What is Palmar Erythema?
Palmar erythema is a clinical finding characterized by redness of the palms, which can occur as either a primary physiologic condition (hereditary, pregnancy-related, or idiopathic) or as a secondary marker of underlying systemic disease, most notably chronic liver disease, rheumatoid arthritis, thyroid disorders, and drug-induced reactions, particularly from chemotherapy agents. 1
Primary (Physiologic) Causes
Hereditary palmar erythema (Lane's disease or erythema palmare hereditarium) presents as persistent erythema of the palms, typically involving the thenar and hypothenar eminences, and can appear at birth or later in life, affecting women almost three times more than men. 2
Pregnancy-associated palmar erythema occurs in at least 30% of pregnant women due to hyperestrogenic states and hyperdynamic circulation, representing a normal physiologic change that requires no treatment. 3, 1
Idiopathic palmar erythema is a diagnosis of exclusion when no underlying cause can be identified after appropriate workup. 1
Secondary (Pathologic) Causes
Hepatic Disease
Chronic liver cirrhosis manifests with palmar erythema in 23% of patients, resulting from abnormal serum estradiol levels, and may be accompanied by spider angiomas when frank cirrhosis has developed. 4, 1
Rheumatologic Disease
Rheumatoid arthritis demonstrates palmar erythema in over 60% of patients and is associated with a favorable prognosis, with affected patients showing higher hemoglobin levels and less ulnar deviation of fingers compared to those without palmar erythema. 1, 5
Endocrine Disorders
Thyrotoxicosis causes palmar erythema in up to 18% of patients, while diabetes mellitus manifests this finding in 4.1% of cases—more frequently than classic diabetic skin manifestations like necrobiosis lipoidica diabeticorum (0.6%). 1
Drug-Induced Palmar Erythema
Chemotherapy-induced palmar-plantar erythrodysesthesia syndrome (PPES) represents a distinct entity characterized by redness, marked discomfort, swelling, and tingling in the palms, occurring in 6-60% of patients depending on the agent used. 4, 3
- 5-fluorouracil causes PPES in 6-34% of patients 4
- Capecitabine causes PPES in 50-60% of patients 4
- Doxorubicin causes PPES in 22-29% of patients 4
- PEGylated liposomal doxorubicin causes PPES in 40-50% of patients 4
The clinical progression of chemotherapy-induced palmar erythema begins with dysesthesia and tingling within days to weeks (occasionally up to 6 months), evolving to burning pain, swelling, and erythema with consecutive hyperkeratosis, potentially progressing to blisters, desquamation, erosions, ulcerations, and bleeding. 4, 3
BRAF and MEK inhibitors (vemurafenib, dabrafenib, sorafenib, cabozantinib, sunitinib, regorafenib) cause hand-foot skin reaction (HFSR) in 10-62% of patients, presenting with well-defined painful hyperkeratosis rather than the classic erythema pattern, more frequently involving the soles with callus-like hyperkeratosis at pressure-bearing areas. 4, 3
Infectious Causes
Rocky Mountain spotted fever presents with maculopapular rash spreading to palms and soles 2-4 days after fever onset, though this distribution typically occurs late in the disease course. 4, 6
Ehrlichiosis involves palms and soles in approximately 30% of adults and 60% of children with rash. 4, 6
Early gestational syphilis (Treponema pallidum) can manifest with palmar involvement. 4, 1
Neoplastic Disease
Brain neoplasms (both metastatic and primary) demonstrate palmar erythema in 15% of patients, postulated to result from increased angiogenic factors and estrogens from solid tumors. 1
Clinical Pitfalls
A rash on the palms is not pathognomonic for any single condition and occurs in diverse illnesses including drug hypersensitivity reactions, infective endocarditis, meningococcal infection, and various enteroviral infections. 4
Chemotherapy-induced PPES differs from other causes by its characteristic progression pattern and timing relative to treatment initiation, requiring specific management rather than treatment of an underlying systemic disease. 4, 3
Do not delay treatment for suspected Rocky Mountain spotted fever while waiting for palmar involvement to develop, as this represents late-stage disease with increased mortality risk. 4, 6
Management Approach
Primary palmar erythema requires no treatment. 1
Drug-induced palmar erythema should prompt discontinuation of the causative medication if possible, though chemotherapy-induced PPES may be managed with behavioral modifications (avoiding mechanical and chemical stress), urea 10% cream three times daily for prevention, and topical high-potency steroids twice daily for active lesions. 4, 1
Secondary palmar erythema requires identification and treatment of the underlying systemic condition. 1