Abstract
Palmar erythema (PE), an often overlooked physical finding, is due to several physiologic or systemic pathologic states. PE can exist as a primary physiologic finding or as a secondary marker of systemic pathology.
Primary or physiologic PE 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 PE).
Secondary PE from systemic pathology encompasses a wide range of disease states. Twenty-three percent of patients with liver cirrhosis, from varying causes, can manifest PE as a result of abnormal serum estradiol levels. Patients with a rare neonatal liver disease such as Wilson disease and hereditary hemochromatosis may exhibit PE along with the other systemic manifestations of the genodermatoses. PE 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 PE. This cutaneous manifestation of diabetes occurs more often than the more classic diseases such as necrobiosis lipoidica diabeticorum (0.6%). PE can be seen in early gestational syphilis and among patients with human T-lymphotrophic virus-1-associated myelopathy. Drug-induced PE with hepatic damage has been documented with use of amiodarone, gemfibrozil, and cholestyramine, while topiramate and albuterol (salbutamol) have been reported to cause PE in the setting of normal liver function. Fifteen percent of patients with both metastatic and primary brain neoplasms may have PE. Increased levels of angiogenic factors and estrogens from solid tumors have been postulated as the cause of PE in such cases. Erythema ab igne can mimic PE, and patients with atopic diathesis are more likely to have PE than matched control subjects. Smoking and chronic mercury poisoning are environmental causes of PE.
No treatment of primary PE is indicated. If medication is the cause of PE, the drug responsible should be discontinued if possible. Identification of PE related to underlying disorders should be followed by treatment of the underlying condition.
In light of the numerous etiologies of PE, this article reviews the current literature and provides a framework to help guide the clinician in determining the cause of PE in patients presenting with this finding.
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References
Perera GA. A note on palmar erythema (so-called liver palms). JAMA 1942; 119 (17): 1417–8
Bean W. Acquired palmar erythema and cutaneous vascular ‘spiders’. Am Heart J 1943; 25: 463–77
Bland JH, O’Brien R, Bouchard RE. Palmar erythema and spider angiomata in rheumatoid arthritis. Ann Intern Med 1958; 48 (5): 1026–31
Walsh EN, Becker SW. Erythema palmare and naevus-araneus-like telangiectases. Arch Derm Syphilol 1941; 44: 616–30
Bean WB. A note on the development of cutaneous arterial ‘spiders’ and palmar erythema in persons with liver disease and their development following the administration of estrogens. Am J Med Sci 1942; 204: 251–2
Israel SL, Meranze DR, Johnston CG. The inactivation of estrogen by the liver. Am J Med Sci 1937; 194: 835–43
Chopra IJ, Abraham GE, Chopra U, et al. Alterations in circulating estradiol-17 in male patients with Grave’s disease. N Engl J Med 1972; 286 (3): 124–9
Tan YK, Birch CR, Valerio D. Bilateral gynaecomastia as the primary complaint in hyperthyroidism. J R Coll Surg Edinb 2001; 46: 176–7
Sodhi VK, Sausker WF. Dermatosis of pregnancy. Am Fam Physician 1998; 37 (1): 131–8
