Palmar Skin Changes (Tripe Palms)—an Early Paraneoplastic Warning Sign

A 66-year-old female patient presented with a ≈ 1-year history of cracked palms. Emollients and topical glucocorticoids had failed to improve the findings. From a clinical perspective, marked palmar crease formation with cobblestone pattern, velvety white hyperkeratosis, and axillary acanthosis nigricans were striking. The patient was known to have a history of endometrial adenocarcinoma, for which which she had undergone R0 resection a good 3 years previously. Due to parailiac and retroperitoneal lymph node recurrence 2 years later, the patient had received paclitaxel/carboplatin chemotherapy. Treatment was switched to pembrolizumab as a result of tumor progression and microsatellite instability. As is often the case in this patient population, pembrolizumab significantly reduced tumor size in our patient at good tolerability (KEYNOTE-158). The palmar skin lesions had manifested 6 months prior to the diagnosis of lymph node recurrence. The nature and appearance of this rare facultative paraneoplastic dermatosis gave rise to the designation “tripe palms.” In 7/10 of cases, tripe palms coincide with acanthosis nigricans, while in 9/10 cases they are associated with primarily gastrointestinal, pulmonary, or gynecological adenocarcinomas. In just under 5/10 cases, tripe palms precede the malignancy as a warning sign worthy of comprehensive investigation.

Figure.

Tripe palm (including magnified section), (1) velvety white hyperkeratosis, (2) palmar crease formation, and (3) cobblestone pattern