Isolated Tender Nodules on Palms: A Case Report

Dear Editor,

Tender nodular lesions on palms can mimic other dermatoses and might be a clue to serious internal diseases. Neutrophilic dermatosis of dorsal hands is a rare localized variant of Sweet's syndrome.[1,2] Clinically, it presents as violaceous oedematous plaques, bullous, haemorrhagic, and ulcerated lesions on dorsal hands. However, only palmar involvement in NDDH is still less reported.[2,3] Review article on 123 cases of NDDH by Micallef D et al. reported only 5 cases having palmar involvement.[4]

A 55-year-old female presented with painful lesions over palms for 3 days. On examination, there were multiple erythematous to violaceous, tender oedematous plaques and nodules of size 1 × 2 cm² to 2 × 3 cm² over bilateral palms, sides of fingers and fingertips [Figure 1]. Some nodules and plaques were showing vesiculation on surface. The hands were swollen. The lesions were absent on dorsum of hands and on feet. There were no systemic features like fever, joint pain, sore throat, or loose stool. There was also no similar episode in the past or any relevant drug history. General, mucosal and systemic examinations revealed no abnormality. Differential diagnoses like palmoplantar eccrine hidranitis (PEH), erythema multiforme, localised sweet's syndrome, drug reactions, cutaneous vasculitis, secondary syphilis, Palisaded neutrophilic granulomatous dermatitis (PNGD) and Osler's nodes were kept. Investigations revealed haemoglobin 10.4 gm%, total leukocyte count of 10,000/mm3 with 81% neutrophilia. Her erythrocyte sedimentation rate was 72 mm in the first hour, and C-reactive protein was 98 mg/L (0–6 mg/L). Peripheral smear comment showed normochromic normocytic anaemia. Her urine analysis, liver and renal function tests, thyroid profile and serology for HIV, HBs Antigen, hepatitis C virus (HCV) and venereal disease research laboratory (VDRL) were non-reactive. Rheumatoid factor, and antinuclear antibody were also negative. No abnormality was detected on chest X-ray, ultrasonography of abdomen and pelvis and electrocardiogram. Stool examination for occult blood was negative. Culture from the exudate of finger lesions showed no growth. Histopathology of the lesion showed dense aggregation of neutrophils in the dermis, with subepidermal vesicles [Figure 2]. Leukocytoclasia along with endothelial swelling of blood vessels and extravasation of RBCs were found at places [Figure 3]. Based on the clinicopathologic features, diagnosis of neutrophilic dermatoses of dorsal hands (localised sweet's syndrome) was made. The patient was started with oral prednisolone 30 mg for 2 weeks and then tapered over 3 weeks. There was a significant response after 2 weeks [Figure 4] and no recurrence in the next 6-month follow-up.

Figure 1.

Erythematous tender nodules over bilateral palms

Figure 2.

Low power viewshowing dense infiltration of neutrophils in the dermis with subepidermal vesicles. (H & E,100 X)

Figure 3.

High power view showing neutrophils, leukocytoclasia, endothelial swelling of blood vessels and RBC extravasation at places. (H& E, 400 X)

Figure 4.

Response after 15 days of steroid therapy.

Tender nodules on palms can occur in various dermatological conditions [Table 1]. Thorough history taking, examination and pathological correlation are utmost important for the dermatologists in managing this condition.

Table 1.

