What is the appropriate treatment for a swollen hand?

Treatment of a Swollen Hand

The appropriate treatment for a swollen hand depends critically on whether the swelling is unilateral or bilateral, as unilateral swelling requires urgent evaluation to exclude upper extremity deep vein thrombosis (UEDVT), which can lead to pulmonary embolism and death. 1

Immediate Assessment: Rule Out Life-Threatening Causes

Unilateral vs. Bilateral Swelling

• Unilateral hand swelling indicates an obstructive process at the level of the brachiocephalic, subclavian, or axillary veins and requires urgent evaluation. 1
• Perform urgent duplex ultrasound to exclude UEDVT, which accounts for up to 10% of all DVTs. 1
• Bilateral swelling suggests systemic causes (heart failure, renal disease, hypoproteinemia) rather than vascular obstruction. 1

Critical Red Flags Requiring Emergency Evaluation

• New findings of ischemia in patients with arteriovenous fistulas (AVF) require emergent referral to a vascular surgeon. 2
• Signs of infection (erythema, warmth, systemic symptoms) suggesting cellulitis or sepsis from Streptococcus pyogenes. 3
• Severe pain with passive motion, suggesting compartment syndrome or intrinsic plus hand contracture. 4

Diagnostic Imaging Algorithm for Unilateral Swelling

First-Line Imaging

• Duplex ultrasound of the upper extremity is the initial imaging modality of choice, with sensitivity and specificity above 80% for UEDVT. 1
• Perform grayscale imaging to directly visualize echogenic thrombus and assess vein compressibility; lack of compression indicates acute or chronic thrombus. 1
• Use Doppler assessment to evaluate blood flow patterns, cardiac pulsatility, and respiratory variation; dampening of these waveforms indicates central venous obstruction. 1
• Test for central vein collapse with rapid inspiration ("sniffing maneuver"); impaired collapse suggests central obstructive process such as thrombus, mass, or stricture. 1

Advanced Imaging When Indicated

• If central venous stenosis is suspected (particularly in dialysis patients), perform venography or CT venography, as ultrasound has limitations in the thoracic cavity. 1
• In dialysis patients, swelling persisting beyond 2 weeks after access placement requires venography or other noncontrast study to evaluate central veins. 1

Treatment Based on Etiology

If UEDVT Confirmed

• Initiate therapeutic anticoagulation immediately following standard DVT treatment protocols. 1
• Investigate lower extremities if UEDVT is confirmed without local cause, as correlation between upper and lower extremity DVT exists. 1

If Related to Dialysis Access (AVF/Graft)

• Persistent swelling of the hand or arm should be expeditiously evaluated and the underlying pathology corrected. 2
• Minor swelling is normal postoperatively after AVF placement and disappears within the first week; treat with hand elevation and patient reassurance. 2
• Persistent swelling beyond 2-6 weeks requires further attention to exclude major outflow obstruction, hematoma, infection, and venous hypertension. 2
• If stenosis is found on ultrasound, treat with balloon angioplasty. 2
• Persistent hand edema usually follows a side-to-side anastomosis and invariably results from downstream stenosis forcing flow through venous collaterals; treat early by ligation of tributaries. 2

If Hand Dermatitis (Irritant or Allergic Contact Dermatitis)

• Hand dermatitis can present with acute edema, erythema, and vesicle formation. 2, 5
• Identify and avoid irritants (detergents, frequent hand washing, hot water) and allergens; use lukewarm or cool water for hand washing. 5
• Pat dry hands gently rather than rubbing. 5
• Apply moisturizer immediately after hand washing, using two fingertip units for adequate hand coverage. 5
• Use soaps/synthetic detergents without allergenic surfactants, preservatives, fragrances, or dyes, and choose products with added moisturizers. 2, 5
• Apply topical steroids to mitigate flares when conservative measures fail. 5
• For severe dryness, use "soak and smear" technique: soak hands in plain water for 20 minutes followed by immediate moisturizer application nightly for up to 2 weeks. 2, 5
• Individuals with suspected allergic contact dermatitis should be patch tested to evaluate for a clinically relevant causal allergen. 2, 5

If Chemical Exposure (Acid Burns)

• Immediately irrigate the affected area with copious amounts of water for at least 15-20 minutes to dilute and remove the acid. 6
• Use lukewarm or cool water rather than hot water to prevent additional skin barrier damage. 6
• Pat dry hands gently rather than rubbing to avoid further irritation. 6

General Edema Management (When Serious Causes Excluded)

• Elevation, compression, and active exercise are the primary methods of controlling edema in the hand. 7
• Early intervention and treatment of the edematous hand can prevent subsequent hand dysfunction and sequelae. 7

Pharmacological Management for Pain

First-Line Analgesics

• Topical NSAIDs are the first-choice pharmacological treatment for mild to moderate pain, given their superior safety profile compared to systemic agents. 1
• For hand osteoarthritis with swelling, local treatments are preferred over systemic treatments, especially for mild to moderate pain and when only a few joints are affected; topical NSAIDs and capsaicin are effective and safe treatments. 2

Systemic Analgesics When Needed

• Oral NSAIDs should be used at the lowest effective dose and for the shortest duration in patients who respond inadequately to topical agents. 2
• In patients with increased gastrointestinal risk, non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor should be used. 2
• NSAIDs can cause serious side effects including increased risk of heart attack, stroke, bleeding, ulcers, and gastrointestinal perforation. 8

Follow-Up Protocol

Short-Term Follow-Up

• Reassess within 48-72 hours to evaluate response to initial management and ensure no progression of symptoms. 1
• Patients with AVF should be evaluated no later than 6 weeks after access placement to detect early access dysfunction, particularly delays in maturation. 2

Long-Term Follow-Up

• Schedule formal evaluation at 6 weeks if edema persists, to detect delayed complications or underlying pathology maturation. 1
• For recalcitrant hand dermatitis not responding to initial treatments after 6 weeks, refer to dermatology for patch testing and consideration of stronger topical steroids, phototherapy, or systemic therapy. 5

Common Pitfalls to Avoid

• Do not dismiss unilateral swelling as benign, as it indicates obstruction requiring urgent evaluation, unlike bilateral swelling which suggests systemic causes. 1
• Do not delay irrigation after chemical exposure. 6
• Recognize that catheter-associated UEDVT may be asymptomatic, manifesting only as catheter dysfunction or incidental imaging finding. 1
• For hand dermatitis, avoid applying gloves when hands are still wet from hand washing or sanitizer, using very hot water for hand washing, washing hands with dish detergent or other known irritants, and increased duration of glove occlusion without underlying moisturizer. 5