What is the management for a patient with itchy palms?

Management of Itchy Palms

For a patient presenting with itchy palms, immediately initiate a stepwise approach: identify and eliminate irritants/allergens, apply emollients liberally, and use medium-potency topical corticosteroids for active inflammation, while simultaneously investigating for underlying systemic causes if the condition is bilateral, persistent, or accompanied by constitutional symptoms. 1, 2

Initial Assessment and Red Flags

Critical History Elements

• Recent changes in hand hygiene practices (increased washing, new sanitizers, occupational exposures) suggest irritant or allergic contact dermatitis 1, 2
• Bilateral palmar involvement with constitutional symptoms (fever, weight loss, night sweats) raises concern for systemic disease including Rocky Mountain Spotted Fever, which classically presents with rash on wrists/palms 3
• Occupational exposures in healthcare workers, food service, cleaning, or hairdressing point toward contact dermatitis 1, 2
• Water contact triggering itch suggests aquagenic pruritus, which is characteristic of polycythemia vera 3

Physical Examination Priorities

• Look for primary skin lesions (vesicles, pustules, scaling, hyperkeratosis) versus secondary changes from scratching 4
• Examine finger webs, nails, and both palmar and dorsal surfaces to distinguish between conditions 4
• Check for petechial rash involving palms and soles, which indicates advanced Rocky Mountain Spotted Fever requiring immediate treatment 3
• Assess for hyperkeratotic plaques and fissures suggesting palmoplantar psoriasis 3

First-Line Management for Contact Dermatitis (Most Common Cause)

Immediate Trigger Avoidance

• Stop all harsh soaps, detergents, fragrances, and potential irritants immediately 1, 2
• Use lukewarm or cool water only—avoid hot water which strips protective lipids from the stratum corneum 1, 2, 5
• Pat dry gently rather than rubbing to minimize trauma 1, 2, 5
• Avoid disinfectant wipes for hand cleaning 1

Aggressive Moisturization Protocol

• Apply moisturizer immediately after every hand washing using two fingertip units for adequate coverage 1, 5
• Choose fragrance-free, dye-free moisturizers containing petrolatum or mineral oil in tubes (not jars) to prevent contamination 1, 5
• For severe cases, 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, 5
• Reapply moisturizer frequently throughout the day using pocket-sized tubes 1, 5

Topical Anti-Inflammatory Therapy

• Apply medium-potency topical corticosteroid (e.g., clobetasol propionate 0.05%) to affected areas when conservative measures fail 2
• FDA-approved hydrocortisone can be applied 3-4 times daily for temporary relief of itching associated with minor skin irritations, eczema, and contact dermatitis 6
• Limit prolonged corticosteroid use to avoid steroid-induced skin barrier damage, but do not hesitate to use for active flares 5

Investigation for Systemic Causes

When to Pursue Laboratory Testing

Order initial screening tests if pruritus is generalized, bilateral, persistent beyond 6 weeks, or accompanied by constitutional symptoms 3, 7:

• Complete blood count with differential to evaluate for polycythemia vera, eosinophilia (suggesting T-helper-2 polarization), or hematologic malignancy 3, 7
• Hepatic and renal function tests to screen for cholestatic liver disease and chronic kidney disease 3, 7
• Thyroid function and fasting glucose/A1C to evaluate endocrine/metabolic causes 3, 7
• Iron studies as iron deficiency may accompany polycythemia vera 3
• Lactate dehydrogenase and ESR if lymphoma is suspected 3

Specific Systemic Conditions to Consider

Polycythemia Vera

• Suspect when aquagenic pruritus is present (intense itching triggered by water contact without skin lesions) 3
• Check for JAK2 V617F mutation if elevated hemoglobin/hematocrit, microcytosis, or elevated white cell/platelet count with low ESR 3
• Treatment with aspirin 300 mg daily has been shown effective for pruritus in polycythemia vera 3

Rocky Mountain Spotted Fever

• Consider in patients with fever, headache, and palmar rash appearing 2-4 days after fever onset 3
• Classic triad of fever, rash, and tick bite is present in only a minority at initial presentation 3
• Maculopapular rash spreading to palms and soles is indicative of advanced disease requiring immediate antibiotic therapy 3

Lymphoma

• Suspect with nocturnal itching, weight loss, fevers, night sweats, or lymphadenopathy 3
• Treatment options include cimetidine, gabapentin, carbamazepine, mirtazapine, or phototherapy 3

Management of Specific Dermatologic Conditions

Palmoplantar Psoriasis

• Characterized by erythematous, scaly, fissured hyperkeratotic plaques affecting palms and soles 3
• Start with intensive topical therapy: high-potency corticosteroids under occlusion 3
• Consider systemic therapy (acitretin, methotrexate, cyclosporine, or biologics) when topical therapy fails, as quality of life impact justifies systemic treatment despite small body surface area involved 3
• Topical PUVA (soak PUVA with 15-30 minute methoxsalen solution soaks) is effective for recalcitrant cases 3

Hand-Foot Skin Reaction from Chemotherapy

• Presents as palmar-plantar erythrodysesthesia with redness, discomfort, swelling, and tingling 3
• Associated with 5-fluorouracil, capecitabine, doxorubicin, and multikinase VEGFR inhibitors 3
• Symptoms typically appear within days to weeks after chemotherapy initiation 3

Occupational and Protective Measures

For Healthcare Workers and High-Risk Occupations

• Use cotton glove liners under protective gloves if occupational exposure is unavoidable 1, 5
• Choose accelerator-free gloves (neoprene or nitrile) if glove-related allergic contact dermatitis is suspected 1, 5
• Apply water-based moisturizers under gloves (oil-based products break down latex and rubber) 1, 5
• Never apply gloves when hands are still wet from washing or sanitizer 1, 5

Critical Pitfalls to Avoid

• Do not use superglue to seal fissures as ethyl cyanoacrylate is a known allergen 2, 5
• Avoid topical antibiotics (neomycin, bacitracin) which are common allergens that worsen allergic contact dermatitis 2
• Do not wash hands immediately before or after using alcohol-based sanitizers as this increases dermatitis risk 1, 2
• Avoid washing hands with dish detergent or other known irritants 1, 5
• Do not increase glove occlusion duration without underlying moisturizer application 1, 5

Escalation and Referral Criteria

When to Refer to Dermatology

• No improvement after 6 weeks of appropriate conservative treatment 1, 2, 5
• Suspected allergic contact dermatitis requiring patch testing 1, 2, 5
• Change in baseline dermatitis pattern 1, 2, 5
• Recalcitrant cases requiring consideration of phototherapy or systemic therapy 1, 5

Advanced Treatment Options for Recalcitrant Cases

• Stronger topical steroids, phototherapy (narrowband UVB or PUVA), or systemic therapy may be considered when first-line treatments fail after 6 weeks 1
• For elderly patients with persistent pruritus, reassess after 2 weeks of emollients and topical steroids, and consider high-lipid-content moisturizers 3

General Pruritus Management Without Primary Lesions

If no primary skin lesions are identified and systemic workup is negative, consider chronic pruritus of unknown origin (CPUO) 3, 8:

• Provide self-care advice: keep nails short, avoid scratching 3
• Trial of nonsedating antihistamine for symptomatic relief 3
• Regular follow-up is essential as underlying systemic causes may not be evident initially 3
• Heightened concern for malignancy in patients over 60 years with diffuse itch less than 12 months duration 7