Other Disorders Affecting The Hands And Feet

Several other generalized skin disorders have classic clinical findings on the palms and soles. These disorders are discussed in more detail in Chap 241; however, they are mentioned briefly here so as to be reminded of these disorders when a patient presents with a complaint in one of these body regions.

Erythema multiforme has characteristic findings on the palms and soles. These lesions are erythematous macules with a violaceous, dusky or bullous center. They are commonly referred to as target or iris lesions. Discovering such lesions should incite a search for similar lesions on the rest of the body, hemorrhagic erosions on the mucosal surfaces, and conjunctival hemorrhage in the eyes.

Secondary syphilis also has characteristic palm and sole lesions. These lesions are red-brown to brown macules on the palms and soles. Although patients with darker pigmented skin may have several hyperpigmented macules as a normal finding, recent onset or failure of the patient to recall such lesions should increase the clinician's suspicion of secondary syphilis. These lesions are often asymptomatic and may be the only indication of secondary syphilis. A high index of suspicion is necessary, and appropriate further clinical examination and serology should be carried out.

Rocky Mountain spotted fever may also present initially with palm or sole lesions. These appear as blanching erythematous macules that later become nonblanching petechial lesions. These lesions start distally and spread proximally.

Kawasaki disease, scarlet fever, and toxic shock syndrome may all have palmar erythema as a prominent feature. The palms and soles will desquamate as these diseases progress.

Furthermore, when considering pruritic eruptions of the extremities, one must always think about scabies. The hands, feet, and elbows along with the groin are the most common areas of involvement. Diagnostic burrows will most likely be found in the hyperkeratotic skin of the palms and soles particularly along the web spaces and the wrist. When the scabetic mite burden becomes quite high, Norwegian scabies results. Thick hyperkeratosis resembling dermatitis results [ Fig 239-9 (Pjate

24)]. See Chap 242 for further discussion.

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FIG. 239-9 (PJateM). Norwegian scabies. The thick scale, erythema, and exudate resemble a foot dermatitis. This disorder should not be forgotten when presented with a patient with extremely pruritic scaly eruption. Norwegian scabies is more common in immunocompromised and debilitated patients.

Finally, all the major types of skin cancer including malignant melanoma, squamous cell carcinoma, and basal cell carcinoma can occur on the extremities. BIBLIOGRAPHY

Omura EF, Rye B: Dermatologic disorders of the foot. Clin Sports Med 13(4):825, 1994.

Hochman LG: Paronychia: More than just an abscess. Int J Dermatol 34(6):385, 1995.

Epstein E: Hand dermatitis: Practical management and current concepts. J Am Acad Dermatol 10:395, 1984.

Epstein E, Maibach HI: Palms and soles, in Roenigk HH, Maibach HI (eds): Psoriasis, 2d ed. New York, Marcel Dekker, 1990, p 121.

Katz HI: Systemic antifungal agents used to treat onychomycosis. J Am Acad Dermatol 38:S48, 1998.

Ryan TJ, Burnand K: Diseases of the veins and arteries—Leg ulcers, in Champion, et al (eds): Rook/Wilkinson/Ebling Textbook of Dermatology, 5th ed. Oxford, Blackwell Scientific, 1992, pp 1963-2013.

Bondi EE, Lazarus GS: Panniculitis, in Fitzpatrick TB, et al (eds): Dermatology in General Medicine, 4th ed. New York, McGraw-Hill, 1993, pp 1392-1345.

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