Management of NF1 Cutaneous Neurofibromas on the Palms of the Hands
Cutaneous neurofibromas (cNFs) on the palms of the hands in NF1 patients should be treated with surgical excision, laser removal, or electrodesiccation based on the patient's preference and local expertise, as these approaches have demonstrated high patient satisfaction with minimal scarring and discomfort. 1
Understanding Palmar Cutaneous Neurofibromas in NF1
Cutaneous neurofibromas are benign tumors that:
- Occur in >99% of adults with NF1, making them the most common tumor manifestation
- Often begin to appear during puberty and increase in number with age
- Show periods of rapid growth during puberty and pregnancy
- Can cause significant morbidity through cosmetic burden, tenderness, bleeding, and itching
- Negatively impact quality of life, affecting emotions, physical symptoms, and functioning
While cNFs rarely undergo malignant transformation, they can significantly impact quality of life, particularly when located in visible or functionally important areas like the palms of the hands.
Treatment Options for Palmar Neurofibromas
1. Surgical Excision
- Best for targeting a modest number of symptomatic cNFs
- Leaves a scar
- May be preferred for larger or deeper palmar neurofibromas
2. Laser Removal
- CO2 laser ablation and photocoagulation have been used for decades
- A retrospective study of 106 NF1 patients showed >90% satisfaction with CO2 laser treatment
- Minimal pain, good healing, and few complications (bleeding, scarring, infection)
- Requires anesthesia for removing 50-100 lesions per session
- 755 nm alexandrite laser with suction has been shown to be fast and less painful 2
3. Electrodesiccation
- Dehydrates and denatures the dermis
- A retrospective study of 97 NF1 individuals showed a mean of 450 lesions removed per session
- High patient satisfaction with minimal scarring and minor discomfort
- Radiofrequency needle coagulation has shown efficacy for small (2-4 mm) cNFs 2
4. Newer Minimally Invasive Options
- Intratumoral injection of deoxycholate (10 mg/mL) has shown promise for small cNFs
- Fast and less painful than some laser treatments 2
Treatment Selection Algorithm
Assess the characteristics of the palmar neurofibromas:
- Size (small: <5mm, medium: 5-10mm, large: >10mm)
- Number of lesions
- Depth (superficial vs. deep)
- Symptoms (pain, tenderness, functional limitation)
For small, superficial, multiple lesions:
- Consider electrodesiccation or laser removal
- Alexandrite laser or radiofrequency for minimal pain
For medium to large, symptomatic, or deeper lesions:
- Consider surgical excision
- Balance between functional preservation and cosmetic outcome
For numerous small lesions:
- High-quantity (HQ) electrosurgical removal allows hundreds of tumors to be removed per session 3
Important Considerations for Palmar Lesions
- Functional impact: Treatment of palmar lesions must prioritize hand function preservation
- Pain management: Palmar procedures may be more painful due to high nerve density
- Recovery time: Consider impact on daily activities requiring hand use
- Follow-up: Additional cNFs will appear over time, requiring repeated treatments 1
Pitfalls and Caveats
Diagnostic confusion: Ensure proper diagnosis, as palmar lesions could be glomus tumors, which are also associated with NF1 and present with localized tenderness, severe paroxysmal pain, and sensitivity to cold 1
Insurance coverage: Treatment may be incorrectly classified as cosmetic rather than medically necessary, creating barriers to access 3
Recurrence: New cNFs will develop over time, requiring ongoing management
Functional limitations: Overly aggressive treatment on the palms could impair hand function
Scarring concerns: Palmar skin has unique characteristics that can affect healing and scarring outcomes
Remember that while these treatments can improve appearance and symptoms, they are not curative for the underlying NF1 condition. Regular monitoring for other NF1 manifestations should continue as part of comprehensive care.