Apart from the other well-recognised changes in the appearance of an individual with Down's syndrome, certain specific changes may be noticed in the hands.
The hands themselves tend to be small with short fingers, while the palmar creases are different from the norm in that, usually, there is just one single crease running straight across the palm and a second one that curves around the base of the thumb.
Burns to the palm of the hand
Although the hand is a small part of the whole body surface, burns of the palm pose a future threat as well as the considerable disability at the time of injury.
Oedema develops early, impairs movement and is thought to play a major part in the formation of contractures; hence the recommendation that the hands are kept elevated and properly splinted. Specialist advice is needed.
This patient sustained burns in a propane gas explosion. The burns were superficial, and after a few days the damaged skin could be peeled off. Normal healing followed.
Treatment of recalcitrant warts
In cases of patients with persistent multiple warts that fail to respond to conventional measures, it has been found that immunotherapy with the allergic contact sensitiser diphencyprone may be successful. However, it seems that over half the patients experienced adverse reactions.
The multiple warts on this man's hands responded well to the treatment but he developed a marked eczematous reaction as a result. Other possible reactions include painful blistering and pompholyx-like changes.
Granuloma annulare
The cause of this common condition is unknown. Isolated, well-defined red plaques develop, mainly on the backs of the hands and dorsum of the feet, appearing as a ring with central depression and a margin of flat topped papules. The papules are symptomless but may be tender if knocked.
This patient had a patch on the palm of his hand. The condition may clear spontaneously leaving no scars but in some cases may be more persistent. A clinical diagnosis can usually be made but, if necessary, biopsy will confirm the cause. Normally no treatment is required.
Hyperhidrosis
Excessive sweating may occur as a generalised problem that affects the whole body, or be localised.
The cause of hyperhidrosis is unknown but it seems to be related to over-activity of the body temperature regulator in the hypothalamus or the sympathetic nerves.
Antiperspirants, such as aluminium chloride, and avoidance of possible triggers did not help this patient. Iontophoresis, although helpful, did not give enough relief and so, eventually, she elected to have a sympathectomy.
Palmar wart
Viral warts are commonly seen. Those found on the palms and soles of the feet are usually due to the human papilloma virus and are most likely to develop in areas subject to trauma.
This patient had had the lesion for two years and had scratched the top of it to try to remove it. This had made an area of pin point bleeding in the centre of the sharply demarcated, round nodule, particularly obvious.
He had tried the use of topical irritants such as salicylic acid or podophyllum but decided to proceed to cryosurgery.
Dermatomyositis
Dermatomyositis is a rare autoimmune problem affecting the connective tissues, sometimes found in patients with an underlying malignancy or related to the use of certain drugs, such as penicillamine, statins or hydroxyurea.
This 60-year-old man presented with symptomless purplish patches, mainly on sun-exposed areas. He had similar patches on the backs of his hands, shins and upper parts of his feet. He also had the typical changes of ragged, erythematous nail folds and telangiectasia. Treatment was with oral prednisolone and careful follow-up.
Carpal tunnel syndrome
Carpal tunnel syndrome results from pressure on the median nerve as it lies in the carpal tunnel. It may be related to wrist trauma or sometimes myxoedema or rheumatoid arthritis. Other factors in its development may be repetitive movements, vibrations at the wrist or fluid retention.
Initially, patients complain of burning, itching or numbness on the thumb side of the palm, middle and index fingers. Symptoms first appear at night when lying with the wrists flexed. In well-established cases, as in this patient, wasting of the thenar eminence will be noted.
