汗皰疹(急性掌蹠濕疹/出汗障礙性濕疹）Acute palmoplantar eczema (dyshidrotic eczema)

2023-08-11 11:19AM

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Acute palmoplantar eczema (dyshidrotic eczema)
介紹
急性掌蹠濕疹（更普遍地稱為出汗障礙性濕疹或汗皰症）是一種嚴重瘙癢的水皰性皮疹，影響手掌、腳底或兩者[ 1,2 ]。臨床上其特徵為深部病變，從小水泡到大而緊張的大皰，組織學上表現為海綿狀水泡。復發很常見，患者通常會經歷數月或數年的頻繁發作。
INTRODUCTION
Acute palmoplantar eczema (more popularly known as dyshidrotic eczema or pompholyx) is an intensely pruritic, vesicular eruption affecting the palms, soles, or both [1,2]. It is characterized by deep-seated lesions ranging from small vesicles to large, tense bullae clinically and by spongiotic vesicles histologically. Recurrence is common, and patients typically experience frequent episodes for months or years.

術語(名稱)

急性掌蹠濕疹的術語(名稱)很混亂。“出汗困難”一詞於 1873 年創造，用於描述手掌和腳底的水皰疾病，人們認為這是汗腺疾病 [ 3 ]。現在人們普遍認為汗腺不參與發病機制[ 4,5 ]。然而，術語(名稱)“出汗障礙性濕疹”仍在使用。

TERMINOLOGY
The terminology for acute palmoplantar eczema is confusing. The term "dyshidrosis" was coined in 1873 to describe a blistering disease of the palms and soles that was believed to be a disorder of the sweat glands [3]. It is now accepted that the sweat glands are not involved in the pathogenesis [4,5]. However, the term "dyshidrotic eczema" continues to be used.

急性掌蹠濕疹的其他術語包括“汗皰症”、“出汗困難”、“水皰性掌蹠濕疹”、“急性和復發性水皰性手部皮炎”、“手汗症”（影響手）或“足汗症”（影響腳）。這些術語並不代表具體的診斷，而是表明手/足濕疹的形態模式，可能因刺激性接觸、過敏性接觸或內源性濕疹而發生。
Other terms for acute palmoplantar eczema include "pompholyx," "dyshidrosis," "vesicular palmoplantar eczema," "acute and recurrent vesicular hand dermatitis," "cheiropompholyx" (affecting the hands), or "podopompholyx" (affecting the feet). These terms do not represent a specific diagnosis but, rather, indicate a morphologic pattern of hand/foot eczema that can occur with irritant contact, allergic contact, or endogenous eczema.

流行病學
出汗不良性濕疹最常見於年輕人和女性[ 6 ]。
一般人群中輕度或重度多汗性濕疹的患病率尚不清楚。對瑞典 107,000 多人的調查和檢查發現患病率為 0.05% [ 7 ]。在手部皮炎患者中，出汗障礙性濕疹佔病例的 5% 至 20% [ 3,8-10 ]。
EPIDEMIOLOGY
Dyshidrotic eczema occurs most commonly in young adults and in females [6].
The prevalence of either mild or severe dyshidrotic eczema in the general population is unknown. A survey and examination of over 107,000 people in Sweden found a prevalence of 0.05 percent [7]. Among patients with hand dermatitis, dyshidrotic eczema accounts for 5 to 20 percent of cases [3,8-10].

風險因素
出汗困難性濕疹的原因尚不清楚，但可能是多因素的。儘管在大多數情況下無法確定病因或誘發因素，但與出汗困難性濕疹的發生相關的因素包括：
●特應性皮炎史[ 11,12 ]
●接觸接觸性過敏原，特別是金屬 [ 11,13,14 ]
●接觸接觸刺激物（例如金屬加工液）[ 15 ]
●全身暴露於接觸性過敏原（例如攝入鎳或鈷）[ 16 ]
●遠處部位的皮膚癬菌感染（id反應）[ 12 ]
●靜脈或皮下免疫球蛋白治療[ 13,17-22 ]
●使用蘇金單抗治療，這是一種白細胞介素 (IL) 17 抑製劑，已被批准用於治療銀屑病和銀屑病關節炎 [ 23 ]
●多汗症 [ 11 ]
●吸煙 [ 24 ]
●暴露於紫外線 (UV) 輻射 [ 25 ]

RISK FACTORS

The cause of dyshidrotic eczema is unknown, but it is probably multifactorial. Although, in most cases, a causative or predisposing factor cannot be identified, factors that have been associated with the development of dyshidrotic eczema include:

●History of atopic dermatitis [11,12]
●Exposure to contact allergens, particularly metals [11,13,14]
●Exposure to contact irritants (eg, metalworking fluids) [15]
●Systemic exposure to contact allergens (eg, ingestion of nickel or cobalt) [16]
●Dermatophyte infection at a distant site (id reaction) [12]
●Treatment with intravenous or subcutaneous immune globulin [13,17-22]
●Treatment with secukinumab, an interleukin (IL) 17 inhibitor approved for the treatment of psoriasis and psoriatic arthritis [23]
●Hyperhidrosis [11]
●Smoking [24]
●Exposure to ultraviolet (UV) radiation [25]

發病(病理學)

多汗性濕疹發生的機制很大程度上尚不清楚。一種假設是，兩種水/甘油通道蛋白（aquaporin-3 和aquaporin-10）在表皮所有層的過度表達可能會改變表皮水滲透屏障的功能，暴露於水和鹼性環境會加劇經表皮失水。皮膚 pH 值 [ 26,27 ]。

PATHOGENESIS
The mechanisms underlying the development of dyshidrotic eczema are largely unknown. One hypothesis is that the overexpression of two water/glycerol channel proteins, aquaporin-3 and aquaporin-10, across all layers of the epidermis may alter the function of the epidermal water permeability barrier, with transepidermal water loss exacerbated by exposure to water and alkaline skin pH [26,27].

