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March 2008: Hand problems

By Dr Nigel Stollery

By Dr Nigel Stollery

1 Acromegaly



In acromegaly, excess circulating growth hormone increases the levels of somatomedins, insulin-like growth factors, which in turn causes a number of physical changes, such as oedema, broad nose, prognathism, interdental separation, a prominent suborbital ridge and a large tongue.

One of the earliest changes is a thickening or increased sponginess of the skin overlying the soles and palms.1 This gives the hands a characteristic appearance and typical, sausage-like fingers.

About 95% of cases are caused by a pituitary adenoma. The condition is most common in patients in their early 20s and often has a slow and insidious progression. This can lead to a delay in diagnosis, resulting in severe disfigurement in some cases.

Treatment options include surgery, radiotherapy, bromocriptine or a combination of these therapies.

2 Dupuytren's contracture



Dupuytren's contracture is caused by a thickening and shortening of the fibrous bands of the palmar fascia. It can be quite disabling in its advanced stages, especially if the dominant hand is affected. A similar condition is seen in the penis (Peyronie's disease) and the feet (Ledderhose's disease).

Surgery is the mainstay of treatment, and is usually performed when the angle between the finger and palm is less that 30oC.

A number of non-surgical treatments, including calcium channel blockers, interferon gamma, skeletal traction and percutaneous needle fasciotomy, are currently being evaluated.

3 Pompholyx



Pompholyx, also known as dyshidrotic eczema, typically affects the palms, soles and fingers with a characteristic pruritic vesicular rash. It is twice as common in women than men and the peak age of onset is 20-40 years.

Topical steroids and emollients can be used, although pompholyx can often be resistant to treatment.

In the majority of cases the cause is unknown, but risk factors are thought to include stress, exposure to metal salts and allergic contact dermatitis. Exposure to immunoglobulins may also be a risk factor.2

4 Erythema multiforme



Erythema multiforme is part of a spectrum of diseases that includes Stevens-Johnson syndrome and toxic epidermal necrolysis (Lyell's syndrome).

The condition typically presents with characteristic target lesions, which may arise suddenly after an immunological insult, such as a herpes simplex infection. In 50% of cases there is no obvious cause and the condition is deemed idiopathic.

Patients tend to report a burning sensation but pruritus is usually absent. Concomitant symptoms can include fever, malaise, myalgia, arthralgia, headache, sore throat, cough, nausea, vomiting and diarrhoea.

In mild cases treatment is symptomatic with NSAIDs, cold compresses and topical steroids. In more severe cases hospital admission may be required.

5 Mallet finger



In mallet finger, trauma to an extended finger results in an inability to extend the fingertip, which rests in a flexed state.

The condition is usually treated by splinting the distal interphalangeal joint.3 This should be for six to eight weeks for tendinous injuries, and slightly less for bony injuries.

Many patients delay in seeking help, which ultimately results in a permanent deformity, usually of no functional consequence.

An x-ray can be useful in the assessment of mallet finger injuries to differentiate between simple tendon damage and avulsion fractures.

6 Digital mucoid cyst



Digital mucoid cysts are benign ganglions of the distal interphalangeal joints or proximal nail folds. Depending on the position of the cyst, nails may be normal or have a characteristic groove distal to the cyst.

Women are more commonly affected than men and the mean age of onset is 60 years.

Mucoid cysts are often asymptomatic and treatment is not always required. If a patient wants treatment, options include aspiration, topical steroids under occlusion and cryotherapy. However, recurrence is common and can occur in up to 28% of cases.4

One study found that infrared coagulation therapy is effective.5

Spontaneous resolution will occur in around 50% of cases after two years.

7 Pyogenic granuloma



Pyogenic granulomas usually occur after trauma. They can grow rapidly and cause alarm and fear that there is an underlying malignancy.

The lesions are typically solitary, bright red and friable, and may be polypoid, as in the case shown in the picture. They most commonly occur on the head, neck and distal extremities, such as the fingers.

When the diagnosis is in doubt, dermoscopy can be useful. Pyogenic granulomas have a characteristic red homogeneous centre with a surrounding white collarette.

Treatment of choice is curettage or shaving with cautery. Other options include cryotherapy and chemical cauterisation with silver nitrate.

8 Raynaud's disease



Raynaud's disease is reversible ischaemia of peripheral arterioles, usually in response to stress or cold, which results in a characteristic white or blue appearance of the fingers.

Raynaud's disease is a primary (idiopathic) condition. Raynaud's phenomenon is identical in appearance, but occurs secondary to another disease process, usually of autoimmune origin.

General measures, for example warming affected areas and avoiding vasoconstrictors such as nicotine6 and beta-blockers, are very important.

In more severe cases, calcium channel blockers and ACE inhibitors have been shown to help.7

9 Vitiligo



Vitiligo can be a devastating condition, especially in patients with Fitzpatrick skin types V or VI.

In a small number of cases repigmentation will occur, typically starting around the hair follicles and resulting in a speckled appearance.

Various treatments are used to stimulate repigmentation, including potent topical steroids, tacrolimus8 and light therapy (PUVA and narrow band UVB). However, no treatment has a guaranteed outcome and the psychological effect of treatment failure must not be underestimated.

In extreme cases, bleaching of non-affected areas is an option, but this is irreversible. Patients need to be carefully selected and counselled beforehand.

10 Palmoplantar keratoderma



The palmoplantar keratodermas are a heterogeneous group of disorders in which there is a thickening of the palms or soles. There are many different forms and classification is complex. The condition may be acquired or inherited.9

Treatment is difficult. In milder cases, topical keratolytics, such as salicylic or lactic acid, are effective. Topical retinoids also have a role but may cause skin irritation. If there is an inflammatory component, potent topical steroids can be used.

In severe cases, excision of the affected areas followed by grafting may be required.

Author

Dr Nigel Stollery
MB BS
GP, Kibworth, Leicestershire and clinical assistant in dermatology, Leicester Royal Infirmary

1 Acromegaly 2 Dupuytren's contracture 4 Erythema multiforme 4 Pompholyx 5 Mallet finger 6 Digital mucoid cyst 7 Pyogenic granuloma 8 Raynaud's disease 9 Vitiligo 10 Palmoplantar keratoderma

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