patient is not suffering from hay fever or asthma, never had neurodermatitis and there also is no family predisposition, it gets difficult. And then there is still the magic trick: It could be an intrinsic form of neurodermatitis, meaning non-allergic neurodermatitis or non-allergic atopic eczema. Thus it would be Dyshidrosis. For the medical specialist this diagnosis includes an accompanying atopy, if this is not the case, the causes are not determinable. As a second cause the physician needs to be able to preclude an existing acromycosis (fungal infection) of the palms of the hands for instance. A fungus can sometimes also lead to types of Dyshidrosis.
MEDICA.de: If worst comes to worst, what kind of complications with Dyshidrosis do you need to count on?
Hölzle: At first the patient is bothered by itching, later the blisters converge and form larger blisters and this gets painful. The skin can rupture and the patient has an entry way which opens the door for germs, which could trigger a super infection. This can result in erysipelas, which also can trigger phlegmon if pyogenic bacteria enter. In the worst case this can lead to sepsis. This is the maximum complication imaginable.
MEDICA.de: What types of treatment are most effective based on the current state of research?
Hölzle: General measures are desiccative baths for hands and feet. For example with tannic acid, supplemented by external use of cortisone-containing preparations, which should be diluted in their texture and therefore are solutions, emulsions or creams. In another step these cortisone-containing preparations can be replaced by cortisone replacement preparations. If the Dyshidrosis heals, pure skin care is being used again. This is the ideal case in an atopic treatment. However, this case only occurs rarely and you thus need to often work with systemic drugs. The emergency brake for an acute containment of the disease are cortisone pills or systemic use of cortisone. For long-term use, a Vitamin A-like substance, a retinoid, lends itself for treatment. It has already been used for hand and foot eczema, admittedly only for dry dermatoses, which tend to painful tears. However, it now was revealed that this drug has a positive effect on Dyshidrosis, although it needs to be taken for a long time and it only has a positive impact in 50 percent of patients.
MEDICA.de: Some patients trace relief back to the intake of selenium.
Hölzle: If selenium was this great, we would certainly have an active substance that contains it. I don’t think that this intake makes any sense.
MEDICA.de: Can this skin disease be cured?
Hölzle: How often such attacks occur or whether attacks even take place permanently, differs with each patient. Only those dermatological reactions are curable, that can be suppressed to the greatest possible extent so that the skin looks healthy. Yet a person’s predisposition cannot be corrected. The causes, which we also only know in part, cannot be eliminated. However, the skin can be controlled in a way to where the person can regain a good quality of life.
MEDICA.de: Does the disease also depend on mental factors in the patient?
Hölzle:Definitely. When we talk about neurodermatitis which triggers attacks, stress is at the top of the list.
The interview was conducted by Diana Posth.
(Translated by Elena O'Meara)
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