臨床表現
出汗不良性濕疹的發作通常以瘙癢開始，隨後在手掌、手指的側面和背面（圖片 1A-D）或腳底上突然、對稱地出現嚴重瘙癢的水皰。70% 至 80% 的患者僅涉及手部 [ 13 ]。輕度病例中，水皰僅出現在手指的側面（圖片 1A、1D）。在一年中最溫暖的月份中，新的發作或惡化往往更為常見。
CLINICAL PRESENTATION
Episodes of dyshidrotic eczema often start with pruritus followed by a sudden, symmetric eruption of intensely pruritic vesicles on the palms, lateral and dorsal aspects of the fingers (picture 1A-D), or on the soles. In 70 to 80 percent of patients, only the hands are involved [13]. In mild cases, vesicles develop only on the lateral aspect of fingers (picture 1A, 1D). New episodes or worsening tend to be more common during the warmest months of the year.

水皰通常是深部的、多房的（“木薯或西米布丁”病變）；它們可能會合併成大皰（圖 2A）。在某些患者中，症狀可能嚴重到足以乾擾職業職責和日常活動（圖 2B）。
The vesicles are typically deep seated and multilocular ("tapioca or sago pudding" lesions); they may coalesce into large bullae (picture 2A). In some patients, symptoms may be severe enough to interfere with occupational duties and daily activities (picture 2B).

臨床病程和並發症

水皰和大皰持續數週，乾燥並脫皮消退（圖片 3）[ 1,3 ]。頻繁複發可能導致慢性手部皮炎，其特徵為紅色、苔蘚樣變、鱗屑斑塊或有裂隙的斑塊（圖片1E）。
CLINICAL COURSE AND COMPLICATIONS

Vesicles and bullae persist for several weeks, desiccate, and resolve with desquamation (picture 3) [1,3]. Frequent relapses may result in chronic hand dermatitis, characterized by red, lichenified, and scaling patches or plaques with fissures (picture 1E).

發作可能每隔三到四個星期就會復發，持續數月或數年。在某些患者中，症狀發作可能與情緒或身體壓力有關，但大多數情況下，症狀發作是在沒有可識別觸發因素的情況下發生的。在發作之間，皮膚恢復正常外觀，這與繼發於刺激性或過敏性接觸性皮炎或特應性皮炎的慢性水皰性手部皮炎的持續體徵和症狀形成鮮明對比。
Episodes may recur at intervals of three to four weeks for months or years. In some patients, flares may be associated with emotional or physical stress, but most often, they occur in the absence of an identifiable trigger. Between episodes, the skin returns to a normal appearance, in contrast to the persistent signs and symptoms of chronic vesicular hand dermatitis secondary to irritant or allergic contact dermatitis or atopic dermatitis.

嚴重的發作會影響指甲基質並產生營養不良的指甲變化，例如水平起皺和顏色變化（圖片1E）。可能會發生繼發感染，通常是金黃色葡萄球菌感染。
Severe episodes can affect the nail matrix and produce dystrophic nail changes such as horizontal ridging and color changes (picture 1E). Secondary infection, usually with Staphylococcus aureus, may occur.

診斷
臨床診斷 — 多汗性皮炎的診斷通常根據臨床表現、症狀和病史進行：
●緊張的深層水皰或大皰位於手掌和腳底，通常位於手指的側面（圖片 1B、1D）
●僅限於手指側面的微小水泡（圖1A）
●劇烈瘙癢
●急性發作
●復發史
DIAGNOSIS
Clinical diagnosis — The diagnosis of dyshidrotic dermatitis is usually made based upon clinical findings, symptoms, and history:
●Tense, deep-seated vesicles or bullae localized on the palms and soles and often on the lateral aspect of the fingers (picture 1B, 1D)
●Tiny vesicles limited to the lateral aspect of fingers (picture 1A)
●Intense pruritus
●Acute onset
●History of recurrence


嚴重程度評估 — 出汗障礙性濕疹的嚴重程度通常是主觀評估的。一種稱為出汗不良性濕疹面積和嚴重程度指數(DASI) 的評分工具，基於水皰的數量、紅斑、脫屑和瘙癢的強度，設計用於臨床試驗，但在臨床實踐中並不常規使用[28 ]：
Assessment of severity — The severity of dyshidrotic eczema is generally assessed subjectively. A scoring tool called the Dyshidrotic Eczema Area and Severity Index (DASI), based upon the number of vesicles, intensity of erythema, desquamation, and itch, was designed for use in clinical trials but is not routinely used in clinical practice [28]:

●輕度至中度- 

如果出汗障礙性濕疹不累及整個手掌或足底表面，我們認為其為輕度至中度；表現為少量水皰或散在的小水皰，無紅斑或輕度紅斑（圖片 1B、1E-G）；患者沒有抱怨難以忍受的瘙癢、燒灼感或疼痛。
●Mild to moderate − We consider dyshidrotic eczema to be mild to moderate if it does not involve the entire palmar or plantar surface; presents as a few crops of vesicles or scattered, small vesicles with absent or modest erythema (picture 1B, 1E-G); and the patient does not complain of intolerable pruritus, burning, or pain.


