What is the diagnosis and treatment for palmer erythema?

Palmer Erythema: Diagnosis and Treatment

Palmer erythema is primarily a clinical sign of underlying physiological or pathological conditions rather than a disease itself, requiring identification and treatment of the underlying cause for proper management. 1

Diagnostic Approach

Clinical Presentation

• Redness of the palms, typically involving:
  • Thenar and hypothenar eminences
  • Palmar aspects of fingers
  • Sometimes accompanied by plantar (sole) erythema

Classification of Palmer Erythema

Primary (Physiological) Causes:

• Hereditary (Lane's disease/Erythema Palmare Hereditarium)
  • Autosomal dominant transmission
  • Present since birth or appearing later in life
  • Affects multiple family members 2, 3
• Pregnancy-related (occurs in ~30% of pregnant women)
• Idiopathic (diagnosis of exclusion)

Secondary (Pathological) Causes:

1. Hepatic Disorders:

   • Cirrhosis (23% of patients)
   • Wilson's disease
   • Hereditary hemochromatosis

2. Autoimmune Conditions:

   • Rheumatoid arthritis (>60% of patients) 4
   • Associated with favorable prognosis in RA

3. Endocrine Disorders:

   • Thyrotoxicosis (up to 18% of patients)
   • Diabetes mellitus (4.1% of patients)

4. Infectious Diseases:

   • Early gestational syphilis
   • Human T-lymphotrophic virus-1-associated myelopathy

5. Medication-Induced:

   • With hepatic damage: amiodarone, gemfibrozil, cholestyramine
   • Without hepatic damage: topiramate, albuterol
   • Certain chemotherapy agents 5

6. Neoplastic Conditions:

   • Brain tumors (15% of patients with primary or metastatic brain neoplasms)
   • Solid tumors with increased angiogenic factors or estrogens

7. Other Causes:

   • Smoking
   • Chronic mercury poisoning
   • Atopic diathesis

Diagnostic Workup

1. Detailed History:

   • Family history (for hereditary cases)
   • Medication review
   • Symptoms of underlying conditions
   • Onset and duration of erythema

2. Physical Examination:

   • Distribution pattern of erythema
   • Associated skin findings
   • Signs of systemic disease (jaundice, spider angiomas, etc.)

3. Laboratory Tests (based on suspected etiology):

   • Liver function tests
   • Thyroid function tests
   • Blood glucose levels
   • Rheumatoid factor
   • Serological tests for infectious causes

4. Dermoscopy:

   • In hereditary cases: red structureless areas with arborizing vessels running parallel along follicular openings 3

Treatment Approach

1. Primary Palmer Erythema:

   • No specific treatment indicated for hereditary or idiopathic forms 1
   • Patient reassurance about benign nature

2. Secondary Palmer Erythema:

   • Treatment focuses on the underlying condition 1

   • Liver Disease:

     • Management of cirrhosis or specific hepatic disorder
     • Discontinuation of hepatotoxic medications

   • Rheumatoid Arthritis:

     • Standard RA treatment protocols
     • Note: presence of palmer erythema in RA is associated with better prognosis 4

   • Medication-Induced:

     • Discontinuation of causative medication if possible 1
     • Consider alternative medications

   • Endocrine Disorders:

     • Treatment of thyrotoxicosis or diabetes management

   • Infectious Causes:

     • Appropriate antimicrobial therapy

   • Neoplastic Conditions:

     • Treatment of underlying malignancy

3. Symptomatic Management (if needed):

   • Moisturizers for dryness
   • Mild topical corticosteroids for inflammation or discomfort

Clinical Pearls and Pitfalls

• Palmer erythema is often overlooked but can be an important diagnostic clue to systemic disease 1
• Distinguish from other palmar conditions like hand-foot skin reaction from chemotherapy agents 6
• Palmer erythema in cirrhosis is related to abnormal serum estradiol levels 1
• In rheumatoid arthritis, palmer erythema is associated with less ulnar deviation of fingers and higher hemoglobin levels 4
• Hereditary palmer erythema (Lane's disease) affects women almost three times more than men 3
• Don't confuse with palmar-plantar erythrodysesthesia syndrome (PPES) from chemotherapy, which presents with pain, swelling, and tingling in addition to erythema 6

Remember that palmer erythema itself is typically not harmful, but identifying and treating the underlying cause is essential for proper management.