Losordo DW, Isner JM. Estrogen and angiogenesis: a review. Arterioscler Thromb Vasc Biol 2001; 21: 6–12
Fitzpatrick T, Arndt K, Clark W, et al. Dermatology in general medicine. New York: McGraw-Hill, 1971
Hautmann G, Campanile G, Bianchi B, et al. Alcoholic intake, cytokines, neuropeptides and the skin. Clin Dermatol 1999; 17: 391–4
Ruocco V, Psilogenis M, Schiavo AL, et al. Dermatological manifestations of alcoholic cirrhosis. Clin Dermatol 1999; 17 (4): 463–8
Noble JP, Boisnic S, Branchet-Gumila MC, et al. Palmar erythema: cutaneous marker of neoplasms. Dermatology 2002; 204 (3): 209–13
Chalmers HJ. A symmetrical palmar erythema. Lancet 1899; II: 1514–6
Ambler JV. Erythema palmare hereditarium. Arch Derm Syphilol 1932; 25: 1156–7
Lane JE. Erythema palmare hereditarium. Arch Derm Syphilol 1929; 20: 445–8
Rupec RA, Wolff H, Lindner A, et al. Erythema palmare hereditarium. Hautarzt 2000; 51 (4): 264–5
Feldman S. A case for diagnosis (palmar eruption due to endocrine disturbance during pregnancy?). Arch Derm Syphilol 1939; 39: 784–5
Esteve E, Sadeau L, Pierre F, et al. Physiological cutaneous signs in normal pregnancy: a study of pregnant women. Ann Dermatol Venereol 1994; 121 (3): 227–31
Kroumpouzos G, Cohen L. Dermatosis of pregnancy. J Am Acad Dermatol 2001; 45 (1): 1–18
Fr´ederique H, Quatresooz P, Valverde-Lopez JC, et al. Blood vessel changes during pregnancy. Am J Clin Dermatol 2006; 7 (1): 65–9
Knox T, Olans L. Liver disease in pregnancy. N Engl J Med 1996; 335 (8): 569–76
Mullally BA, Hansen WF. Intrahepatic cholestasis of pregnancy: review of literature. Obstet Gynecol Surv 2002; 57 (1): 47–52
Elling S, Powell F. Physiologic changes in the skin during pregnancy. Clin Dermatol 1997; 15: 35–43
Morrison GR. Causative factors in palmar erythema. Geriatrics 1975; 30: 463–77
Maruyama Y, Adachi Y, Aoki N, et al. Mechanism of feminization in male patients with non-alcoholic liver cirrhosis: role of sex hormone-binding globulin. Gastroenterol Jpn 1991; 26 (4): 435–9
Leonardo G, Arpaia M, Guercio RD, et al. Local deterioration of the cutaneous venoarterial reflex of the hand in cirrhosis. Scand J Gastroenterol 1992; 27 (4): 326–32
Carrella M, Hunter J, Fazio S, et al. Capillary blood flow to the skin of forearm in cirrhosis. Angiology 1992; 43 (12): 969–74
Okumura H, Aramaki T, Katsuta Y, et al. Regional differences in peripheral circulation between upper and lower extremity in patients with cirrhosis. Scand J Gastroenterol 1990; 25 (9): 883–9
Nadeem M, Yousof MA, Zakaria M, et al. The value of clinical signs in diagnosis of cirrhosis. Pak J Med Sci 2005; 21 (2): 121–4
Crawford D, Powell L, Halliday J. Factors influencing disease expression in hemochromatosis. Ann Rev Nutr 1996; 16: 139–60
Massarrat S, Fallahazad V, Kamalian N. Clinical, biochemical and imaging-verified regression of hepatitis B-induced cirrhosis. Liver Int 2004; 24 (2): 105–9
Criber B, Samain F, Vetter D, et al. Systematic cutaneous examination in hepatitis C virus infected patients. Acta Derm Venereol (Stockh) 1998; 78: 355–7
Lange PA, Stoller JK. The hepatopulmonary syndrome. Ann Intern Med 1995; 122 (7): 521–9
Clayton PT. Diagnosis of inherited disorders of liver metabolism. J Inherit Metab Dis 2003; 26 (2-3): 135–46