●嚴重- 如果出汗不良性濕疹涉及整個手掌或足底表面，並出現大的水皰或大皰，導致殘疾（圖2A-C）（即妨礙行走或使用手），或者如果情況嚴重，則我們認為出汗不良性濕疹為嚴重。疼痛或瘙癢（無論病變大小）。
●Severe − We consider dyshidrotic eczema to be severe if it involves the entire palmar or plantar surface and presents with large vesicles or bullae that are disabling (picture 2A-C) (ie, prevent walking or use of the hands) or if it is intensely painful or pruritic (regardless of the size of the lesions).

活檢的指徵(皮膚切片適應症) —(那些情況需考慮皮膚切片)
很少需要進行皮膚活檢進行組織病理學檢查。皮膚活檢的潛在指徵包括對治療缺乏反應以及在鑑別診斷中排除其他病症（例如牛皮癬或掌蹠膿皰病）。
Indications for biopsy — A skin biopsy for histopathologic examination is rarely needed. Potential indications for skin biopsy include lack of response to treatment and exclusion of other conditions in the differential diagnosis (eg, psoriasis or palmoplantar pustulosis).

如果進行皮膚活檢，對真菌成分進行高碘酸希夫 (PAS) 染色可能有助於排除真菌感染
If a skin biopsy is performed, periodic acid-Schiff (PAS) staining for fungal elements may be useful in excluding a fungal infection. (See 'Differential diagnosis' below.)

組織病理學 — 

出汗障礙性濕疹的組織學特徵取決於疾病的階段（急性或慢性）：
Histopathology — 

The histologic features of dyshidrotic eczema depend upon the stage (acute or chronic) of the disease:

急性階段- 

急性形式的特徵是表皮內海綿狀囊泡或大皰，不涉及小汗腺汗管（頂汗腺）的表皮內部分。通常存在稀疏、淺表、血管周圍的淋巴細胞浸潤。表皮厚度正常，肢端皮膚厚角質層完整。
●Acute stage − The acute form is characterized by intraepidermal spongiotic vesicles or bullae that do not involve the intraepidermal portion of the eccrine sweat duct (acrosyringium). A sparse, superficial, perivascular infiltrate of lymphocytes is usually present. The epidermal thickness is normal, and the thick stratum corneum of acral skin is intact.

慢性階段- 

在慢性病例中，主要是角化不全和棘層肥厚，很少或沒有海綿組織增生以及真皮、淋巴細胞浸潤。
●Chronic stage − 

In chronic cases, there is a predominance of parakeratosis and acanthosis with minimal or no spongiosis and a dermal, lymphocytic infiltrate.

斑貼(貼片)測試 — 

斑貼(貼片)測試通常對診斷出汗困難性濕疹沒有幫助。然而，皮膚科醫生通常會進行此檢查來確定是否存在過敏性接觸性皮炎的成分。對於對初始治療沒有反應的患者也可能需要進行斑貼(貼片)試驗[ 1,3 ]。
Patch testing — 

Patch testing is generally not helpful in making the diagnosis of dyshidrotic eczema. However, it is often performed by dermatologists to determine whether there is a component of allergic contact dermatitis. Patch testing may also be warranted in patients who do not respond to initial therapy [1,3]


鑑別診斷
出汗不良性濕疹的鑑別診斷包括炎症性和傳染性水皰大皰性皮膚病[ 1,3 ]：

DIFFERENTIAL DIAGNOSIS

The differential diagnosis of dyshidrotic eczema includes inflammatory and infectious vesicobullous skin diseases [1,3]:

過敏性接觸性皮炎– 

過敏性接觸性皮炎在臨床上可能與出汗困難性濕疹無法區分(圖片 4A-B )。正確的診斷基於過敏原暴露的評估和斑貼測試的結果。
●Allergic contact dermatitis – 

Allergic contact dermatitis may be clinically indistinguishable from dyshidrotic eczema (picture 4A-B). The correct diagnosis is based upon the assessment of allergen exposure and results of patch testing.

大皰性癬– 

大皰性癬在腳上比在手上更常見，並且通常是單側的（圖片 5A-B）。對病灶刮片進行氫氧化鉀 (KOH) 顯微鏡檢查可發現真菌成分。
●Bullous tinea – 

Bullous tinea occurs more often on the feet than on the hands and is usually unilateral (picture 5A-B). Potassium hydroxide (KOH) microscopic examination of scrapings from the lesions reveals fungal elements.

刺激性接觸性皮炎– 

刺激性接觸性皮炎通常涉及手背和蹼部（圖片 6A-B）。患者經常報告有刺激物接觸史。水皰和大皰很少出現，除非暴露於強烈刺激物並導致化學燒傷。
●Irritant contact dermatitis – 

Irritant contact dermatitis usually involves the dorsal aspect of the hands and web spaces (picture 6A-B). Patients often report a history of irritant exposure. Vesicles and bullae are rarely present, unless there was exposure to a strong irritant with a resultant chemical burn.

特應性手部皮炎– 

特應性手部皮炎通常累及手背（圖 7）。患者報告有特應性皮炎、季節性過敏或哮喘病史，並可能出現濕疹病變或涉及彎曲區域（即肘前窩和膕窩）的苔蘚樣變（圖 7 ）。
●Atopic hand dermatitis – 

Atopic hand dermatitis commonly involves the dorsum of the hands (picture 7). Patients report a history of atopic dermatitis, seasonal allergies, or asthma and may present with eczema lesions or lichenification involving flexural areas (ie, antecubital and popliteal fossae) (picture 7).

