Palmar erythema

Synonym: liver palms

What is palmar erythema?

Palmar erythema is a reddening of the skin on the palmar aspect of the hands, usually over the hypothenar eminence. It may also involve the thenar eminence and fingers. It can also be found on the soles of the feet, when it is termed plantar erythema.

Palmar erythema

Jmarchn, CC BY-SA 3.0, via Wikimedia Commons

The condition can be:

• Primary (or physiological).

• Secondary (to various disease states).

It is probably a manifestation of a number of underlying pathophysiological processes, the balance of which varies between different causes. These processes include:

• Increased cardiac output/hyperdynamic circulation.

• Capillary dilatation in the palms, due to local factors or systemic mediators.

• Localised inflammation.

• High circulating oestrogen levels.

How common is palmar erythema? (Epidemiology)¹

The prevalence of palmar erythema depends on the populations being discussed - idiopathic/primary palmar erythema is much less common than secondary palmar erythema.

• Pregnant women - 30-70%

• Patients with cirrhosis - 23%.

• Patients with rheumatoid arthritis - 60%.

• Patients with thyrotoxicosis - 18%.

• Patients with diabetes - 4%.

Causes of palmar erythema

Primary palmar erythema

• Heredity.

• Pregnancy (due to alterations in skin function and vasculature).²

• Idiopathic.

Secondary palmar erythema³

• Liver cirrhosis and its many causes including alcohol abuse.⁴ (Palmar erythema develops as a result of abnormal oestradiol levels.)

• Hereditary liver disease such as Wilson's disease and hereditary haemochromatosis .

• Rheumatoid arthritis (associated with a favourable prognosis) .

• Systemic lupus erythematosus.⁵

• Thyrotoxicosis.⁶

• Diabetes mellitus.

• Sarcoidosis.⁷

• Gestational syphilis.

• Human T-lymphotropic virus type 1 (HTLV-1)-associated myelopathy.

• Neoplastic disease (as a paraneoplastic disorder), particularly primary or metastatic brain neoplasms . However, also associated with ovarian carcinoma.⁸

• Drug-induced (amiodarone, gemfibrozil, cholestyramine, topiramate and salbutamol have all been implicated).

• Smoking.

• Chronic mercury poisoning.

• Polycythaemia.

Diagnosing palmar erythema (investigations)¹

These will depend on the underlying condition(s) suggested by the overall clinical picture. Idiopathic palmar erythema should be a diagnosis of exclusion.

If there is no known cause, DermNet suggests that a reasonable first work-up would be to take a complete history and do a physical examination and then do a chest x-ray and the following blood tests - FBC, U&E, LFT, hepatitis B and C serology, ferritin, fasting glucose and TSH. Other tests to consider would include copper, rheumatoid factor, anti-CCP antibodies and ANA. If it is felt that an underlying cause has evaded diagnosis then referral for imaging such as a CT of the chest, abdomen and pelvis may be appropriate.

Management of palmar erythema

There is no specific treatment for palmar erythema. If an underlying disease process is found to be the cause, this will dictate management. If a drug is thought to be responsible, this should be discontinued if possible. There is no treatment for idiopathic palmar erythema.