Presentations to the Pharmacist would include irritant and allergic contact dermatitis, pompholyx eczema, palmar psoriasis, tinea infections and possibly granuloma annulare and vitiligo.
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| Solar lentigo back of hand |
Granuloma annulare (GSA) is an annular condition that is often seen over joints on the back of the hands, particularly the MP joints. It looks like ringworm but of course there is no scale associated, just papules of granuloma under the skin mainly seen at the edge of the annular lesion.
Rx Treatment of these is best with some diluted intralesional Kenacort, 1ml of Kenacort A10 with 3ml of local anaesthetic just injected into the edge in the dermis. They will often melt away with just one injection. This treatment is particularly effective for early lesions. Topical steroids just wont penetrate adequately. A rarer variant of GA on the back of the hand can show percutaneous perforation expulsion of the damaged collagen.
GSA
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| Spreading non scaly edge of granuloma annulare dorsum hand |
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| GA over the MP joint - no scale |
Examining the palm of the hand you may notice palmar fascia thickening with an early Dupytren's contracture. Ultimately this will require surgical release,
A couple of annular rashes on the palms are worth diagnosing.
The first is
secondary syphilis (GSA) with salmon pink scaly macules on both palms. Check the mouth and genital areas for other features of secondary syphilis, do a VDRL and treat with penicillin IM. Look for other sexually acquired diseases as well.
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| Secondary syphilis Scaly macules |
The other condition presenting with annular "target" lesions on the palms and lower legs is Erythema multiforme. (GSA) This is usually secondary to recent herpes simplex elsewhere or a mycoplasma chest infection. The lesions are not scaly. They resolve without treatment. See this example in GSA
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| Erythema multiforme Target lesions |
In colder areas, painful, itchy purplish nodules on the back of the hands, particularly over the joints, may be a feature of perniosis, (GSA) but generally this is acute, and it is not a chronic thing that a skin cancer doctor is going to see much. Generally perniosis affects children or young women. Rx Nicotinic acid or other vasodilators can help but protection from cold with appropriate clothing is best.
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| Perniosis |
Hands that have been subject to rheumatoid arthritis or scleroderma over the years can show characteristic binding down of the skin of the fingers and tapering of the tips (sclerodactyly) giving a pencil shaped deformity, particularly in scleroderma, and ultimate atrophy of the tips of the fingers. Rheumatoid arthritis and gout can give rise to nodules. They are fairly soft with rheumatoid but can be quite firm under the skin in gout. Also with chronic scleroderma calcification under the skin is not uncommon, and this may present as firm lumps in this area.
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| Gouty nodules fingers |
Changes in the colouration of the palm of the hand - Red palms, can be a feature of underlying liver disease. Purple palms with papules can be a feature of lichen planus. Keratoderma of the palms of the hands can be a presentation of psoriasis particularly if it is over the friction involved areas, but the association of malignancy occurs when you see palmar plantar keratoderma with oesophageal cancers. There are various congenital disorders that will give thickening of the palms but these are really too rare for us to discuss.
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| Violaceous colour of lichen planus of the palms |
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| Plaque of palmar psoriasis on the thenar eminence |
Rx A plaque of psoriasis like the one above would be best treated with Enstilar foam. This is a combination of calcipotriol and a strong steroid Betamethasone which penetrates the thick psoriatic scale and reduces the thickness preventing splitting of the keratin.
Presentation of scale just on one palm with the other palm being normal and similar scale on the soles of the feet, is one that is typically seen with a fungal infection called trichophyton rubrum. These patients invariably need oral Terbinafine 250 mgs daily for three months to try and clear this fungus.
Thickened psoriasis on the palms of the hands is best treated with some Enstilar Foam particularly at night. You can use some Glad Wrap occlusion to make it penetrate it better, but you then have to protect the hands with gloves from frictional factors that tend to keep the psoriasis going.
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| Tinea rubrum of the palm |
Tinea nigra (GSA) (Dermnet) is an uncommon pigmented fungus that is seen on the palms and soles in tropical areas. It will scrape off with a blade and the scrapings can be sent for microscopy and culture. It is easily treated with an azole anti fungal cream or with terbinafine cream.
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| Brown spot of Tinea nigra |
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| Dermatoscopy of Tinea nigra |
Pompholyx (GSA) is an acute dermatitis involving the palms of the hands and the sides of the fingers with small vesicles of clear fluid trapped under a thick overlying stratum corneum. It is very itchy. The vesicles may join up to form blisters as in this case below. Pompholyx has a variety of causes but consider irritant or allergic contact dermatitis, occlusion causing hyperhidrosis or emotional stress. Some cases may be an ID reaction to a fungal infection between the toes.
(Dermnet) Rx A strong topical steroid such as full strength betamethasone 0.1% cream or Diprosone OV cream or even a short course of oral steroids. Protect the hands from irritants after the skin overlying the blisters peels off. It takes two months for the normal skin barrier function to return so keep protecting plus gloves even after the skin looks normal at 3 weeks!
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| Blistering pompholyx |
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| Pustular pompholyx Secondary Staph infection |
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| Keratolysis exfoliativa |
Keratolysis exfoliativa is a common superficial peeling disorder which is best regarded as a mild form of dermatitis but it does not respond to topical steroids and only needs a moisturiser and protection from irritants. It is not itchy.
(Dermnet) It seems to just flare up with the change of the seasons in some people.
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| Crusted or Norwiegian scabies |
Crusted scabies (GSA) is one hand you dont want to touch without gloves! It will probably be a Nursing home patient whom you are seeing for skin cancer who has had a stroke or is immunosuppressed in some way, who has been itchy for some time. Look at all the usual places for scabies and confirm with a dermatoscope.
(Dermnet)
Rx is with oral Ivermectin 12 mgs daily (4x 3 mgs tabs) on alternate days 3 times in a week with daily application of Permethrin (Lyclear cream 30 gms) all over for a week. Treat nearest and dearest as well with a couple of applications of Lyclear cream a week apart, plus probably the rest of the nursing home and Nursing staff!