 
皮膚癬菌反應——

皮膚癬菌反應，也稱為“自身濕疹”，是一種繼發性、瘙癢性、丘皰疹，可能發生在手掌上，與遠處部位的皮膚癬菌感染有關，更常見於腳部，但也發生在手掌上。頭皮或其他身體部位（圖8）。為了確診，需要進行完整的皮膚檢查和對遠處可疑病變處的刮片進行 KOH 製備。
●Dermatophytid (id) reaction – 

A dermatophytid reaction, also called "autoeczematization," is a secondary, pruritic, papulovesicular eruption that may occur on the palms in association with a dermatophyte infection at a distant site, more often on the foot but also on the scalp or other body area (picture 8). A complete skin examination and a KOH preparation of scrapings from suspicious lesions at a distant site are necessary to confirm the diagnosis.

 
皰疹瘰癧– 

皰疹瘰癧可能模仿出汗障礙性濕疹[ 29 ]。通常，它表現為紅色基底上的成群的水泡，疼痛多於瘙癢，並且通常是單側的（圖 9）。可通過病毒培養、免疫熒光染色、聚合酶鏈反應或 Tzanck 塗片進行診斷。
●Herpetic whitlow – 

Herpetic whitlow may mimic dyshidrotic eczema [29]. Typically, it presents as grouped vesicles on a red base, is more often painful than pruritic, and is usually unilateral (picture 9). The diagnosis can be made by viral culture, immunofluorescence staining, polymerase chain reaction, or Tzanck smear.

掌蹠膿皰病–

掌蹠膿皰病可能有早期的水皰階段，但膿皰通常在幾天內形成（圖片 10A-B）。8～10天后，膿皰顏色變為深褐色，乾燥、脫落（圖11）。
●Palmoplantar pustulosis – 

Palmoplantar pustulosis may have an early, vesicular stage, but pustules usually develop in a few days (picture 10A-B). In 8 to 10 days, the pustules change their color to dark brown, become dry, and desquamate (picture 11).

自身免疫性大皰性疾病– 

大皰性類天皰瘡和尋常型天皰瘡可能很少表現為累及手或腳的局部疾病（圖片 12）。歷史反映了一個更為漫長、不懈的歷程。常規組織學活檢、直接免疫熒光和特定自身抗體的血清學檢測可提供正確的診斷。
●Autoimmune bullous diseases – 

Bullous pemphigoid and pemphigus vulgaris may rarely present as localized disease involving the hands or feet (picture 12). The history reflects a longer and unremitting course. Biopsy for routine histology, direct immunofluorescence, and serologic testing for specific autoantibodies provide the correct diagnosis.

臨床課程(臨床病程)
出汗不良性濕疹發作往往會在幾週內自然消退。然而，出汗不良性濕疹是一種複發性疾病，患者通常會多年經歷水皰性皮炎的頻繁發作。隨著年齡的增長，發作的頻率往往會降低，大多數患者最終會得到完全緩解[ 30 ]。

CLINICAL COURSE
Episodes of dyshidrotic eczema tend to spontaneously resolve over several weeks. However, dyshidrotic eczema is a recurrent disease, and patients typically experience frequent attacks of vesicular dermatitis for many years. Episodes tend to occur less frequently with age, and most patients eventually experience a complete remission [30].

管理(處置)

大多數出現瘙癢或其他症狀的患者都需要治療。治療方法以疾病的嚴重程度為指導（參見上文‘嚴重程度的評估’），包括以下內容：
●識別和避免致病因素或加劇因素
●治療皮膚炎症
●採取皮膚護理措施，減少皮膚刺激

MANAGEMENT
Treatment is required for most patients who present with complaints of pruritus or other symptoms. The approach to management is guided by the severity of the disease and involves the following:
●Identification and avoidance of causative or exacerbating factors
●Treatment of skin inflammation
●Adoption of skin care measures to reduce skin irritation

一般措施 — 

根據臨床經驗，避免刺激物或加重因素對大多數出汗困難性濕疹患者是有益的。旨在減少皮膚刺激和恢復皮膚屏障的一般皮膚護理措施包括[ 31 ]：
●使用溫水和溫和的合成洗滌劑（非肥皂）清潔劑洗手。大多數液體沐浴露實際上是具有中性pH值的合成洗滌劑產品。相比之下，“天然”肥皂（例如卡斯提爾肥皂）具有鹼性 pH 值，並且往往是更具腐蝕性的清潔劑。
●洗手後徹底擦乾雙手。
●擦乾手後立即塗抹潤膚劑（例如凡士林）並儘可能頻繁地塗抹。
●進行濕作業時，在乙烯基或其他非乳膠手套下佩戴棉質手套。
●在濕作業前摘下戒指、手錶和手鐲。
●在寒冷的天氣裡戴防護手套。
●佩戴針對摩擦暴露的任務專用手套（例如園藝、木工）。
●避免皮膚接觸刺激物（例如刺激性清潔劑、溶劑、染髮劑、酸性食物[例如柑橘類水果]）。General measures —
In clinical experience, the avoidance of irritants or exacerbating factors is beneficial for most patients with dyshidrotic eczema. General skin care measures aimed at reducing skin irritation and restoring the skin barrier include [31]:
●Using lukewarm water and mild, synthetic detergent (nonsoap) cleansers to wash hands. Most liquid body cleansers are actually synthetic detergent products with a neutral pH. In contrast, "natural" soaps (eg, Castile soap) have an alkaline pH and tend to be more aggressive detergents.
●Drying hands thoroughly after washing.
●Applying emollients (eg, petroleum jelly) immediately after hand drying and as often as possible.
●Wearing cotton gloves under vinyl or other nonlatex gloves when performing wet work.
●Removing rings, watches, and bracelets before wet work.
●Wearing protective gloves in cold weather.
●Wearing task-specific gloves for frictional exposures (eg, gardening, carpentry).
●Avoiding cutaneous exposure to irritants (eg, harsh detergents, solvents, hair dyes, acidic foods [eg, citrus fruit]).

在臨床實踐中, 諸如次乙酸鋁（Burow's 溶液）或金縷梅等收斂劑溶液用於治療潮濕、流淚的皮膚。將手或腳浸泡在該溶液中 15 分鐘，每天 2 至 4 次。或者，可以用薄的濕敷料代替浸泡，空氣可以通過敷料循環，從而增強收斂劑溶液的干燥效果。大的大皰可以使用無菌注射器引流或抽吸，以減輕疼痛并防止自發破裂和局部感染的風險。
In clinical practice, astringent solutions such as aluminum subacetate (Burow's solution) or witch hazel are used for wet, weeping skin. Hands or feet are soaked in the solution for 15 minutes two to four times per day. Alternately, soakings can be replaced by thin, wet dressings through which air will circulate, enhancing the drying effect of astringent solutions. Large bullae may be drained or aspirated using a sterile syringe to reduce pain and prevent spontaneous rupture with risk of local infection.

輕度至中度疾病
Mild to moderate disease
外用皮質類固醇– 

對於一般措施無反應的輕度至中度出汗性濕疹患者（圖 1B、1E-G），我們建議使用超高效或高效外用皮質類固醇（第 1 至第 3 組（表1） ）：一線治療。
●Topical corticosteroids – 

For patients with mild to moderate dyshidrotic eczema (picture 1B, 1E-G) that has not responded to general measures, we suggest super high-potency or high-potency topical corticosteroids (groups 1 to 3 (table 1)) as first-line therapy.

外用皮質類固醇每天使用兩次，持續兩到四個星期。軟膏劑通常優於其他載體（霜劑、溶液或泡沫），因為它們含有較少的潛在刺激物和過敏原，例如添加劑或防腐劑[ 1,3,31 ]。然而，一些患者更喜歡其他工具，因為藥膏使他們的手太油膩，無法執行任務。
Topical corticosteroids are applied twice daily for two to four weeks. Ointments are generally preferred to other vehicles (creams, solutions, or foams) because they contain fewer potential irritants and allergens, such as additives or preservatives [1,3,31]. However, some patients prefer other vehicles because ointments make their hands too greasy for performing tasks.

隨機試驗尚未充分評估外用皮質類固醇與安慰劑或不治療多汗性濕疹的療效。然而，由於它們的抗炎特性和對其他形式的手部濕疹的功效，它們被用於臨床實踐。
The efficacy of topical corticosteroids versus placebo or no treatment for dyshidrotic eczema has not been adequately evaluated in randomized trials. However, they are used in clinical practice because of their anti-inflammatory properties and their efficacy in other forms of hand eczema.

長期使用外用皮質類固醇受到其副作用的限制，包括皮膚萎縮、皮紋和毛細血管擴張。
The long-term use of topical corticosteroids is limited by their side effects, which include skin atrophy, striae, and telangiectasia.

外用鈣調磷酸酶抑製劑——

我們通常不建議將外用鈣調磷酸酶抑製劑作為多汗性濕疹的一線抗炎治療。外用鈣調神經磷酸酶抑製劑的抗炎作用大約相當於中等效力的外用皮質類固醇[ 32 ]。此外，外用鈣調神經磷酸酶抑製劑比許多外用皮質類固醇更昂貴。
●Topical calcineurin inhibitors – We generally do not suggest a topical calcineurin inhibitor as the first-line anti-inflammatory treatment for dyshidrotic eczema. The anti-inflammatory effect of topical calcineurin inhibitors is approximately equivalent to moderate-potency topical corticosteroids [32]. In addition, topical calcineurin inhibitors are more expensive than many topical corticosteroids.

然而，當患者和/或臨床醫生希望避免長期使用外用皮質類固醇來治療輕度至中度出汗性濕疹時（圖 1A -B、1F），外用鈣調神經磷酸酶抑製劑他克莫司是一種替代選擇[ 33,34 ]。他克莫司 0.1% 軟膏每天塗抹兩次，直至症狀消失。
However, when patients and/or clinicians prefer to avoid long-term use of topical corticosteroids for the treatment of mild to moderate dyshidrotic eczema (picture 1A-B, 1F), the topical calcineurin inhibitor tacrolimus is an alternative [33,34]. Tacrolimus 0.1% ointment is applied twice daily until resolution.

在一項納入 16 名中度至重度出汗不良性濕疹患者的隨機試驗中，將外用他克莫司與糠酸莫米松（一種高效外用皮質類固醇）進行了比較（第 3 組）[ 35 ]。使用軟膏治療 4 週後，與基線相比，外用 0.1% 他克莫司和 0.1% 糠酸莫米松均可使出汗不良性濕疹面積和嚴重程度指數 (DASI) 減少 50% 以上。
In a randomized trial including 16 patients with moderate to severe dyshidrotic eczema, topical tacrolimus was compared with mometasone furoate, a high-potency topical corticosteroid (group 3) [35]. After four weeks of treatment ointment, both topical tacrolimus 0.1% and mometasone furoate 0.1% reduced the Dyshidrotic Eczema Area and Severity Index (DASI) by more than 50 percent compared with baseline.

