What's The Diagnosis?


25 year old patient presents with the rash below for the previous two weeks. Started on Acyclovir for herpes by primary care physician, but not getting better.  Mouth was sore previous week but no lesions noted. Now no mouth symptoms.
What’s the diagnosis? (Picture used with patient’s permission)
Answer here and here.



  1. I guessed, eczema, but only because I have a similar issue. In winter, my hands get teeny weepy blisters between my fingers, knuckle tops and the back of my ears. That looks much more painful.

  2. I had this about six weeks ago. Primary care sent me on to dermatology who had no clue. I never find it good when the doc disappears and comes back with his senior partner and a camera. Took a biopsy and by the time it came back, the skin had broken and most of the pain was gone.


  3. I’m just curious – how do you go about getting permission from the patient to share these photos? I would find it disconcerting if my emergency doc asked, “Say, do you mind if I blog about you?” but maybe others wouldn’t.

    • If there is an interesting finding, I wait until the end of the visit so that patients don’t feel as if they will be treated differently based on their answer to my request.
      At the end of the visit, after patients have received their discharge instructions, I will ask the patient for a favor. Then I explain that I teach at a residency program and medical school (I really do) and that the findings they have would be helpful in teaching others about their disease. I tell them that I have used pictures in both classroom and online presentations (I really do) but that I would never disclose anyone’s identity and that the pictures are used for teaching. I then ask for permission to take the picture(s), adding that it is entirely fine and I completely understand and won’t take any offense if they don’t want their picture taken. After I take the pictures, I show the pictures on the camera to the patient so that they can see the pictures for themselves. I even offer to print and/or e-mail copies of the pictures to the patient if they would like them. Many take me up on the offer.
      I don’t keep identifying information on/with the pictures, so that way even I don’t remember where pictures came from after they’ve been taken.

      Presentation of patient information is probably the only reason that I try to maintain my anonymity. The pictures I show and the patient encounters I write about are “deidentified” so that no one could use these things by themselves to find the identity of a patient. That complies with HIPAA laws and with patient privacy.
      I change things around a little in the stories, including age, gender, etc, and I’ll reverse pictures and x-rays to make it even less likely that patients could be identified from the these items themselves. I just don’t want someone to use my identity to find out where I work, then use my hospital as a starting point to work backwards and try to learn the identity of specific patients.

      • Good on you for showing these photos. It helps a lot. I get these mostly in summer, when I’m more likely to use heavy creams. The blisters are painful and after they’re gone the skin is red and irritated. It takes a while for skin to return to normal. Stress is a big factor. A foot bath with bi-carb and epsom salts helps a lot.

  4. How interesting! I used to get this fairly often as a child (with very sweaty hands, I might add). I learned to avoid most lotions as they will produce copious sweating and eventually tiny blisters.

  5. Southern US by any chance?? Looks like fire ant bites to me, and they get weepy (as on the foot) after they pop up as discrete little papules (like the hand). And at all times THEY HURT LIKE LIVING HELLFIRE!!!

  6. I read the first link (e-medicine) about this condition. Am I the only one who laughed out loud when it said “Hands are involved solely in 80% of patients, feet solely in 10%”

    Feet? Solely?

    Oh, nevermind…….

  7. I have had this my entire life on and off and noone could tell me what is was. Thank you for posting this. (In my Doctor’s defense it is a very mild case that resolves quickly)

  8. The hand lesions looked like an ID reaction from the Atlete’s foot. Treat the Atlete’s foot and the hand lesions will resolve as well.

    • What do you use in the Homepathy line? My 1 year old son has this and on our 5th doctor we finally got a name for it. Everytime he sees another doctor they up his dosage of steroid ointment. And none of them have helped.

  9. I have been dealing with this off and on for over 7 years. It is a form of eczema. I went to several doctors, spent lots of money of several different prescriptions that didn’t help. I originally thought it was athlete’s foot because I’d never had it and it itched like crazy so I bought an over the counter remedy. By the time I returned from a vacation in Hawaii the bottom of my foot was completely open and I worried they would amputate it in the emergency room or it would rot off. I now go to a dermatologist that seems to be able to temporarily relieve the symptoms, but he says it looks like I have a chronic case. The biggest problem came last year when it got so aggravated (especially since it is on the bottom of your feet and does affect the hands) and my entire calf turned red, was hot to the touch, and I had a fever of 104.5. I was in the emergency room for almost a week and on home IV’s for over a month fighting cellulitis. This can become a serious problem and so far nobody has been able to make it go away permanently. Stress can make it flare up, but I wish I knew what caused it in the first place. The remedies cause side effects…get rid of one problem and replaced it with others. I worry that my body eventually won’t respond to the meds since they keep increasing the dosage.

