What are the treatment options for a swollen palm?

Treatment of Swollen Palm

For a swollen palm, immediately identify the underlying cause through targeted clinical assessment, then initiate cause-specific treatment: hand dermatitis requires barrier protection and topical corticosteroids, palmar psoriasis responds to high-potency topical steroids under occlusion, chemotherapy-induced hand-foot syndrome needs dose interruption and supportive care, and inflammatory arthropathy requires systemic disease management. 1, 2, 3

Immediate Diagnostic Approach

Key Clinical Features to Identify

Dermatologic causes:

• Vesicles with erythema and pruritus suggest hand dermatitis (irritant or allergic contact dermatitis, dyshidrotic eczema) 1, 4
• Erythematous plaques with silvery scale indicate palmar psoriasis 2
• Painful erythema with dysesthesia and tingling developing days to weeks after chemotherapy suggests hand-foot syndrome (palmar-plantar erythrodysesthesia) 3
• White papules appearing after water exposure that resolve with drying indicate aquagenic syringeal keratoderma 5, 6

Non-dermatologic causes:

• Joint swelling with tenderness suggests inflammatory arthropathy or infection 3
• Post-surgical swelling near vascular access sites may indicate hematoma, infection, or venous outflow obstruction 3
• Painless soft tissue swelling over proximal interphalangeal joints in adolescents suggests pachydermodactyly 7

Treatment Algorithm by Cause

Hand Dermatitis (Most Common Cause)

First-line management (initiate immediately):

• Identify and eliminate irritants: avoid harsh soaps, hot water, frequent hand washing, and disinfectant wipes 1
• Use lukewarm water only and pat hands dry gently rather than rubbing 1, 4
• Apply fragrance-free moisturizer immediately after every hand washing using two fingertip units for adequate coverage 1, 4
• Implement "soak and smear" technique nightly: soak hands in plain water for 20 minutes, then immediately apply thick moisturizer to damp skin for up to 2 weeks 1, 4

Topical anti-inflammatory therapy:

• Apply topical corticosteroids for active flares when conservative measures fail 1, 4
• For severe or recalcitrant cases after 6 weeks: consider stronger topical steroids, phototherapy, or systemic therapy 1

Occupational modifications:

• Use cotton glove liners under protective gloves if occupational exposure is unavoidable 1, 4
• Apply water-based moisturizers under gloves (oil-based products break down latex and rubber) 1, 4
• Never apply gloves when hands are still wet from washing or sanitizer 1, 4

Palmar Psoriasis

First-line therapy:

• High-potency topical corticosteroids under occlusion to enhance penetration 2
• Combination therapy with vitamin D analogues and topical corticosteroids provides enhanced efficacy 2

Second-line options for inadequate response:

• Targeted phototherapy with 308-nm excimer laser for localized disease 2
• Soak PUVA therapy 2-3 times weekly for several months 2

Systemic therapy for severe disease:

• Oral acitretin is highly effective and often considered first-line systemic therapy for palmar psoriasis (caution in women of childbearing potential due to 3-year post-dosing pregnancy restriction) 2
• Methotrexate is effective in a significant proportion of patients with palmoplantar psoriasis 2
• Cyclosporine is effective but use with caution due to potential nephrotoxicity 2

Chemotherapy-Induced Hand-Foot Syndrome

Grade 1-2 (papules/pustules covering 10%-30% body surface area):

• Continue chemotherapy at current dose and monitor for severity changes 3
• Initiate oral antibiotic for 6 weeks: doxycycline 100 mg twice daily OR minocycline 50 mg twice daily OR oxytetracycline 500 mg twice daily 3
• Apply topical low/moderate potency steroid 3
• Reassess after 2 weeks: if reactions worsen or do not improve, proceed to next step 3

Grade ≥3 or intolerable Grade 2 (papules/pustules covering >30% body surface area):

• Interrupt chemotherapy until Grade 0/1 3
• Obtain bacterial/viral/fungal cultures if infection is suspected 3
• Continue oral antibiotic for 6 weeks (same regimen as above) 3
• Add systemic corticosteroids: prednisone 0.5-1 mg/kg body weight for 7 days 3
• Consider isotretinoin at low doses (20-30 mg/day) after dermatology consultation 3

Post-Surgical or Vascular Access-Related Swelling

Minor physiological swelling (first week post-procedure):

• Elevate hand and provide reassurance 3
• Rest the arm to prevent further swelling 3

Persistent swelling requiring intervention:

• Perform noninvasive ultrasound examination to exclude hematoma, infection, or venous outflow obstruction 3
• If stenosis is found, treat with balloon angioplasty 3
• If hematoma is compromising the lumen, treat surgically 3

Inflammatory Arthropathy

Hand osteoarthritis with swelling:

• Local application of heat (paraffin wax, hot pack) before exercise 3
• Topical NSAIDs and capsaicin are effective and safe for hand osteoarthritis 3
• Oral paracetamol (up to 4 g/day) is the first-choice oral analgesic 3
• Intra-articular injection of long-acting corticosteroid for painful flares 3

Critical Pitfalls to Avoid

• Do not use superglue to seal fissures or vesicles 1, 4
• Avoid washing hands with dish detergent or other known irritants 1, 4
• Do not apply gloves when hands are still wet from hand washing or sanitizer 1, 4
• Avoid prolonged topical corticosteroid use without monitoring for steroid-induced skin barrier damage 1, 4
• Do not increase glove occlusion duration without underlying moisturizer application 1, 4

When to Refer to Dermatology

• Suspected allergic contact dermatitis requiring patch testing 1, 4
• No improvement after 6 weeks of conservative treatment 1, 4
• Change in baseline pattern of dermatitis 1, 4
• Consideration of phototherapy or systemic therapy in recalcitrant cases 1, 4