嚴重疾病 — 

除了上述一般措施外，我們建議短期口服皮質類固醇治療嚴重多汗性濕疹(圖片 2A-C )。

Severe disease — 

In addition to the general measures described above, we suggest a short course of oral corticosteroids for the treatment of severe dyshidrotic eczema (picture 2A-C).

我們通常從每天早上服用潑尼松40 至 60 毫克開始，持續一周。如果有足夠的反應，則在接下來的 5 至 7 天內將劑量減少 50%，最後在接下來的兩週內逐漸減少並停藥。
We generally start with prednisone 40 to 60 mg once per day in the morning for one week. If there is an adequate response, the dose is then reduced by 50 percent in the next five to seven days and finally tapered and discontinued over the following two weeks.

口服皮質類固醇治療多汗性濕疹尚未在臨床試驗中進行評估。然而，根據臨床經驗，它們對於出汗困難性濕疹和其他形式的嚴重濕疹性皮炎的短期治療是有益的。
Oral corticosteroids for dyshidrotic eczema have not been evaluated in clinical trials. However, in clinical experience, they have been beneficial for the short-term treatment of dyshidrotic eczema and other forms of severe, eczematous dermatitis.

對於禁忌使用全身性糖皮質激素或希望避免全身性皮質類固醇的患者，在封閉敷料（例如手上使用聚乙烯手套或腳上使用保鮮膜）下使用超強效局部皮質類固醇是治療嚴重出汗性濕疹的一種選擇。閉塞敷料通常在夜間使用三到七天。
Superpotent topical corticosteroids applied under occlusive dressings (eg, polyethylene gloves for the hands or plastic wrap for the feet) are a treatment option for severe dyshidrotic eczema in patients for whom systemic glucocorticoids are contraindicated or in patients who prefer to avoid systemic corticosteroids. Occlusive dressings are usually used at nighttime for three to seven days.

治療反應的評估 — 

用於評估治療反應的臨床標準包括水皰停止；清除先前存在的囊泡；並減少紅斑、瘙癢和疼痛。消退通常與皮膚乾燥和脫屑增加有關。
Evaluation of treatment response — 

Clinical criteria used to evaluate the response to treatment include cessation of vesiculation; clearance of pre-existing vesicles; and reduction of erythema, pruritus, and pain. Resolution is usually associated with increased skin dryness and desquamation.

難治性疾病(頑固性疾病) — 

如果經過兩到四個星期的充分治療後，出汗不良性濕疹沒有改善/消退，則被認為是難治性濕疹。難治性病例可能需要額外評估並重新考慮全面的鑑別診斷。
Refractory disease — Dyshidrotic eczema is considered refractory if there is no improvement/resolution in two to four weeks of adequate treatment. Refractory cases may warrant additional evaluation and reconsideration of the full differential diagnosis.
額外的診斷評估 — 具有出汗不良性濕疹臨床特徵的患者，在使用外用皮質類固醇、外用他克莫司或全身性皮質類固醇2 至4 週後沒有反應或未得到充分控制的患者可能需要進一步評估以確認或排除診斷。
Additional diagnostic evaluation — 

Patients with clinical features of dyshidrotic eczema who do not respond or are not adequately controlled after two to four weeks of topical corticosteroids, topical tacrolimus, or systemic corticosteroids may need further evaluation to confirm or rule out the diagnosis.

其他測試可能包括
●氫氧化鉀 (KOH) 製劑可排除真菌感染。
●細菌培養以排除細菌重複感染。金黃色葡萄球菌重複感染是手部濕疹患者治療反應不足的常見原因，特別是對於病情嚴重和濕性滲出性病變的患者。細菌二重感染可以用口服抗生素治療。
●皮膚活檢和組織病理學檢查可確診多汗性濕疹並排除其他病症。應包括真菌成分的高碘酸希夫 (PAS) 染色。如果懷疑大皰性類天皰瘡或天皰瘡，可能需要直接免疫熒光檢查。
●斑貼測試和詳細的家庭或工作相關接觸史，以排除過敏性或刺激性接觸性皮炎。

Additional testing may include
●Potassium hydroxide (KOH) preparation to rule out a fungal infection.
●Bacterial culture to rule out bacterial superinfection. Superinfection with S. aureus is a common cause of inadequate response to treatment in patients with hand eczema, especially with severe disease and wet, weeping lesions. Bacterial superinfection is treated with oral antibiotics
●Skin biopsy and histopathologic examination to confirm the diagnosis of dyshidrotic eczema and exclude other conditions. Periodic acid-Schiff (PAS) staining for fungal elements should be included. Direct immunofluorescence may be necessary if bullous pemphigoid or pemphigus are suspected.
●Patch testing and detailed history of household- or work-related exposures to exclude an allergic or irritant contact dermatitis

治療
光療 — 

對於確診為多汗性濕疹且發作頻繁或嚴重且局部或全身皮質類固醇或局部用藥無法充分控制的患者，我們建議口服或局部補骨脂素加紫外線A (PUVA) 療法或窄帶紫外線B ( NBUVB) 光療。他克莫司。
Treatment
Phototherapy — 

We suggest oral or topical psoralen plus ultraviolet A (PUVA) therapy or narrowband ultraviolet B (NBUVB) phototherapy for patients with a confirmed diagnosis of dyshidrotic eczema who have frequent or severe episodes that are not adequately controlled with topical or systemic corticosteroids or topical tacrolimus.