Common differential diagnosis of tender erythematous palmar nodules

Dermatological Conditions	Clinical morphology	Involvement	Histopathology	Association	Treatment
Neutrophilic dermatosis of dorsal hands (NDDH)[1,2]	Violaceous tender oedematous plaques, bullous, haemorrhagic, and ulcerated lesions	Dorsal hands, legs commonly bilateral legs	Dense dermal infiltrate of neutrophils usually associated with subepidermal edema and leukocytoclastic debris and rarely vasculitis	Myelodysplasia, leukemia, IBD, tumors and haematological malignancies	Dapsone Steroid
Neutrophilic eccrine hidradenitis (NEH)[7]	Asymptomatic or tender erythematous and oedematous papules, plaques or nodules	Trunk, extremities, and face	Neutrophilic infiltrate around eccrine glands and coils and vacuolar degeneration and necrosis of epithelial cells of eccrine coil.	Chemotherapy For acute myelogenous leukaemia, Hodgkin’s lymphoma and solid tumours.	Treatment of underlying cause Dapsone Topical or oral steroid Rarely, antibiotics
Palmoplantar eccrine hidradenitis (PEH)[8]	Painful erythematous papules and nodules	Palm and sole	Neutrophilic eccrine hidradenitis is a neutrophilic infiltrate around eccrine glands and coils	healthy children Triggers-physical activity, excessive sweating and prolonged wetness	Self-limited
Erythema multiforme	Erythematous macules or papules evolve into classic “iris” or “target” lesions, with burning symptoms	Dorsal surfaces of the hands, extensor aspects of the extremities, palm and sole and mucosal involvement	Apoptotic or dyskeratotic keratinocytes, basal layer vacuolisation and dense lymphocytic infiltration at dermo-epidermal junction	Drug Infections (Herpes and Cytomegalovirus, EBV) Inflammatory bowel disease Malignancy	Withdrawal of drug Antiviral or Systemic steroid
Osler’s nodes	Painful erythematous tender nodule, associatedfever, splinter haemorrhage of nail plate and conjunctival haemorrhage	Bilateral extremities, fingertips,	Neutrophilic vasculitis affecting glomus apparatus of ends of fingers or micro-abscesses with bacteria within	Subacute bacterial endocarditis	Antibiotics
Palisaded neutrophilic granulomatous dermatitis (PNGD)[9]	erythematous-to-violaceous papules, plaques, or nodules	Extensor surfaces. Acral (palmar), umbilicated papules overlying bony prominences	Early lesion-Leucocytoclastic vasculitis with neutrophils Establised lesion-Palisaded granulomas with collagen trapping and neutrophils	RA, systemic sclerosis, Sjögren syndrome, autoimmune thyroiditis, hepatitis, inflammatory bowel disease, myelodysplastic syndrome, Wegener granulomatosis and Churg-Strauss syndrome Takayasu arteritis, diabetes, and infections such as Streptococcus, HIV, Epstein-Barr virus, and parvovirus	Systemic steroid Dapsone

Neutrophilic dermatosis of dorsal hands (NDDH) is a rare localized variant of Sweet's syndrome. Clinically it presents as violaceous oedematous plaques, bullous, haemorrhagic, and ulcerated lesions on dorsal hands.[1,2] Only palmar involvement in NDDH is less reported. Del Pozo et al.[2] in his review article includes the presentation of eight cases where three patients presented with lesions on the dorsal hands only, and in these cases, the lesions had Intensely pustular and; three patients presented with lesions only on the palmar surfaces with Erythematous oedematous and and the other two patients presented with lesions on the dorsal and palmar surfaces without pustules. Yang et al.[3] also had mentioned a case of NDDH involving palms. Another review article by Micallef D et al.[4] reported only five cases having palmar involvement out of 123 cases of NDDH. Absence of systemic symptoms like fever, target-like lesions, mucosal involvement, history of sexual contact, genital lesions, negative VDRL rules out common conditions like Osler's nodes, erythema multiformae, and secondary syphilis, respectively. Histopathology of lesions of NDDH reveals a dense dermal infiltrate of neutrophils usually associated with dermal oedema and leukocytoclastic debris.[5] The similar histopathological findings were noted in our case, along with vasculitic changes. Absence of neutrophilic infiltrate around eccrine glands and coils rules out Neutrophilic eccrine hidradenitis (NEH) or Palmoplantar eccrine hidradenitis (PEH). Similarly, absence of palisaded granulomas with collagen trapping rules out palisaded neutrophilic granulomatous dermatitis (PNGD). The leucocytoclastic vasculitis in our case can be explained by proposed theories of Cohen et al.[5] and Malone et al.[6] They explained vascular damage is probably a secondary event related to neutrophilic infiltration. The term pustular vasculitis of hands was revised after recognizing that vasculitis was an inconsistent finding and of secondary importance in its diagnosis. Several important associations have also been observed in patients of NDDH including myelodysplasia, leukaemia, inflammatory bowel disease, seropositive arthritis, sarcoidosis, lymphoma, lenalidomide, thalidomide, vaccinations, fertilizer exposure and HCV infection.[2] In our patient thorough investigations also could not find any of the above association. In our patient, there were typical tender erythematous oedematous plaques and nodules limited to only bilateral palms, which was consistent with NDDH histologically. There was no systemic association and the patient responded well to systemic corticosteroid. This bilateral symmetrical presentation with localized involvement of only palms without any systemic association should not deter us from keeping a diagnosis of NDDH or localised sweet's syndrome in mind.

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