✅ MSRA Deep Dive: Pompholyx – Vesicles, Triggers, and Management

In this focused MSRA revision episode, we explore Pompholyx (also called dyshidrotic eczema), a distinct form of eczema that causes intensely itchy vesicles on the hands and feet. If you're revising dermatology, this one is high-yield. We break down everything from presentation and differentials to treatment and prognosis, following UK NICE-aligned content.

🧠 Key Learning Points

📌 Definition
• Pompholyx is a vesicular eczema primarily affecting palms, fingers, and soles
• Also known as dyshidrotic eczema, but not due to sweat gland blockage
• Name comes from Greek “pompholix” meaning “bubble”

📌 Pathophysiology
• Caused by inflammatory skin changes, not sweat retention
• Thought to involve skin barrier dysfunction, immune dysregulation, and environmental triggers

📌 Triggers
• Stress, heat, humidity, excessive handwashing, contact allergens, and irritants
• More common in people with atopic background (eczema, asthma, hay fever)

🔍 Clinical Features
• Sudden onset of small fluid-filled blisters (1–2mm vesicles) on sides of fingers, palms, or soles
• Severe itching or burning
• Lesions may burst, peel, or crust, leaving behind dry, cracked skin
• Flares typically last 3–4 weeks
• Nail changes (transverse ridges or pits) if inflammation involves nail matrix

🧠 Differential Diagnoses
• Pustular psoriasis (palmar/plantar)
• Tinea infections
• Contact dermatitis (allergic or irritant)
• Bullous impetigo, bullous pemphigoid, linear IgA disease
• Juvenile plantar dermatosis, erythema multiforme, herpes simplex, and fixed drug eruptions

📌 Key point: Always consider testing or referral if the clinical picture is unclear or resistant to treatment

🧪 Diagnosis
• Clinical diagnosis in most cases
• Investigations if atypical or recurrent:
• Bacterial swabs (if secondary infection suspected)
• Fungal scrapings or biopsy (to rule out tinea)
• Patch testing (for contact allergens)
• Bloods/HTLV1 only if suspecting rare T-cell lymphoma variant

💊 Management

🎯 First-line
• Emollients – restore skin barrier
• Topical corticosteroids – reduce inflammation
• Cold compresses, antihistamines (for itching)
• Avoidance of triggers (soaps, irritants, allergens)

🎯 Second-line
• Oral steroids (e.g. prednisolone) for short-term flare control
• Topical calcineurin inhibitors (tacrolimus/pimecrolimus)
• Phototherapy (UV light) for resistant cases

🎯 Severe/Refractory Cases
• Immunosuppressants: methotrexate, azathioprine, mycophenolate, cyclosporin
• Botulinum toxin (may help reduce sweat triggers)
• Allotretinoin (retinoid under specialist care)
• Drainage of tense bullae if painful
• Antibiotics if secondary infection develops

📈 Prognosis
• Usually chronic and relapsing
• Flares resolve in 3–4 weeks, but recurrences are common
• Quality of life often affected due to pain, itch, and disrupted sleep/work
• Secondary infection, lichenification, and post-inflammatory pigmentation may occur
• Prognosis generally good with trigger control and consistent treatment

🩺 MSRA Exam Tip
If you see itchy vesicles on hands/feet, think Pompholyx.
Don’t forget the misnomer: not caused by sweat ducts.
Differentiate from tinea, psoriasis, and contact dermatitis.

📚 MSRA Revision Resources
📝 Notes: https://www.passthemsra.com/topic/pompholyx-revision-notes/
💬 Flashcards: https://www.passthemsra.com/topic/pompholyx-flashcards/
🧠 Accordion Q&A: https://www.passthemsra.com/topic/pompholyx-accordion-qa-notes/
🧪 Rapid Quiz: https://www.passthemsra.com/topic/pompholyx-rapid-quiz/
🎯 Full Quiz: https://www.passthemsra.com/quizzes/pompholyx/
📘 Dermatology Course: https://www.passthemsra.com/courses/dermatology-for-the-msra/

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