NBUVB 和PUVA 在治療出汗困難性濕疹患者中的使用在很大程度上得到了其在其他炎症性皮膚病治療中的支持，因為只有少數小型臨床試驗證明PUVA 對出汗困難性濕疹患者的臨床改善[36-42 ]。
The use of NBUVB and PUVA for patients with dyshidrotic eczema is largely supported by its use in the treatment of other inflammatory dermatoses, as only a few small clinical trials have demonstrated clinical improvement with PUVA in patients with dyshidrotic eczema [36-42].

並非所有社區都提供光療。光療通常每週進行兩到三次。需要幾週的治療才能引起臨床改善，並且需要幾個月的時間才能緩解。因此，應根據具體情況權衡光療的潛在益處與延長治療的不便。僅限於手掌和腳底的光療幾乎沒有副作用。
Phototherapy may not be available in all communities. Phototherapy treatments are usually delivered two or three times per week. Several weeks of treatment are required to induce clinical improvement, and several months are required for resolution. Thus, the potential benefits of phototherapy should be weighed against the inconvenience of prolonged therapy on a case-by-case basis. Phototherapy that is limited to the palms and soles has few adverse effects.

全身治療
●全身性免疫抑製劑——

全身性免疫抑製劑，如小劑量甲氨蝶呤、嗎替麥考酚酯和環孢菌素，偶爾用於治療嚴重的多汗性濕疹患者[ 43-45 ]。然而，它們的使用尚未在高質量的研究中得到評估，並且沒有足夠的證據表明它們在難治性病例中的使用有益。Systemic therapies
●Systemic immunosuppressive agents – 

Systemic immunosuppressive agents, such as low-dose methotrexate, mycophenolate mofetil, and cyclosporine, have been occasionally used in the management of patients with severe dyshidrotic eczema [43-45]. However, their use has not been evaluated in high-quality studies, and there is insufficient evidence of benefit to suggest their use in refractory cases.

Dupilumab – 

Dupilumab是一種白細胞介素(IL) 4 受體拮抗劑，被批准用於治療特應性皮炎，已被證明對先前局部皮質類固醇治療失敗的多汗性濕疹患者俱有良好的耐受性和有效性[45 ]。一項隨機、安慰劑對照試驗正在進行中，該試驗評估 dupilumab 對超強外用皮質類固醇無法控制的手部濕疹的療效 ( NCT03861455 )。
●Dupilumab – 

Dupilumab, an interleukin (IL) 4 receptor antagonist approved for the treatment of atopic dermatitis, has been shown to be well tolerated and effective in a small series of patients with dyshidrotic eczema who had previously failed topical corticosteroids [45]. A randomized, placebo-controlled trial evaluating the efficacy of dupilumab for hand eczema uncontrolled by superpotent topical corticosteroids is ongoing (NCT03861455).

全身性維A酸——

阿利維A酸在美國不上市，是一種全身性維A酸，在英國、歐洲和加拿大被批准用於治療慢性、難治性手部濕疹。這種口服類維生素A通過類維生素A X受體（RXR）和視黃酸受體（RAR）發揮其抗炎和免疫調節作用。最初預計它對過度角化性手部濕疹效果更好，但後來發現它對水皰性手部皮炎同樣有效[ 46,47 ]。
●Systemic retinoids –

  Alitretinoin, not available in the United States, is a systemic retinoid approved for the treatment of chronic, refractory hand eczema in the United Kingdom, Europe, and Canada. This oral retinoid exerts its anti-inflammatory and immunomodulatory effects through both the retinoid X receptor (RXR) and retinoic acid receptor (RAR). Initially expected to work better with hyperkeratotic hand eczema, it was found equally effective in vesicular hand dermatitis [46,47].

阿利維A酸通常每天服用 30 毫克，持續六個月。停止治療後，一些患者會經歷長時間的緩解，而另一些患者則會更快地複發。當複發時可以恢復治療。有些患者可能需要持續治療。
Alitretinoin is usually given at the dose of 30 mg daily for six months. Upon stopping treatment, some patients experience prolonged remissions, while others will relapse more quickly. Treatment can be resumed when relapse occurs. Some patients may require continuous treatment.

最常見的不良反應是治療最初幾週的頭痛。懷孕注意事項與異維A酸類似。在可用的情況下，這種藥物在超強外用皮質類固醇或光療和全身免疫抑製劑之間找到了一個利基。
The most common adverse effect is headache during the first few weeks of treatment. Pregnancy precautions are similar to isotretinoin. Where available, this medication has found a niche between superpotent topical corticosteroids or phototherapy and systemic immunosuppressive agents.