Kazumoto M, Shimizu A, Takase K, et al. Asymptomatic primary pulmonary hypertension associated with liver cirrhosis. J Gastroenterol 1997; 32 (1): 102–4
Bulfoni A. Vascular spiders, palmar erythema and Dupuytren’s contracture in alcoholic hepatic cirrhosis: clinical-statistical contribution. Arch Sci Med 1980; 137 (2): 355–60
Izikson L, English JC, Zirwas M. The flushing patient: differential diagnosis, workup, and treatment. J Am Acad Dermatol 2006; 55 (2): 193–208
Gavaler JS, Rosenblu ER, Deal SR, et al. The phytoestrogen congeners of alcoholic beverages: current status. Proc Soc Exp Biol Med 1995; 208 (1): 98–102
Wolf AD, Lavine JE. Hepatomegaly in neonates and children. Pediatr Rev 2000; 21 (9): 303–10
¨ozeri E, Feist D, Ruder H, et al. Proteinuria and other renal functions in Wilson’s disease. Pediatric Nephrol 1997; 11 (3): 307–11
Akil M, Amos RS. ABC of rheumatology: rheumatoid arthritis: I. Clinical features and diagnosis. BMJ 1995; 310: 587–90
Sayah A, English JC. Rheumatoid arthritis: a review of cutaneous manifestations. J Am Acad Dermatol 2005; 53 (2) 191–209
Saario R, Kalliomaki JL. Palmar erythema in rheumatoid arthritis. Clin Rheumatol 1985; 4 (4): 449–51
Rabbini MA, Shah MA, Ahmed A. Cutaneous manifestations of systemic lupus erythematosus in Pakistani patients. J Pak Med Assoc 2003; 53 (11): 539–41
Yell JA, Mbugbaw J, Burge SM. Cutaneous manifestations of systemic lupus erythematosus. Br J Dermatol 1996; 135 (3): 355–62
Skopouli F, Barbatis C, Moutsopoulos H. Liver involvement in primary Sjogren’s syndrome. Rheumatology 1994; 33: 745–8
Silva MM, Bouzas LFS, Filgueira AL. Tegumentary manifestations of graft-vs-host disease in bone marrow transplantation recipients. An Bras Dermatol 2005; 80 (1): 69–80
Zaja F, Russo D, Fuga G, et al. Rituximab for myasthenia gravis developing after bone marrow transplant. Neurology 2000; 55 (7): 1062–3
Braverman I. Skin signs of systemic disease. 2nd ed. Philadelphia (PA): W.B. Saunders Co., 1981
Laupland K, Daves H. Epidemiology, etiology, and management of Kawasaki disease: state of the art. Pediatr Cardiol 1999; 20: 177–83
Weston W, Huff J. The mucocutaneous lymph node syndrome: a critical re- examination. Clin Exp Dermatol 1981; 6 (2): 167–78
Homicz MR, Carvalho D, Kearns D, et al. An atypical presentation of Kawasaki’s disease resembling a retropharyngeal abscess. Int J Pediatr Otorhinolaryngol 2000; 54 (1): 45–9
James DG, Neville E, Sitzbach TE. A worldwide review of sarcoidosis. Ann N Y Acad Sci 1976; 278: 321–34
Cliff S, Hart Y, Knowles G, et al. Sarcoidosis presenting as palmar erythema. Clin Exp Dermatol 1998; 23 (3): 123–4
Makkar RP, Mukhopadhyay S, Monga A, et al. Palmar erythema and hoarseness: an unusual clinical presentation of sarcoidosis. Med J Aust 2003; 178 (2): 75–6
Muhammad S. Cutaneous manifestations of thyrotoxicosis in 100 hospital admitted cases. J Pak Assoc Derm 2003; 13 (1): 17–20
Mahmood T, Bari A, Agha H. Cutaneous manifestations of diabetes mellitus. J Pak Assoc Derm 2005; 15: 227–32
Lenzi MER, Cuzzi-Maya T, Olivera ALA, et al. Dermatological findings of human T lymphotropic virus type 1-associated myelopathy/tropical spastic paraparesis. Clin Infect Dis 2003; 36 (4): 507–13
Metin A, Akdeniz H, Buzgan T, et al. Cutaneous findings encountered in brucellosis and review of the literature. Int J Dermatol 2001; 40 (7): 434–8
