What causes red and blotchy palms?

Red and Blotchy Palms: Differential Diagnosis and Clinical Approach

Red and blotchy palms (palmar erythema) can result from numerous physiologic, systemic, infectious, drug-related, or dermatologic causes, requiring systematic evaluation to identify potentially serious underlying conditions while avoiding unnecessary testing.

Initial Clinical Assessment

When evaluating red and blotchy palms, immediately assess for:

• Fever and systemic symptoms – If present with recent tick exposure, consider Rocky Mountain spotted fever (RMSF), which presents with maculopapular rash spreading to palms and soles 2-4 days after fever onset, with 5-10% mortality if untreated 1
• Recent chemotherapy exposure – Hand-foot syndrome (palmar-plantar erythrodysesthesia) causes redness, marked discomfort, swelling and tingling, occurring in 6-60% of patients on agents like capecitabine, 5-FU, or doxorubicin 1
• Vesicular lesions – In toddlers, hand-foot-mouth disease presents with small pink macules evolving to vesicles on palms and soles, though this distribution also occurs in drug reactions, ehrlichiosis, and syphilis 2
• Pregnancy status – Physiologic palmar erythema occurs in at least 30% of pregnant women due to alterations in skin microvasculature 3

Life-Threatening Causes to Rule Out First

Immediately consider these conditions with significant morbidity/mortality:

• Rocky Mountain spotted fever – Requires urgent doxycycline treatment; delay increases mortality from 5% to potentially fatal outcomes 1
• Ehrlichiosis – Presents with fever, headache, and rash involving palms/soles in 30% of adults and 60% of children, with 3% case-fatality rate 1
• Meningococcal infection – Can present with palmar rash and requires emergent treatment 2
• Infective endocarditis – Palmar rash may be an early sign requiring immediate evaluation 2

Common Secondary Causes by System

Hepatic Disease

• Liver cirrhosis – 23% of cirrhotic patients manifest palmar erythema due to abnormal serum estradiol levels 3
• Wilson disease and hereditary hemochromatosis – Rare neonatal liver diseases presenting with palmar erythema 3
• Drug-induced hepatotoxicity – Amiodarone, gemfibrozil, and cholestyramine cause palmar erythema with hepatic damage 3

Rheumatologic/Autoimmune

• Rheumatoid arthritis – Over 60% of patients exhibit palmar erythema, associated with favorable prognosis 3

Endocrine

• Thyrotoxicosis – Up to 18% of patients develop palmar erythema 3
• Diabetes mellitus – 4.1% of diabetic patients have palmar erythema, more common than necrobiosis lipoidica diabeticorum (0.6%) 3

Malignancy

• Brain neoplasms – 15% of patients with metastatic or primary brain tumors may have palmar erythema, postulated to be from increased angiogenic factors and estrogens 3

Infectious

• Early gestational syphilis – Treponema pallidum can present with palmar rash 2, 3
• HTLV-1-associated myelopathy – Associated with palmar erythema 3
• HIV, Hepatitis C, Chronic Hepatitis B – Red fingers syndrome (persistent redness on finger pulps) is typically secondary to these infections 4

Dermatologic Conditions

• Palmoplantar psoriasis – Presents with erythematous scaly and fissured hyperkeratotic patches affecting 40% of palmar surfaces, significantly impacting quality of life 1
• Palmoplantar pustulosis – Chronic recurrent inflammatory disease with sterile pustules, often triggered by smoking and upper respiratory infections 5
• Irritant or allergic contact dermatitis – Frequent hand washing (especially during COVID-19 precautions) causes irritant contact dermatitis; water temperature >40°C increases risk 1

Primary/Benign Causes

• Hereditary palmar erythema (Lane's disease) – Rare benign condition presenting as persistent erythema on thenar/hypothenar eminences, can be congenital or acquired, affects women three times more than men 6
• Idiopathic palmar erythema – Diagnosis of exclusion when no underlying cause identified 3

Systematic Diagnostic Algorithm

Step 1: Urgent evaluation if present:

• Fever + palmar rash + tick exposure → Treat empirically for RMSF with doxycycline 1
• Fever + systemic symptoms → Check CBC, hepatic transaminases, consider infectious workup 1

Step 2: Medication review:

• Recent chemotherapy → Diagnose hand-foot syndrome, initiate topical steroids and dose modification 1
• Drugs causing palmar erythema without hepatotoxicity: topiramate, albuterol 3
• Discontinue causative medication if possible 3

Step 3: Targeted laboratory evaluation based on clinical suspicion:

• Liver function tests, hepatitis panel (if hepatic disease suspected) 3
• Thyroid function tests (if thyrotoxicosis suspected) 3
• Rheumatoid factor, anti-CCP (if joint symptoms present) 3
• Fasting glucose, HbA1c (if diabetes suspected) 3
• RPR/VDRL (if syphilis risk factors present) 2, 3

Step 4: If no underlying cause identified:

• Consider hereditary palmar erythema, especially if family history present 6
• Dermoscopy shows red structureless areas with arborizing vessels running parallel along follicular openings 6
• No treatment indicated for primary palmar erythema 3

Critical Pitfalls to Avoid

• Do not wait for the classic triad (fever, rash, tick bite) before treating suspected RMSF – only a minority present with all three initially, and delayed treatment increases mortality 1
• Do not overlook malignancy – 15% of brain tumor patients have palmar erythema as an early sign 3
• Do not dismiss in pregnant patients – While 30% have physiologic palmar erythema, still evaluate for other causes if presentation is atypical 3
• Do not confuse hand-foot syndrome with hand-foot skin reaction – The former (from conventional chemotherapy) presents with dysesthesia and erythema; the latter (from BRAF/MEK inhibitors) presents with well-defined painful hyperkeratosis on pressure areas 1
• Avoid hot water and excessive soap – Water temperature >40°C increases skin permeability and worsens irritant contact dermatitis 1

Treatment Approach

For secondary causes:

• Treat the underlying condition; palmar erythema typically resolves with successful treatment of the primary disease 3
• For drug-induced cases, discontinue the offending agent if medically feasible 3

For chemotherapy-induced hand-foot syndrome:

• Grade 1: Continue drug, apply topical low/moderate steroid 1
• Grade 2: Continue drug with oral antibiotics (doxycycline 100mg BID for 6 weeks) plus topical steroids 1
• Grade ≥3: Interrupt treatment until Grade 0/1, use oral antibiotics, topical steroids, and consider systemic corticosteroids (prednisone 0.5-1 mg/kg for 7 days) 1

For palmoplantar psoriasis:

• Topical clobetasol solution for scalp involvement 1
• Oral acitretin (25mg daily) shows substantial improvement within 2 months for severe palmar involvement 1
• Soak PUVA (15-30 minutes in methoxsalen solution) or 308-nm excimer laser for refractory cases 1
• Biologics (adalimumab, infliximab) may be effective, though formal trial results pending 1

For irritant contact dermatitis:

• Apply moisturizer after every hand wash using two fingertip units 1
• Use lukewarm (not hot) water for hand washing 1
• Apply moderate-to-high potency topical corticosteroids (betamethasone valerate 0.1% ointment) twice daily for 2 weeks if conservative measures fail 7

For primary/hereditary palmar erythema:

• No treatment indicated; condition is benign 3, 6