總結和建議
●流行病學和危險因素——急性掌蹠濕疹（也稱為“出汗障礙性濕疹”或“汗皰疹”）是一種相對罕見的、反復發作的皮疹，影響手掌、腳底或兩者。它最常見於年輕人，更常見於女性。主要危險因素包括特應性皮炎病史、接觸接觸刺激物和過敏原以及靜脈注射免疫球蛋白治療。SUMMARY AND RECOMMENDATIONS
●Epidemiology and risk factors –

 Acute palmoplantar eczema (also known as "dyshidrotic eczema" or "pompholyx") is a relatively uncommon, recurrent eruption affecting the palms, soles, or both. It occurs most commonly in young adults and more frequently in females. Main risk factors include a history of atopic dermatitis, exposure to contact irritants and allergens, and treatment with intravenous immunoglobulins

臨床特徵– 

出汗不良性濕疹的特徵是手掌（圖片 1G）、腳底或手指側面（圖片 1D）突然出現劇烈瘙癢的水皰。水泡持續數週，乾燥並脫落。發作可能每隔三到四個星期就會復發，持續數月或數年。
●Clinical features – Dyshidrotic eczema is characterized by the sudden eruption of intensely pruritic vesicles on the palms (picture 1G), soles, or lateral aspects of the fingers (picture 1D). The vesicles persist for several weeks, desiccate, and resolve with desquamation. Episodes may recur at intervals of three to four weeks for months or years.

診斷——

出汗障礙性濕疹的診斷通常基於臨床表現和病變部位、症狀和病史。對於患有頑固性疾病的選擇性患者，斑貼試驗有助於確定是否存在過敏性接觸性皮炎的成分。
●Diagnosis – 

The diagnosis of dyshidrotic eczema is usually based upon the clinical appearance and location of lesions, symptoms, and history. In selective patients with recalcitrant disease, patch testing is useful to determine whether there is a component of allergic contact dermatitis. (See 'Diagnosis' above.)

鑑別診斷——出汗不良性濕疹的鑑別診斷包括大皰性癬（圖5B）、皮膚癬菌反應（圖8）、大皰性膿皰瘡、單純皰疹感染（圖9）、過敏性接觸性皮炎（圖4A）、掌蹠膿皰病（圖10A-） B）。
Differential diagnosis – The differential diagnosis of dyshidrotic eczema includes bullous tinea (picture 5B), dermatophytid reaction (picture 8), bullous impetigo, herpes simplex infection (picture 9), allergic contact dermatitis (picture 4A), and palmoplantar pustulosis (picture 10A-B). (See 'Differential diagnosis' above.)

管理：
•一般措施– 避免刺激物或加重因素對於大多數出汗困難性濕疹患者很重要。
●Management:
•General measures – Avoidance of irritants or exacerbating factors is important for most patients with dyshidrotic eczema.

輕度至中度疾病– 

對於對一般措施沒有反應的輕度至中度出汗不良性濕疹（圖片 1B、1E-G ）患者（參見上文‘一般措施’），我們建議使用超高效或高效外用皮質類固醇（組1至組3（表1））作為一線治療（2C級）。外用皮質類固醇每天使用兩次，持續兩到四個星期。軟膏優於其他載體。對於希望避免長期使用外用皮質類固醇的患者來說，外用他克莫司是一種替代治療方法。
•Mild to moderate disease – 

For patients with mild to moderate dyshidrotic eczema (picture 1B, 1E-G) that has not responded to general measures (see 'General measures' above), we suggest super high-potency or high-potency topical corticosteroids (groups 1 to 3 (table 1)) as first-line therapy (Grade 2C). Topical corticosteroids are applied twice daily for two to four weeks. Ointments are preferred to other vehicles. Topical tacrolimus is an alternative treatment for patients who wish to avoid long-term use of topical corticosteroids. (See 'Mild to moderate disease' above.)

嚴重疾病– 

除了上述一般措施外，我們建議短期口服皮質類固醇治療嚴重出汗性濕疹（2C 級）。治療開始時每天使用潑尼松40 至 60 毫克，持續一周。在接下來的五到七天內，劑量可能會減少 50%，然後在接下來的兩週內逐漸減少並停藥。
•Severe disease – 

In addition to the general measures described above, we suggest a short course of oral corticosteroids for the treatment of severe dyshidrotic eczema (Grade 2C). Treatment is started with prednisone 40 to 60 mg per day for one week. The dose may be reduced by 50 percent in the next five to seven days and then tapered and discontinued over the following two weeks.

難治性(頑固性)疾病– 

對於具有出汗困難性濕疹臨床特徵的患者，在使用超強外用皮質類固醇或全身皮質類固醇2 至4 週後疾病沒有反應或未得到充分控制，可能需要進一步的診斷評估以確認或排除診斷。
•Refractory disease – 

For patients with clinical features of dyshidrotic eczema whose disease does not respond or is not adequately controlled after two to four weeks of superpotent topical corticosteroids or systemic corticosteroids, further diagnostic evaluation may be needed to confirm or rule out the diagnosis. 

對於確診的難治性出汗困難性濕疹患者，我們建議採用口服或局部補骨脂素加紫外線 A (PUVA) 或窄帶紫外線 B (NBUVB) 療法進行光療，而不是全身免疫抑製劑（2C 級）。
For patients with confirmed, refractory dyshidrotic eczema, we suggest phototherapy with oral or topical psoralen plus ultraviolet A (PUVA) or narrowband ultraviolet B (NBUVB) therapy rather than systemic immunosuppressants (Grade 2C).

口服阿利維A酸是一種全身性維A酸，在英國、歐洲和加拿大被批准用於治療慢性、難治性手部濕疹（但在美國尚未上市），對於難治性汗濕性濕疹患者來說，它可能是光療的替代方案。
Oral alitretinoin, a systemic retinoid approved for the treatment of chronic, refractory hand eczema in the United Kingdom, Europe, and Canada (but not available in the United States), may be an alternative to phototherapy for patients with refractory dyshidrotic eczema