Scaling rash on the palms - Clinical Advisor

Scaling rash on the palms

Slideshow

  • Case #1

    October 2015 Dermatology Look-Alikes

    Case #1

  • Case #2

    October 2015 Dermatology Look-Alikes

    Case #2

Case #1

A 56-year-old woman presents with a 2-month history of a very itchy rash on the palm of her right hand. Another provider had prescribed a triamcinolone cream that offered improvement in the first few days of use, after which the rash spread and became worse. The patient has a family history of psoriasis, takes metoprolol for hypertension, and is otherwise in good health. Examination of her palm reveals numerous areas of erythematous scaling, some of which has an annular appearance, and no vesicles or pustules appreciated. Interdigital maceration and peeling with hyperkeratosis was noted on the heels.


Case #2

A 62-year-old woman presents with a rash on her hands that has been treated by many providers over the last 2 years without any significant success. Frustrated about the lack of resolution, the patient describes receiving numerous diagnoses and many different creams. Some creams helped temporarily, but when they were discontinued, the rash recurred. The patient has no medical or family history of skin disease. She works as a house cleaner and reports always using gloves while working. Examination reveals hyperkeratosis and scaling of the bilateral palms and scaling and hyperkeratosis on both soles.



This The Clinical Advisor CME activity consists of 3 articles. To obtain credit, read Pink, scaly rash on the trunk and extremities and Maculopapular rash 
after swimming. Then take the post-test here.


Case #1Tinea manuum is a dermatophyte infection of the hands, although this term is sometimes reserved more specifically for infection of the interdigital and palmar surfaces only.1 The term tinea manus, although rarely used, would indicate involvement of one hand...

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Case #1

Tinea manuum is a dermatophyte infection of the hands, although this term is sometimes reserved more specifically for infection of the interdigital and palmar surfaces only.1 The term tinea manus, although rarely used, would indicate involvement of one hand only. After the organism invades the skin, it persists in the stratum corneum of the epidermis and proliferation is increased, resulting in the visible rash. Trichophyton rubrum is the most prevalent pathogen that results in tinea manuum, accounting for approximately 80% of cases.2

Typical findings on physical examination of a patient with tinea manuum include epidermal thickening, scaling, erythema, and/or white appearance of skin markings.3 When both hands are involved, the rash is often asymmetrical. Most patients describe itchiness as the main symptom. 


An inflammatory variant of tinea manuum presents with tiny clear vesicles on the palms, sometimes involving the feet as well.3 This condition is typically intensely pruritic. Another variant of dermatophytosis is a combined tinea manuum and tinea pedis, also known as “two-foot-one-hand syndrome.”4 This occurs when a patient with concomitant tinea pedis or toenail onychomycosis develops tinea manuum after touching or picking at his/her feet. 


Incidence is most common after puberty. An individual affected with any hand dermatitis is more likely to contract a tinea superinfection. In addition, those suffering from hyperhidrosis are favorable hosts due to the presence of a moist, and often warm, skin environment. 


Transmission of the fungus occurs through direct contact with an infected individual, or less commonly, via an animal (zoophilic) or the soil (geophilic).5

Although tinea is often diagnosed clinically, confirmation of the diagnosis by laboratory testing is strongly recommended as other dermatoses mimic tinea closely. An in-office potassium hydroxide (KOH) test is quick and easy. A scale from the leading edge of a lesion is prepped and then examined for the appearance of hyphae. A fungal culture, although time-consuming and possibly more expensive, should strongly be considered in patients who are considering systemic treatment. Other helpful diagnostic tests include hematoxylin and eosin stain of a skin biopsy to diagnose other hand dermatoses and bacterial culture and rule out superimposed infections. 


Several other conditions can be mistaken for tinea manuum. Palmar psoriasis often presents with a similar erythematous scaling of the palms, but psoriasis usually presents in a symmetrical pattern. Nummular eczema often has a misleading annular “ringworm” appearance that can lead to misdiagnosis. Allergic contact dermatitis of the palms may also cause lichenification and scaling. 


Most cases of tinea manuum can be treated topically. Common antifungals used include the imidazoles (eg, ketoconazole and oxiconazole), the allylamines (eg, naftifine and terbinafine), and ciclopirox olamine. Guidelines issued by the American Academy of Dermatology in 1996 for treatment of superficial mycotic infections of the skin include less common topical treatments, such as benzoic acid, salicylic acid, and other keratolytic agents.1 When choosing a topical medication, factors to consider include efficacy, cost, and vehicle. While ointment formulations are beneficial for thickened lesions on palmar skin, creams may be preferred by patients who are concerned about the resulting greasiness. Topical corticosteroids are often added to the treatment of tinea manuum, as they help to rapidly relieve itching and may quickly help suppress the inflammatory response. However, care must be taken to avoid the long-term use of corticosteroids in order to minimize the risk of side effects and reduce the risk of fungal proliferation. 


Systemic treatment, which carries the risk of toxicity and drug interactions, should be reserved for patients who are resistant to topical therapy.1 Traditionally, griseofulvin has been the gold standard for the systemic treatment of dermatophytoses.5 However, terbinafine has been found to be more effective with a shorter treatment time.6

In our case, because the patient’s diagnosis was uncertain clinically, a skin biopsy was performed after a 14-day vacation from use of the topical corticosteroid. A KOH stain revealed numerous hyphae, confirming the diagnosis of tinea. The patient was prescribed naftifine cream to be applied once daily. Complete resolution of the symptoms was noted after 4 weeks of treatment.


