Synonym: liver palms

• 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 be found on the soles of the feet, when it is termed plantar erythema.
• It is a sign associated with many diseases but is probably most commonly seen as a normal variant.
• It can be present in individuals without an identifiable illness or underlying cause. This makes it difficult to confirm true associations between conditions and the finding of palmar erythema.
• There have been no useful surveys of its prevalence in the community or the exact incidence in specific disease populations.
• It is probably a manifestation of many underlying pathophysiological processes, the balance of which will vary between different individuals and causes. These processes include:
  • Increased cardiac output
  • Capillary dilatation in the palms due to local factors or systemic mediators
  • Localised inflammation
  • High circulating oestrogen levels
  • A toxic dermatological reaction
• It is not a very discriminative sign in terms of reaching a diagnosis, but can be useful as a marker. It may also suggest an alternative diagnosis when conducting an initial clinical assessment.

Causes of palmar erythema

• Established:
  • Idiopathic
  • Cirrhosis
  • Chronic liver disease
  • Excess alcohol consumption
  • Pregnancy¹
  • Connective tissue disorders:
    • Particularly rheumatoid arthritis
    • Rarely, sarcoidosis^2,3
    • Systemic lupus erythematosus^4,5
    • Polyarthritis⁶
  • Thyrotoxicosis
  • Polycythaemia
  • Leukaemia
  • Eczema and psoriasis
• Purported or recently suggested:
  • Shoulder-hand syndrome/algodystrophy (reflex sympathetic dystrophy)
  • Associated with use of a variety of chemotherapeutic agents as early manifestation of palmar-plantar erythrodysesthesia^7,8
  • Neoplastic disease, particularly cerebral tumours⁹
  • Some antiepileptic drugs¹⁰
  • Infection with human T lymphotropic virus (HTLV-I) causing myelopathy/tropical paraparesis¹¹

Document references

1. Henry F, Quatresooz P, Valverde-Lopez JC, et al; Blood vessel changes during pregnancy: a review. Am J Clin Dermatol. 2006;7(1):65-9. [abstract]
2. Makkar RP, Mukhopadhyay S, Monga A, et al; Palmar erythema and hoarseness: an unusual clinical presentation of sarcoidosis. Med J Aust. 2003 Jan 20;178(2):75-6. [abstract]
3. Cliff S, Hart Y, Knowles G, et al; Sarcoidosis presenting as palmar erythema. Clin Exp Dermatol. 1998 May;23(3):123-4. [abstract]
4. Rabbani MA, Shah SM, Ahmed A; Cutaneous manifestations of systemic lupus erythematosus in Pakistani patients. J Pak Med Assoc. 2003 Nov;53(11):539-41. [abstract]
5. Yell JA, Mbuagbaw J, Burge SM; Cutaneous manifestations of systemic lupus erythematosus. Br J Dermatol. 1996 Sep;135(3):355-62. [abstract]
6. Preda VA, Frederiksen P, Kossard S; Indurated reticulate palmar erythema as a sign of paraneoplastic palmar fasciitis Australas J Dermatol. 2009 Aug;50(3):198-201. [abstract]
7. Webster-Gandy JD, How C, Harrold K; Palmar-plantar erythrodysesthesia (PPE): A literature review with commentary on experience in a cancer centre. Eur J Oncol Nurs. 2007 Jul;11(3):238-46. Epub 2007 Mar 9. [abstract]
8. Bhasin S, Sunita, Gupta DK, et al; Chemotherapy-induced palmer planter erythrodysesthesia. J Assoc Physicians India. 2005 Feb;53:155-6. [abstract]
9. Noble JP, Boisnic S, Branchet-Gumila MC, et al; Palmar erythema: cutaneous marker of neoplasms. Dermatology. 2002;204(3):209-13. [abstract]
10. Scheinfeld N, Spahn C; Palmar erythema due to topiramate. J Drugs Dermatol. 2004 May-Jun;3(3):321-2. [abstract]
11. Lenzi ME, Cuzzi-Maya T, Oliveira AL, et al; Dermatological findings of human T lymphotropic virus type 1 (HTLV-I)-associated myelopathy/tropical spastic paraparesis. Clin Infect Dis. 2003 Feb 15;36(4):507-13. Epub 2003 Jan 30. [abstract]

Acknowledgements