What are the causes of palmar erythema?

Causes of Palmar Erythema

Palmar erythema can be caused by numerous physiological and pathological conditions, with the most common etiologies being liver disease, pregnancy, rheumatoid arthritis, thyroid disorders, and certain medications or chemotherapy agents. 1

Physiological Causes

• Hereditary/Primary
  • Lane's disease (hereditary palmar erythema) - autosomal dominant condition affecting women almost three times more than men 1, 2
  • Idiopathic - diagnosis of exclusion when no underlying cause is identified 3
  • Pregnancy - occurs in approximately 30% of pregnant women due to hormonal changes 3
  • Aging - can appear as part of normal aging process 4

Pathological Causes

Hepatic Disorders

• Liver cirrhosis - present in approximately 23% of patients with cirrhosis, regardless of etiology 3
• Wilson disease - rare genetic disorder with copper accumulation 3
• Hereditary hemochromatosis - iron overload disorder 3

Autoimmune Conditions

• Rheumatoid arthritis - occurs in >60% of patients and is associated with:
  • Less ulnar deviation of fingers
  • Higher hemoglobin levels
  • Generally favorable prognosis 1, 5

Endocrine Disorders

• Thyrotoxicosis - present in up to 18% of patients 3
• Diabetes mellitus - occurs in approximately 4.1% of patients (more common than necrobiosis lipoidica diabeticorum) 3

Infectious Diseases

• Early gestational syphilis 3
• Human T-lymphotrophic virus-1-associated myelopathy 3

Medication-Induced Causes

• With hepatic damage:

  • Amiodarone
  • Gemfibrozil
  • Cholestyramine 3

• Without hepatic damage:

  • Topiramate
  • Albuterol (salbutamol) 3
  • Chemotherapy agents - particularly causing palmar-plantar erythrodysesthesia syndrome (PPES) 6
    • 5-fluorouracil (6%-34%)
    • Capecitabine (50%-60%)
    • Doxorubicin (22%-29%)
    • PEGylated liposomal doxorubicin (40%-50%)
    • Docetaxel (6%-58%)
    • Cytarabine (14%-33%)

• Hand sanitizers - can cause contact dermatitis presenting as palmar erythema, especially with frequent use 7

Neoplastic Conditions

• Brain neoplasms - both primary and metastatic (15% of patients)
• Solid tumors - due to increased levels of angiogenic factors and estrogens 3

Environmental Causes

• Smoking
• Chronic mercury poisoning 3
• Erythema ab igne - can mimic palmar erythema 3

Diagnostic Approach

When evaluating palmar erythema, consider:

1. Detailed history:

   • Family history (for hereditary cases)
   • Medication review
   • Symptoms of underlying conditions 1
   • Environmental exposures

2. Physical examination:

   • Distribution pattern of erythema
   • Associated skin findings
   • Signs of systemic disease (jaundice, spider angiomas) 1

3. Laboratory tests based on suspected etiology:

   • Liver function tests
   • Thyroid function tests
   • Blood glucose levels
   • Rheumatoid factor
   • Serological tests for infectious causes 1

Management Considerations

Treatment should focus on addressing the underlying condition:

• For hereditary or physiological causes, no specific treatment is required
• For medication-induced cases, discontinue the offending agent when possible
• For systemic diseases, treat the primary condition according to standard protocols 1, 3

Symptomatic management may include moisturizers for dryness and mild topical corticosteroids for inflammation or discomfort in selected cases 1.