What are the management and treatment options for a quarter-size erythema on the back of the hand of a patient with hemiplegia (paralysis of one side of the body)?

Management of Quarter-Size Erythema on Hemiplegic Hand

This erythema requires immediate assessment for pressure injury, cellulitis, or Complex Regional Pain Syndrome (CRPS), with management prioritizing skin integrity preservation and infection exclusion to prevent morbidity in this vulnerable limb.

Initial Assessment Priority

The hemiplegic limb is at high risk for multiple complications that can present as erythema. Your assessment must systematically evaluate:

• Pressure injury risk: Use the Braden scale to objectively assess risk, as hemiplegic patients have impaired circulation, reduced mobility, and altered sensation that predispose to skin breakdown 1
• Infection signs: Assess for warmth, tenderness, advancing borders, and systemic symptoms (fever, elevated white blood cell count) that would indicate cellulitis 1
• CRPS features: Examine for pain disproportionate to findings, edema over dorsum of fingers, hyperesthesia, trophic skin changes, and limited range of motion in adjacent joints 1
• Blanching characteristics: Apply pressure to determine if the erythema blanches, which helps differentiate inflammatory conditions from purpura or deeper pathology 2

Management Algorithm

If Pressure-Related Erythema (Most Common in Hemiplegia)

Immediate interventions to prevent progression:

• Eliminate pressure and friction: Reposition the hand immediately and minimize all contact pressure to the affected area 1
• Provide appropriate support surfaces: Use specialized cushioning for wheelchair armrests and positioning devices 1
• Turn/reposition regularly: Ensure repositioning at least every 2 hours, with particular attention to the hemiplegic hand 1
• Maintain skin hygiene: Keep the area clean and dry, avoiding excessive moisture 1
• Optimize nutrition and hydration: Address any deficiencies that impair healing 1

If Cellulitis is Suspected

Start empiric antibiotics immediately if infection is likely:

• Oral therapy (if patient can tolerate and infection is uncomplicated): Dicloxacillin, cephalexin, or clindamycin for 5 days 1
• Parenteral therapy (if severely ill or unable to take oral medications): Nafcillin, cefazolin, or vancomycin (if penicillin-allergic) 1
• Elevate the extremity: This critical but often neglected intervention promotes gravity drainage of edema and inflammatory substances 1
• Consider short-course corticosteroids: A tapering course starting with 30 mg prednisolone may hasten resolution in uncomplicated cases, though this requires careful patient selection 1

If CRPS is Suspected

Early aggressive treatment is essential:

• Initiate corticosteroids promptly: Start oral corticosteroids at 30-50 mg daily for 3-5 days, then taper over 1-2 weeks to reduce swelling and pain 1
• Implement range of motion exercises: Active, active-assisted, or passive ROM exercises should be performed to prevent progression 1
• Consider diagnostic confirmation: Triple-phase bone scan showing increased periarticular uptake in distal upper extremity joints can assist diagnosis if clinical findings are unclear 1
• Analgesics: Use acetaminophen or ibuprofen if no contraindications 1

Prevention Strategies for Hemiplegic Limb

Critical ongoing measures to prevent recurrence:

• Daily skin inspection: Document findings objectively using validated scales 1
• Proper positioning: Position the hemiplegic shoulder in maximum external rotation for 30 minutes daily while sitting or in bed to prevent shoulder contracture and improve overall limb positioning 1
• Stretching program: Teach patients and caregivers proper daily stretching techniques for hemiplegic limbs to avoid contractures that can lead to pressure points 1
• Consider splinting: Resting hand/wrist splints combined with regular stretching and spasticity management may be beneficial in patients lacking active hand movement 1
• Specialized equipment: Provide appropriate wheelchair cushions, armrest padding, and positioning devices until mobility returns 1

Critical Pitfalls to Avoid

• Do not dismiss as "just redness": Hemiplegic limbs have compromised sensation and circulation, making them vulnerable to rapid progression of skin breakdown 1
• Avoid ice or prolonged cold water immersion: If the patient has been using cooling measures for any reason, limit to 10 minutes, 4 times daily maximum, as prolonged exposure can cause tissue damage 1
• Do not delay treatment: Early intervention prevents progression to full-thickness pressure ulcers or systemic infection 1
• Educate caregivers: Patients, staff, and family members must understand prevention strategies and warning signs 1