Differential diagnoses: Conditions of the hands

Dr Nigel Stollery compares four presentations and offers clues for their diagnosis including vasculitis, erythema multiforme, cutaneous lupus erythematosus, palmar erythema.

Vasculitis

Presentation

  • Rare condition, in which there is inflammation of blood vessels
  • 3,000 cases in the UK per year
  • Can be primary or secondary
  • 45% idiopathic, 20% secondary to infection, 15% drug induced
  • May be associated with systemic symptoms, such as arthralgia and lethargy

Management

  • Skin biopsy can be useful if differentiating between types
  • Investigations aimed at finding underlying cause, which directs treatment
  • Urinalysis can be helpful in detecting renal involvement
  • Immunosuppressants may be required in the longer term
  • Newer biologicals also helpful

Erythema multiforme

Presentation

  • Hypersensitivity reaction with trigger, such as herpes simplex infection
  • Rash forms target or iris lesions
  • May affect mucus membranes
  • Acute onset most commonly in young adults aged 20-40 years
  • Usually self limiting
  • May recur following further herpes outbreaks

Management

  • If diagnosis in doubt, skin biopsy can be helpful
  • Symptomatic treatment with antihistamines, analgesia
  • Rash usually clears in two to three weeks without scarring
  • In recurrent cases associated with herpes simplex, daily aciclovir can be helpful

Cutaneous lupus erythematosus

Presentation

  • Most commonly affects women aged 20-50 years
  • Autoimmune condition
  • Often exacerbated by UV light
  • May be more severe in smokers
  • Often leaves postinflammatory hyperpigmentation
  • May be localised or widespread
  • Often leaves scars
  • Other affected areas include face, neck and rarely, palms
  • May cause scarring alopecia

Management

  • Treatment includes topical steroids, calcineurin inhibitors, antimalarials, oral steroids
  • Avoiding UV light is important
  • Camouflage can be helpful

Palmar erythema

Presentation

  • Reddening of palms and fingers
  • Combination of underlying processes, including increased cardiac output, localised inflammation, capillary dilation and high cord estrogen levels
  • Seen in 30% of pregnant women, 23% of patients with cirrhosis, 60% of patients who have rheumatoid arthritis
  • Associated with certain drugs, smoking, polycythaemia, sarcoidosis, systemic lupus erythematosus

Management

  • No specific treatment
  • May improve when underlying condition is treated
  • Dr Stollery is a GP in Kibworth, Leicestershire, and clinical assistant in dermatology at Leicester Royal Infirmary.

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