Palmar Erythema in Cirrhosis
Palmar erythema in cirrhosis is a cutaneous manifestation of chronic liver disease that indicates established cirrhosis and reflects the severity of hepatic dysfunction, but it requires no specific treatment and serves primarily as a clinical marker for underlying disease progression. 1
Clinical Significance and Pathophysiology
Palmar erythema is one of the cardinal physical examination findings in patients with cirrhosis and represents a hormonal and vascular change associated with chronic liver disease. 1, 2, 3
Key clinical points:
Palmar erythema appears when frank cirrhosis has developed and is grouped with other stigmata of chronic liver disease including spider nevi, both reflecting the severity of underlying hepatic pathology. 1, 4
This finding is described more frequently as a marker for alcoholic etiology of chronic liver disease, though it can occur in cirrhosis of any cause. 5, 4
The presence of palmar erythema correlates with disease severity and is part of the spectrum of cutaneous manifestations that result from hormonal changes and vascular alterations in cirrhosis. 2, 3
Evaluation Approach
When palmar erythema is identified, the evaluation should focus on confirming cirrhosis, determining etiology, and assessing for complications rather than treating the skin finding itself.
Initial diagnostic workup should include: 6
- Comprehensive hepatic function panel: bilirubin, AST, ALT, alkaline phosphatase, albumin, PT/INR, and platelet count 6
- Complete blood count and renal function tests 6
- Etiologic testing: hepatitis B panel, hepatitis C antibody with confirmatory RNA when positive, ferritin and transferrin saturation, autoimmune markers if etiology unclear 6
Imaging and non-invasive assessment: 6
- Abdominal ultrasound as initial imaging modality (65-95% sensitivity for detecting cirrhosis) 6
- Transient elastography to assess fibrosis stage (cirrhosis typically confirmed at ≥15 kPa) 6
- Hepatocellular carcinoma screening with ultrasound every 6 months for all patients with cirrhosis 6
Assessment for Complications
The presence of palmar erythema signals established cirrhosis and mandates evaluation for complications: 1
- Portal hypertension manifestations: ascites, splenomegaly, variceal hemorrhage 1
- Hepatic encephalopathy 1
- Hepatorenal syndrome 1
- Spontaneous bacterial peritonitis in patients with ascites 1, 6
Prognostic scoring should be calculated: 6
- MELD-Na score (incorporates bilirubin, INR, creatinine, and sodium) 6
- Child-Pugh score components 6
- These scores should be reassessed every 6 months 6
Management Strategy
Palmar erythema itself requires no specific treatment. 2, 4 Management focuses entirely on the underlying cirrhosis and its complications.
Primary management priorities:
- Address the underlying etiology: antiviral therapy for viral hepatitis, alcohol cessation for alcoholic liver disease, weight loss for nonalcoholic fatty liver disease 6, 7
- Screen for and manage complications: varices, ascites, hepatic encephalopathy, hepatocellular carcinoma 1, 7
- Optimize nutrition and avoid hepatotoxic medications 7
Upper endoscopy screening: 6
- Perform for all patients with newly diagnosed cirrhosis unless BOTH criteria are met: platelets >150,000/μL AND liver stiffness <20 kPa by transient elastography 6
Ascites evaluation if present: 1, 6
- Diagnostic paracentesis must be performed immediately in any hospitalized patient with cirrhosis or new-onset ascites 1, 6
- Calculate serum-ascites albumin gradient (SAAG) to confirm portal hypertension 6
- Neutrophil count >250 cells/mm³ confirms spontaneous bacterial peritonitis 6
Critical Clinical Pitfalls
Common mistakes to avoid:
- Do not assume normal aminotransferases exclude cirrhosis – up to half of cirrhotic patients may have normal ALT/AST values. 6
- Do not delay paracentesis based on coagulopathy or thrombocytopenia – diagnostic paracentesis is not contraindicated by prolonged PT/INR or low platelets. 6
- Do not ignore the absence of fever in suspected infection – fever is often absent in cirrhotic patients with sepsis, requiring high clinical suspicion. 8
- Peripheral stigmata like palmar erythema are seen less routinely now due to earlier diagnosis and better therapy, so their absence does not exclude cirrhosis. 5
Monitoring Schedule
For patients with established cirrhosis indicated by palmar erythema and other stigmata: 6