Evaluation and Management of Palmar Nodules in Children
Palmar nodules in children most commonly represent benign self-limited conditions including cutaneous mastocytosis (mastocytomas), idiopathic palmoplantar eccrine hidradenitis, or subcutaneous palisading granulomas, and should be evaluated based on clinical presentation, associated symptoms, and characteristic physical findings to guide appropriate management.
Initial Clinical Assessment
Key Distinguishing Features to Identify
Cutaneous Mastocytosis (Mastocytomas):
- Solitary or few red-brown to yellow nodules measuring several centimeters in diameter 1
- Positive Darier's sign (wheal and flare formation after stroking the lesion) 1
- May present with erythema, swelling, or blister formation when rubbed 1
- Associated symptoms include pruritus, flushing (up to 36% of cases), and dermatographism 1
- Palms are less commonly affected than trunk and extremities 1
- Typically present at birth or develop within one week in solitary mastocytomas 1
Idiopathic Palmoplantar Eccrine Hidradenitis:
- Sudden onset of painful, tender erythematous-violaceous nodules 2, 3
- Bilateral palmoplantar involvement possible 2
- Associated with low-grade fever in some cases 2, 3
- History of hyperhidrosis or intense physical activity preceding onset 3
- Self-limited with recurrent episodes typical 2
- Resolution typically occurs within 7 days 3
Subcutaneous Palisading Granulomas (Benign Rheumatoid Nodules):
- Painless, nonmobile subcutaneous nodules 4
- Lower extremities most common, but upper extremities and scalp can be affected 4
- Peak age 4-5 years (range 10 months to 15 years) 4
- New lesions develop in nearly two-thirds of patients during follow-up 4
- Spontaneous involution is typical 4
Diagnostic Workup
When to Perform Skin Biopsy
Biopsy is indicated when:
- Clinical diagnosis is uncertain 1, 3
- Lesions persist beyond expected timeframe for self-limited conditions 3
- Atypical features are present 5
Expected histopathologic findings:
- Mastocytomas: Increased mast cells in papillary dermis 1
- Palmoplantar hidradenitis: Dense neutrophilic infiltrates localized to eccrine units with neutrophilic abscesses 2, 3
- Palisading granulomas: Same histology as rheumatoid nodules in adults 4
Laboratory Evaluation
Limited laboratory testing is needed:
- Most cases require no laboratory studies 4
- Consider ESR only if systemic symptoms suggest rheumatologic disease 4
- Elevated ESR warrants long-term follow-up for potential rheumatoid arthritis development 4
Management Approach
Cutaneous Mastocytosis (Mastocytomas)
Conservative management is appropriate:
- Most cases resolve spontaneously by puberty 1
- Systemic symptoms and visceral involvement are rare 1
- Monitor for acute mast cell activation events (flushing, wheezing, hypotension) 1
- Reassure parents that diarrhea and systemic disease are uncommon 1
Idiopathic Palmoplantar Eccrine Hidradenitis
Symptomatic treatment only:
- Oral NSAIDs for pain control 3
- Rest from physical activity 3
- Lesions resolve spontaneously within 7 days 3
- Reassure families about benign, self-limited nature 3
Subcutaneous Palisading Granulomas
Observation is preferred over intervention:
- Excisional biopsy should be avoided unless diagnosis is uncertain 4
- Spontaneous involution is expected 4
- Avoid radiation therapy or topical steroid therapy 4
- Long-term follow-up recommended as new lesions develop in two-thirds of cases 4
Critical Pitfalls to Avoid
Do not confuse with child abuse:
- Palm bruising in infants represents a distinct pattern of physical abuse from forceful squeezing 6
- Bruising along palmar and interdigital creases differs from nodular lesions 6
- Bruising should prompt evaluation for occult injuries 6
Do not perform unnecessary interventions:
- Avoid surgical excision of benign rheumatoid nodules unless diagnosis uncertain 4
- Do not initiate systemic therapy for self-limited conditions 3
- Prevent unnecessary alarm in families by recognizing benign nature 3
Do not miss systemic disease associations: