The palm of the hand

Contributed by Dr Jean Watkins, a sessional GP in Hampshire.

Skin creases in atopic eczema

Whatever we may believe about reading palms, careful inspection of the palms of the hand in the surgery may shed light on a number of diagnoses. As in this patient with atopic eczema, the palmar skin creases on both hands are deeper and more marked than normal (hyperlinearity).

A number of studies have shown that these changes are more common in patients with atopic eczema than control patients with dry skin. These signs may also occur in patients with ichthyosis vulgaris.

Dermatitis of the hands

Patients with atopic eczema have a genetic basis for their hand dermatitis, but there is an increased risk for any patients who frequently immerse their hands in water, or are in contact with irritant substances. Some may be allergic to substances with which they are in contact while others, like this patient, have flares at the time of stress.

The patient should be advised to wear cotton-lined gloves when in contact with water or irritants, to apply emollients frequently and use topical corticosteroids to reduce the inflammation.

Tinea manuum

Tinea manuum is often misdiagnosed as dermatitis but, as in this case, it is usually unilateral. The patient notices a gradual area of dry, itchy, peeling skin on the palm and a 'powdery filling' in the skin creases. Sometimes blisters form. Skin scrapings for microscopy and culture should confirm the diagnosis of the fungal infection.

Patients may have other affected areas.

A topical antifungal preparation such as econazole or terbinafine will normally clear the condition but in widespread cases or if the nails are involved, an oral antifungal agent may be required.

Psoriasis of the palms

Psoriasis on the palms may also be misdiagnosed as dermatitis or confused with keratoderma. Clearly demarcated, thick, red scaly patches, often with deep, painful cracks are seen. If a search is made there are usually other signs, such as plaques on the extensor surfaces of the elbows and knees, the scalp or nail changes.

Frequent emollients may help to soften the skin and reduce the risk of fissures, together with a keratolytic such as salicylic acid or urea cream. Topical steroids, coal tar preparations, calcipotriol, acitretin, methotrexate or PUVA may also be used.

Pustular psoriasis of the palms

Some patients develop crops of sterile blisters as well as thickened, scaly patches of skin on the hands. The feet are also often similarly affected. The condition may persist for years, causing considerable discomfort and interfering with the patient's quality of life.

This particular type of pustular psoriasis is more common in current or ex-smokers and patients should be advised to quit.

Treatment of pustular palmar psoriasis is the same as for straightforward palmar psoriasis.

Palmar keratoderma

Palmar keratoderma presents with a thickening hyperkeratosis and often a yellowish discolouration of the skin of the palms and the soles of the feet. It may cause discomfort or interfere with manual dexterity.

The condition may be genetically inherited or associated with inflammatory skin conditions, infections, medications, myxoedema or malignancy.

Treatment involves the plentiful use of emollients, keratolytics, topical retinoids, calcipotriol or systemic retinoids such as acetretin.

Hand, foot and mouth disease

This child presented with a rash on both hands of oval, yellowish vesicles surrounded by erythema. She had been a little off-colour and off her food in the last few days. On examination she had a similar rash on her feet and some small ulcers in the mouth.

The mother was reassured that hand, foot and mouth disease has nothing to do with the animal disease and would resolve spontaneously within a few days.

The condition is caused by coxsackie virus A16, has an incubation time of three to five days and is very infectious.

Erythema multiforme

Erythema multiforme (EM) often develops as a rash on the palms of the hands. These reddish, annular lesions have a slightly raised central area typical of target lesions.

Sometimes blisters will form which, if severe and widespread would suggest the more serious Stevens-Johnson syndrome.

The rash is symptomless or slightly itchy. The condition usually settles spontaneously in a few weeks. If necessary, oral antihistamines or topical corticosteroids may help to relieve symptoms. EM is due to a reaction to an infection or medication.


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