Palmar erythema

Palmar erythema is redness involving the heel of the palm, and occasionally the fingers. The redness of palmar erythema is due to increased dilatation of surface capillaries in the hand. The degree of redness is often related to the severity of any underlying disease (if present). In many cases, this can be related to the amount of circulating estrogen.

Palmar erythema may be completely normal for an individual (primary) or be a sign of underlying disease (secondary).

The characteristics of palmar erythema include:

• Symmetrical (both hands)
• Non-painful
• Non-itchy
• Slightly warm.

The degree of redness varies with emotional states, elevation of the hand, temperature and pressure on the palm.

No treatment of primary palmar erythema is indicated. If medication is the cause of palmar erythema, the drug responsible should be discontinued if possible. Identification of palmar erythema related to underlying disorders should be followed by treatment of the underlying condition.

Palmar erythema causes

Palmar erythema is an often overlooked physical finding, is due to several physiologic or systemic pathologic states. Palmar erythema can exist as a primary physiologic finding or as a secondary marker of systemic pathology.

Primary or physiologic palmar erythema can be due to heredity, occurs in at least 30% of pregnant women as a result of associated alterations in the function of the skin and its microvasculature, or may be a diagnosis of exclusion (i.e. idiopathic palmar erythema).

Secondary palmar erythema from systemic pathology encompasses a wide range of disease states. Twenty-three percent of patients with liver cirrhosis, from varying causes, can manifest palmar erythema as a result of abnormal serum estradiol levels. Patients with a rare neonatal liver disease such as Wilson disease and hereditary hemochromatosis may exhibit palmar erythema along with the other systemic manifestations of the genodermatoses. palmar erythema has been reported to occur in >60% of patients with rheumatoid arthritis and is associated with a favorable prognosis. Up to 18% of patients with thyrotoxicosis and 4.1% of patients with diabetes mellitus can have palmar erythema. This cutaneous manifestation of diabetes occurs more often than the more classic diseases such as necrobiosis lipoidica diabeticorum (0.6%). Palmar erythema can be seen in early gestational syphilis and among patients with human T-lymphotrophic virus-1-associated myelopathy. Drug-induced palmar erythema with hepatic damage has been documented with use of amiodarone, gemfibrozil, and cholestyramine, while topiramate and albuterol (salbutamol) have been reported to cause palmar erythema in the setting of normal liver function. Fifteen percent of patients with both metastatic and primary brain neoplasms may have palmar erythema. Increased levels of angiogenic factors and estrogens from solid tumors have been postulated as the cause of palmar erythema in such cases. Erythema ab igne can mimic palmar erythema, and patients with atopic diathesis are more likely to have palmar erythema than matched control subjects. Smoking and chronic mercury poisoning are environmental causes of palmar erythema.

Primary palmar erythema

Primary palmar erythema or physiologic palmar erythema is classified as:

• Hereditary
• Pregnancy-related (30% of pregnant women will develop palmar erythema)
• Unknown cause (idiopathic)

Primary or physiologic palmar erythema can be due to heredity, occurs in at least 30% of pregnant women as a result of associated alterations in the function of the skin and its microvasculature, or may be a diagnosis of exclusion (i.e. idiopathic palmar erythema).

Secondary palmar erythema

Causes of secondary palmar erythema include:

• Liver disease: cirrhosis (23% of people with liver cirrhosis develop palmar erythema), Wilson disease, hemochromatosis
• Endocrine/nutritional: 18% of people with thyrotoxicosis and 4% of people with diabetes develop palmar erythema
• Autoimmune diseases: over 60% of people with rheumatoid arthritis develop palmar erythema
• Drug-induced palmar erythema: drugs include topiramate and salbutamol if the liver is functioning normally, or amiodarone, cholestyramine and gemfibrozil if there is liver impairment
• Other: including infections, atopic dermatitis, primary or metastatic brain cancer, smoking and chronic obstructive lung disease

In children, the most common causes of palmar erythema are:

• Hereditary palmar erythema
• Poisoning
• Kawasaki disease
• Congenital syphilis
• Wilson disease
• Hepatopulmonary hypertension.

Secondary palmar erythema from systemic pathology encompasses a wide range of disease states. Twenty-three percent of patients with liver cirrhosis, from varying causes, can manifest palmar erythema as a result of abnormal serum estradiol levels. Patients with a rare neonatal liver disease such as Wilson disease and hereditary hemochromatosis may exhibit palmar erythema along with the other systemic manifestations of the genodermatoses. palmar erythema has been reported to occur in >60% of patients with rheumatoid arthritis and is associated with a favorable prognosis. Up to 18% of patients with thyrotoxicosis and 4.1% of patients with diabetes mellitus can have palmar erythema. This cutaneous manifestation of diabetes occurs more often than the more classic diseases such as necrobiosis lipoidica diabeticorum (0.6%). Palmar erythema can be seen in early gestational syphilis and among patients with human T-lymphotrophic virus-1-associated myelopathy. Drug-induced palmar erythema with hepatic damage has been documented with use of amiodarone, gemfibrozil, and cholestyramine, while topiramate and albuterol (salbutamol) have been reported to cause palmar erythema in the setting of normal liver function. Fifteen percent of patients with both metastatic and primary brain neoplasms may have palmar erythema. Increased levels of angiogenic factors and estrogens from solid tumors have been postulated as the cause of palmar erythema in such cases. Erythema ab igne can mimic palmar erythema, and patients with atopic diathesis are more likely to have palmar erythema than matched control subjects. Smoking and chronic mercury poisoning are environmental causes of palmar erythema.

Palmar erythema diagnosis

The following work-up is recommended for all patients presenting with palmar erythema:

• Complete history and physical examination
• Complete blood count
• Liver function and blood urea nitrogen/creatinine
• Hepatitis B and C virus serology
• Ferritin
• Fasting glucose
• Thyroid stimulating hormone
• Chest x-ray.

In addition to these tests, a clinician may consider ordering ceruloplasmin, proalbumin, albumin, rheumatoid factor, Cyclic Citrullinated Peptide Antibodies (CCPA), ANA, SSA, SSB, MRI brain, CT chest/abdomen/pelvis or a bone marrow biopsy.

Palmar erythema treatment

No treatment is indicated for primary palmar erythema.

If the cause of the palmar erythema is thought to be secondary to a drug, then it may be advisable to stop it. Treatment of an underlying cause of the secondary palmar erythema may or may not lead to improvement of the redness.