  10. This is Dyshidrotic Eczema. My hands and feet look exactly like the photo above and i have suffered from it for 16 years. I too have been paraded around to medical students and doctors who just scratch their heads. I found out what i had on the internet!!! My breakouts occur seasonally. I also suffer from Discoid eczema on my legs and arms. The hand and foot eczema is worse in the Spring when the pollen comes out. The Discoid eczema starts in the winter and carries on through the spring until the pollen goes away. I find that bronzing (tanning beds) help my arm and leg eczema disappear, but the hand and foot one just has to take it’s course. It sucks!!!! And i am forever looking for cures.

    • I just went to my urgent care doc thinking I was going to scratch my foot off… She diagnosed it as dyshydrotic eczema and sent me home with a strong steroid cream. Said to use it 2x/day for 2 weeks and it should be gone. If it isn’t, I’m supposed to start a round of Prednisone. 24 hours on the cream and I no longer itch!!!!! 🙂 Good luck finding a cure, but I suggest this route!

  11. I would say treat the patient with an oral anti-fungal to rule out a fungal infection; this is usually quicker than waiting for culture results. But from the looks of it I would say pustular psoriasis or dyshidrosis.

  12. Wow…I’m dealing with this right now as I type =)Dyshidrotic Eczema and it sucks I’ve been dealing with it for like 3 or 4 years every since I moved to Puerto Rico it has gotten worse…I would love to know what is the general cause for it and if there is a cure so that it will stop reappearing as of right now I’m applying Betamethasone Dipropionate and Ketoconazole and trying to do everything and anything to get rid of it…ugh…any other suggestions…I have pics too.

  13. I had never had a skin condition and was freaked when I developed exactly what the images showed, maybe even a little worse… I am Australian 26 male, and moved to Glasgow, Scotland for work at 23-24 years of age. After about 6 months of a very stressful job, and just moving into a new flat. I developed the lumps etc on the palms of my hands and sides of my fingers. Made me very self conscious… I would moisturise daily, as it helped disguise it, especially when it pealed. I soon noticed it on the feet and did the same… The Doctors never knew what it was a prescribed fungal cream that irritated it, like it was fighting back…

    I thought I had an STD, even HIV or Aids. But that wasn’t the case after getting checked several times…

    I left the stressful job and returned to Australia… I still have a mild condition on the feet, however the hands quickly returned to 99% normality and is the same to this date.

    I recommend keep the affected areas as dry as possible. I think the dry weather in Australia has helped clear up my hands and wearing shoes all the time, means the feet have not cleared up.

    I don’t believe it is not contagious, as how would I have developed this out of the blue. I moved from one Flat to a Hotel then a brand new flat.. I am convinced I got it from the Hotel.

    However, I think we would all have it, if that was the case.

  14. I had such problems into my both hands and foot.
    I went to dr but they have no final medicine to cure. So I just brought one old Ayurvedic book and find out this deasease. I have started blood-purifire tablets and some gugal(one type of tree’s gum). I started it for last 5 Years, and till today, I have only 5%. But during winter its come normally.I don’t know the real medicine,but normally I feel better than past.Thanks.

  15. I have this. I have been treated with steroid cream for Dishydroic Ezcema, anti viral pills for herpetic whitlow, and anti fungal ointment for T. Pedia. The anti fungal ointment worked best, but after 2+ years, I still have it….It itches like crazy, hot water irritates it, stress and sugar cause flare ups, I scratched the bottom of my foot on concrete sooo bad I ended up with a secondary systemic blood infection. Since I was treated for that with levofloxacin the skin rashes have been a little more bearable. Everyone in the house I used to live in has Fungus feet, I treat mine more diligently so I ended up with more aggressive outbreaks. Hydrogen Peroxide works very well. But I can not quite get rid of it. Everyone else has rashes isolated to their feet, mine is on my hands, too. I have tiny blisters that form in clusters. The blisters have little black dots. They look like fish eggs. I wear sandles in my new home all the time and no one here has it, but me. I want it gone!

  16. Woops as I was saying I think its spreadible because when I pop one and the juce inside gets spread around or something like that well more pop up in that area so dont pop or break skin mo mater how itchy they are. I siggest that you wash hands and put healing lotion on. I also belive that it is contagious because of how many people have it. And once you got it it dont go away you just learn how to deal with it. I TELL YA DONT iRRITATE AND SCRACH CAUSE IT SPREADS AND FOR YOU FEET IRS ALL ABOUT THE CLEAN DRY SOCKS

  17. I understand that this is dyshidrosis – It flares up for me in summer – possibly when my hands get more sweaty. I find Tea Tree Oil undiluted works – apply it for a few days, and then these generally disappear. They eventually come back again though.

  18. my 2 year old son get this on his feet like eeverything month and a little bit on his hands his pediatrician told me it was herpectic excema and he would have it for the rest of his life and it will come n go….

  19. It is unfortunate but you have herpetic whitlow my friend. Whatever doctor treated you was correct. If first sign is itching , then small boils, finally crusting over, then you have it.

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