Case #2

Psoriasis is a chronic inflammatory condition of the skin, affecting approximately 2% of the population.7 While plaque psoriasis accounts for 80% of cases of psoriasis, other variants of the disease exist. Palmoplantar psoriasis, which represents approximately 5% of cases of psoriasis, refers to disease of the palms and soles. Although it affects a small percentage of the body surface area, palmoplantar psoriasis is a challenging disease and can greatly impact a patient’s quality of life.8

The appearance of palmoplantar psoriasis can vary. Some patients exhibit thick scaly patches with hyperkeratosis of the palms and soles, while cases involving a pustular form of the condition are more rare. 


Psoriasis affects males and females equally. Although the average age of onset is 27 years,9 the disease can begin in the neonatal period. There is a strong genetic component to psoriasis, with susceptibility associated with the class-I and class-II major histocompatibility complex.9

As with all hand dermatoses, clinical diagnosis can be challenging due to several other conditions that mimic palmoplantar psoriasis very closely. Tinea manuum, allergic or irritant contact dermatitis, and the pompholyx form of eczema all present with very similar skin findings. For this reason, a physical examination, including inspection of the entire skin, flexural surfaces, scalp, genitalia, and nails, should be performed. Examination of the fingernails may aid in diagnosis: Pitting of the surface of the nail plate, onycholysis, oil spots, and some hyperkeratosis may be found with psoriasis.10

A skin biopsy will assist in confirming the diagnosis and should be performed, especially if systemic treatment is to be considered. In psoriasis, histologic findings include parakeratosis, absent granular layer, and acanthosis. 


Treatment of palmoplantar psoriasis needs to be tailored to the individual. There is a multitude of treatment options available, but the goal of therapy should be durable remission while minimizing side effects.11 Potent topical corticosteroids, such as clobetasol propionate, with or without occlusion are often the first line of treatment. Although they offer short-term improvement, topical corticosteroids are more often insufficient and inefficient for a lasting benefit, due to potential side effects. Other topical treatments, such as vitamin D analogues, tar, and salicylic acid, are often beneficial when combined with a topical corticosteroid for hyperkeratotic lesions. 


Other treatments to consider include phototherapy, psoralen plus ultraviolet A (PUVA), laser, oral retinoids, methotrexate, cyclosporine, and biologics. PUVA therapy is highly effective, but because of the potential side effects, therapy with narrow-band UVB is preferred.9 Traditional full-profile UVB units are inappropriate for disease limited to the hands and feet. However, the development of UVB units for the hands and feet have allowed patients to benefit from this treatment. Although phototherapy is time-consuming, requiring twice or thrice weekly treatments in the clinic or at home, the side-effect profile is minimal, making it a very favorable option for treatment and maintenance of palmar psoriasis. 


In our case, after a skin biopsy confirmed the diagnosis of psoriasis, the patient was educated regarding the chronic nature of her condition and the need for close follow-up to allow for treatment adjustments. After reviewing all available treatment options, the patient opted for phototherapy with the hand-and-foot UVB unit in our clinic. After approximately 15 sessions, the patient reported almost complete resolution of the condition. She continued sessions once weekly for another 3 months for maintenance and reported feeling better then she has ever felt in the last 2 years.

Esther Stern, NP-C, is a family nurse practitioner at Advanced Dermatology & Skin Surgery, P.C., in Lakewood, N.J.



This The Clinical Advisor CME activity consists of 3 articles. To obtain credit, read Pink, scaly rash on the trunk and extremities and Maculopapular rash 
after swimming. Then take the post-test here.


References


  1. Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for superficial mycotic infections of the skin: Tinea corporis, tinea cruris, tinea faciei, tinea manuum, and tinea pedis. J Am Acad Dermatol. 1996;34(2 Pt 1):282-286. 

  2. Foster KW, Ghannoum MA, Elewski BE. Epidemiologic surveillance of cutaneous fungal infection in the United States from 1999 to 2002. J Am Acad Dermatol. 2004;50(5):748-752. 

  3. James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin: ClinicalDermatology. 10th ed. Philadelphia, Pa.: Saunders Elsevier; 2006:304. 

  4. Daniel CR III, Gupta AK, Daniel MP, Daniel CM. Two-feet-one-hand syndrome: A retrospective multicenter survey. Int J Dermatol. 1997;36(9):658-660. 

  5. Rand S. Overview: The treatment of dermatophytosis. J Am Acad Dermatol. 2000;43(5 Suppl):S104-S112. 

  6. Bell-Syer SE, Hart R, Crawford F, Torgerson DJ, Tyrrell W, Russell I. Oral treatments for fungal infections of the skin of the foot. Cochrane Database Syst Rev. 2002;(2):CD003584. 

  7. Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 5. Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy. J Am Acad Dermatol. 2010;62(1):114-135. Available at jaad.org/article/S0190-9622(09)01058-5/fulltext 

  8. Farley E, Masrour S, McKey J, Menter A. Palmoplantar psoriasis: A phenotypical and clinical review with introduction of a new quality-of-life assessment tool. J Am Acad Dermatol. 2009;60(6):1024-1031. 

  9. James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin: 
Clinical Dermatology. 10th ed. Philadelphia, Pa.: Saunders Elsevier; 
2006:196. 

  10. Langley RG, Krueger GG, Griffiths CE. Psoriasis: Epidemiology, clinical features, and quality of life. Ann Rheum Dis. 2005;64 (Suppl 2):ii18-ii23. Available at ard.bmj.com/content/64/suppl_2/ii18.long 

  11. Callen JP, Krueger GG, Lebwohl M, et el. AAD consensus statement 
on psoriasis therapies. J Am Acad Dermatol. 2003;49(5):897-899. 


All electronic documents accessed on October 2, 2015.



This The Clinical Advisor CME activity consists of 3 articles. To obtain credit, read Pink, scaly rash on the trunk and extremities and Maculopapular rash 
after swimming. Then take the post-test here.


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