Turk M, Kaptan F, Turker N, et al. Clinical and laboratory aspects of a trichinellosis outbreak in Izmir, Turkey. Parasite 2006; 13 (1): 65–70
Rodriguez VL, Uzquiamo CF. Paraneoplastic palmar erythema. Med Cutan Ibero Lat Am 1985; 13 (6): 487–90
Texier L. Palmar erythema and Hodgkin’s disease [letter]. Ann Dermatol Venereol 1978; 105 (3): 349
McArthur G, Firkin B. Smoking: another cause of palmar erythema [letter]. Med J Aust 1992; 156 (1): 71
Nonomura A, Mizukami Y, Kadoya M. Angiomyolipoma of the liver: a collective review. J Gastroenterol 1994; 29 (1): 95–105
Singhal A, Ghosh P, Khan SA. Low dose amiodarone causing pseudo-alcoholic cirrhosis. Age Ageing 2003; 32 (2): 224–5
Punthakee Z, Scully L, Gundi M, et al. Liver fibrosis attributed to lipid lowering medications: two cases. J Intern Med 2001; 250 (3): 249–54
Scheinfeld N, Spahn C. Palmar erythema due to topiramate. J Drugs Dermatol 2004; 3 (3): 321–2
Reygagne P, Lacour JP, Ortonne JP. Palmar and plantar erythema due to infusion of sympathomimetics in pregnant women [letter]. Br J Dermatol 1991; 124 (2): 210
Lebre C, Pawin H, Vige P, et al. A case for diagnosis: palmar erythema caused by salbutamol. Ann Dermatol Venereol 1992; 119 (4): 293–4
Al-Sunaidi M, Shear R, Tulandi T. An unusual case of palmar erythema of pregnancy. J Obstet Gynaecol Can 2006; 28 (6): 497–8
Mor Ze, Caspi E. Cutaneous complications of hormone replacement therapy. Clin Dermatol 1997; 15: 147–54
Yasuda K, Wada E, Kitagawa N, et al. Palmar erythema ab igne without detectable type IV collagen at the basement membrane zone. J Dermatol 1996; 23 (7): 484–8
Schuster C, Smolle J, Aberer W, et al. Vascular pattern of the palms: a clinical feature of atopic skin diathesis. Allergy 2006; 61 (12): 1392–6
Lee HJ, Cho SH, Ha SJ, et al. Minor cutaneous features of atopic dermatitis in South Korea. Int J Dermatol 2000; 39: 337–42
Wilkerson M, Wilkin J. Red lunulae revisited: a clinical and histopathologic examination. J Am Acad Dermatol 1989; 20 (3): 453–7
Donnet A, Khali R, Terrie G, et al. Cerebral infarction, livedo reticularis and familial deficiency in antithrombin-III. Stroke 1992; 23: 611–2
Horowitz Y, Greenberg B, Ling G, et al. Acrodynia: a case report of two siblings [letter]. Arch Dis Child 2002; 86: 453
Dantzig PI. A new cutaneous sign of mercury poisoning? J Am Acad Dermatol 2003; 49 (6): 1109–11
Alarcon-Segoivi D, Amigo D, Reyes PA. Connective tissue disease features after thallium poisoning. J Rheumatol 1989; 16 (2): 171–4
Popli S, Leehey DJ, Soundararajan R, et al. Aggravation of palmar erythema by an arteriovenous fistula [letter]. Clin Nephrol 1991; 36 (3): 158
Janusch M, Fischer M, Marsch WCh, et al. The hand-foot syndrome: a frequent secondary manifestation in antineoplastic chemotherapy. Eur J Dermatol 2006; 16: 494–9
Webster-Gandy JD, How C, Harrold K, et al. Palmar-plantar erythrodysesthesia (PPE): a literature review with commentary on experience in a cancer centre. Eur J Oncol Nurs 2007; 11: 238–46
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Serrao, R., Zirwas, M. & English, J.C. Palmar Erythema. Am J Clin Dermatol 8, 347–356 (2007). https://doi.org/10.2165/00128071-200708060-00004
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DOI: https://doi.org/10.2165/00128071-200708060-00004