A Dermatologic Vignette

Pictured below are the hands of a 35 year-old plumber I saw yesterday. He was not aware of a dermatitis of his feet, but inspection showed mild moccasin-type Tinea pedis on both feet and subtle onychomycosis. KOH prep from the right hand was positive for septate hyaline hyphae.

Dermatologists see two foot and one hand disease regularly. Why this affects both feet and often toe nails and only one hand is a mystery.

This man had been treated with various creams for "hand dermatitis" without relief. Knowing of the entity "Two Hand and One Foot Disease" will enable you to quickly make the right diagnosis. The question of why this occurs is still unanswered.

I prescribed ultramicrosized griseofulvin (Gris-Peg) 375 mg per day. We'll see how it works. I prefer griseofulvin to terbinafine (Lamisil) because I do not trust Novartis (the company that makes the latter). They marked Lamisil too aggressively.



Right Hand


Left Hand

Recurrent Eruption Buttock

Abstract: 65 yo man with recurrent eruption of left buttock

Presented by DJ Elpern

History: This 65 yo engineer lives in the United Arab Emirates and was seen while visiting Massachusetts. For the past few years, he has had pruritic and painful eruptions on his left buttock. He is well and takes no medications by mouth. He was seen by practitioners in Dubai and England. On both occasions, he was treated with oral antibiotics which were not helpful. Over the past few months, he has developed tingling sensations in his left foot and pain in the left leg.

O/E: Photos were taken by patient in the UAE. This shows confluent pustules on buttock. When seen at my office, only pigment changes and mild scarring were noted.

Clinical Photo(s)


Suggestion of grouped vesicles becoming purulent


Appearance at time of office visit. Some mild atrophic scarring and color change is noted.

Lab: None
Histopathology: None

Diagnosis: Recurrent Sacral Herpes Simplex.

Comment: The buttocks and lower back are probably the third most common area for HSV recurrence. Had someone listened to the patient's history one would have heard "recurrent episodes" which suggests HSV. Then the history of clear vesicles at the outset makes the diagnosis. Strictly speaking, this is not "genital herpes." After the mouth and genitalia, the buttocks and thighs are probably the most common sites for recurrent HSV. Sciatic pain has been associated with sacral HSV (see reference) and often these patients are worked up for renal calculi or sciatica. There may be more constant pain, similar to the post herpetic neuralgia seen after herpes zoster.
It would be nice to see the patient with an acute episode so a Tzanck smear could be done. With his travel history, this may not be practical.
Rx: The acute episodes can be treated with acyclovir or a related drug. When patients have neuralgic pain as this man does, there may be some value in long term suppressive therapy with acyclovir. Dose 400 mg tid for three or four weeks.

Reason(s) Presented: This is a relatively common disorder, although it is frequently misdiagnosed as bacterial infection or "bite." The key points are recurrent eruptions associated with itching or pain. Grouped vesicles at onset which quickly become purulent. The lesions resolve in one to two weeks. Sacral herpes is commonly associated with neuralgic pain, in my experience.

References: There are few articles on this common disorder. In 1974 RB Layzer and MA Conant published what remains until today as the most important paper on this subject.
Neuralgia in recurrent herpes simplex.
Arch Neurol. 1974 Oct;31(4):233-7.
A PDF of this article is available. Thank you to Barbara Harness, Librarian and CME Co-Coordinator at Maine General Medical Center facilitated the retrieval of this article.
Basically, it reports on four patients with neuralgic pain associated with HSV infections. One of these had sciatica as the prodrome to new episodes. More needs to be written about this entity.

25 Year History of Foot and Hand Dermatitis

Abstract: 47 yo woman with plantar dermatitis x 25 years

Presented by Natalie Karishev and David Elpern

History: This 47 yo woman has a 25 y h/o a persistent relapsing vesicular dermatitis of the L sole and to lesser extent R sole and both palms. The dermatitis is associated with mild itching, and painful fissures. KOH prep and culture on one occasion in the distant past was positive for T. rubrum. She was treated with Lamisil po for two months without any improvement. At present the rash is managed by Triamcinolone 0.025% without significant results as well. The involved area is expending

O/E: Well defined scaly patches with deep seated vesicles on the lsft palm and localized non-inflammatory scaling on localized areas of the palms.

Clinical Photo(s)







Lab: Repeat KOH prep and fungal culture are negative (April 2008)
Histopathology: NA
Diagnosis or DDx:

Tinea pedis (appears unlikely)

vs Pompholyx, Dyshidrotic Eczema) Cronic and recurrent vesicular hand/foot dermatitis

vs Psoriasis

Reason(s) Presented: For diagnostic and treatment suggestions

Comment: One of us thinks that Fran Storrs article (referenced below) is helpful for understanding this process, although she addresses a similar condition primarily of the hands. The patient described here needs patch testing (if it has not been done) and a bit more work-up. If there are frank pustules, the diagnosis of pustulosis plantaris need to be added. If diagnostic uncertainty persists, biopsy of an acute lesion may be helpful.

References: Acute and recurrent vesicular hand dermatitis not pompholyx or dyshidrosis. Storrs FJ. Arch Dermatol. 2007 Dec;143(12):1578-80.
So now do we know what pompholyx is and what causes it? I am afraid not. I join the European Dermatolo-Epidemiology Network study’s lament that we use inexact terminology in defining all kinds of hand eczema. This lack of precision in definition has rendered accurate analysis of causation and comparisons of therapeutic strategies impossible. Thorough descriptions of methods and definitions of interpretations and relevance are lacking or are simply not adhered to. In short, as the European Dermato-Epidemiology Network study suggests, we should “start again.”
Clearly, the terms pompholyx and dyshidrosis are obsolete in that really no modern investigators use them as originally defined. Some dermatologists (old ones like me) define them rigidly for use in our own patients’ care, but in studies and reviews such rigidity seldom prevails. Until a more concise label can be agreed on, I propose the use of “acute and recur- rent vesicular hand dermatitis,.” This will not include feet-only situations, but dermatologists caring for these patients know that feet can be included in this primarily hand condition. It is time for pompholyx and dyshidrosis to exit. The full article can be obtained as a PDF from Dave Elpern.