Palmar plantar erythrodysesthesia differential diagnosis: Difference between revisions

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{{Palmar plantar erythrodysesthesia}}
__NOTOC__
{{CMG}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Palmar_plantar_erythrodysesthesia]]
{{CMG}}; {{AE}} {{MC}}
 
==Overview==
==Overview==
Palmar plantar erythrodysesthesia (PPE) must be differentiated from other [[Skin disorder|skin disorders]] that involve [[Hand|palms]] and/or [[Sole (foot)|soles]], such as [[Graft-versus-host disease]], [[contact dermatitis]], [[Plaque psoriasis|palmoplantar plaque psoriasis]], [[dyshidrotic eczema]], and [[Pustulosis|palmoplantar pustulosis]].
==Differentiating Palmar Plantar Erythrodysesthesia from other Diseases==
Palmar plantar erythrodysesthesia (PPE) must be differentiated from other [[Skin disorder|skin disorders]] that involve [[Hand|palms]] and/or [[Sole (foot)|soles]], such as [[Graft-versus-host disease]], [[contact dermatitis]], [[Plaque psoriasis|palmoplantar plaque psoriasis]], [[dyshidrotic eczema]], and [[Pustulosis|palmoplantar pustulosis]].
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Disease
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Clinical manifestation
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Histopathology
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Additional diagnostic clues
|-
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''Palmar plantar erythrodysesthesia'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Areas of well-defined intense [[erythema]] and [[edema]]
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* A variable degree of [[Epidermis (skin)|epidermal]] ([[Keratinocyte|keratinocytes]]) [[necrosis]] <ref name="pmid8468414">{{cite journal| author=Fitzpatrick JE| title=The cutaneous histopathology of chemotherapeutic reactions. | journal=J Cutan Pathol | year= 1993 | volume= 20 | issue= 1 | pages= 1-14 | pmid=8468414 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8468414  }} </ref>
* Vacuolar degeneration of the [[Stratum germinativum|basal cell layer]] of [[Epidermis (skin)|epidermis]]
* Spongiosis
*[[Hyperkeratosis]]
* Lymphohistiocytic infiltrates
*[[Superficial (human anatomy)|Superficial]] perivascular infiltration of [[dermis]] by [[Lymphocyte|lymphocytes]] and [[eosinophils]]
*[[Papilla|Papillary]] [[Dermis|dermal]] [[edema]]
* Neutrophilic eccrine hidradenitis
* Eccrine squamous syringometaplasia, in severe PPE ([[World Health Organization|WHO]] grades 3 and 4)<ref name="pmid9236526">{{cite journal| author=Valks R, Fraga J, Porras-Luque J, Figuera A, Garcia-Diéz A, Fernändez-Herrera J| title=Chemotherapy-induced eccrine squamous syringometaplasia. A distinctive eruption in patients receiving hematopoietic progenitor cells. | journal=Arch Dermatol | year= 1997 | volume= 133 | issue= 7 | pages= 873-8 | pmid=9236526 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9236526  }} </ref>
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* History of [[chemotherapeutic agent]] use
|-
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''[[Graft-versus-host disease|Graft-versus-host disease (GVHD)]]'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* A diffuse [[Macule|macular]] [[erythema]] which may form [[Papule|papules]]
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
*[[Histology|Histologic]] features of [[Graft-versus-host disease]] and palmar plantar erythrodysesthesia are identical in early stages and serial [[biopsies]] may be needed to distinguish between these two entities.
* Features suggestive of [[Graft-versus-host disease]]:<ref name="pmid23008">{{cite journal| author=Sale GE, Lerner KG, Barker EA, Shulman HM, Thomas ED| title=The skin biopsy in the diagnosis of acute graft-versus-host disease in man. | journal=Am J Pathol | year= 1977 | volume= 89 | issue= 3 | pages= 621-36 | pmid=23008 | doi= | pmc=2032260 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23008  }} </ref>
:* Degenerate [[Keratinocyte|keratinocytes]] at all levels of the [[Epidermis (skin)|epidermis]]
:* Adjacent [[Lymphocyte|lymphocytes]] (satellite cell [[necrosis]])
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Extracutaneous manifestations of [[Acute (medicine)|Acute]] [[Graft-versus-host disease|GVHD]], including:<ref name="pmid9236526">{{cite journal| author=Valks R, Fraga J, Porras-Luque J, Figuera A, Garcia-Diéz A, Fernändez-Herrera J| title=Chemotherapy-induced eccrine squamous syringometaplasia. A distinctive eruption in patients receiving hematopoietic progenitor cells. | journal=Arch Dermatol | year= 1997 | volume= 133 | issue= 7 | pages= 873-8 | pmid=9236526 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9236526  }} </ref>
:*[[Gastrointestinal]] [[symptoms]], such as [[diarrhea]] and [[abdominal pain]]
:* Elevated [[liver enzymes]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''[[Allergic contact dermatitis]]'''<ref name="">{{cite book | last = Goldsmith | first = Lowell | title = Fitzpatrick's dermatology in general medicine | publisher = McGraw-Hill Medical | location = New York | year = 2012 | isbn = 978-0-07-166904-7 }}</ref>
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Well-demarcated, [[Eczema|eczematous]] eruptions localized to the area of [[skin]] that in contact with the culprit [[allergen]]
:*[[Acute (medicine)|Acute]] eruption: [[Vesicle (biology)|Vesicular]]
:*[[Chronic (medical)|Chronic]] eruption: [[Lichenification|Lichenified]] and scaly [[Plaque|plaques]]
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
*[[Eosinophilic]] spongiosis
*[[Exocytosis]] of [[eosinophils]] and [[Lymphocyte|lymphocytes]]
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* History of [[allergen]] exposure
*[[Pruritis|Pruritic]] [[lesions]]
* Patch [[Experiment|testing]] may help to identify [[Allergen|allergens]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''[[Psoriasis|Palmoplantar plaque psoriasis]]'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Sharply defined [[Erythema|erythematous]], scaly [[Plaque|plaques]] on the [[Hand|palms]] and/or [[Sole (foot)|soles]]
*[[Fissure|Fissures]]
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Acanthosis
*[[Hyperkeratosis]]
* Parakeratosis
* Neutrophilic infiltration in the [[Epidermis (skin)|epidermis]] and [[stratum corneum]] (Kogoj pustules and Munro's [[Abscesses|microabscesses]])
* Abundant mononuclear [[cells]] (mainly [[Myelocyte|myeloid cells]] and [[T cell|T cells]]) in the [[dermis]]
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
*[[Itch|Pruritus]] is common
* Positive [[Koebner phenomenon]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''[[Dyshidrotic eczema]]'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Deep-seated clear [[vesicles]]; later, [[Scaling skin|scaling]], [[Fissure|fissures]] and [[lichenification]] occur
* Deep-seated [[Vesicle|vesicles]] or [[Blister|blisters]] on the tips and lateral sides of the [[Finger|fingers]], [[Hand|palms]], and [[Sole (foot)|soles]] with subsequent [[Scaling skin|scaling]], [[Fissure|fissures]] and [[lichenification]]
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
*[[Acute (medicine)|Acute:]]
:* Intraepidermal spongiotic [[Vesicle|vesicles]] or bullae that do not involve the intraepidermal portion of the [[Eccrine sweat glands|eccrine sweat duct]] (acrosyringium)
:* A sparse, superficial perivascular infiltrate of [[Lymphocyte|lymphocytes]]
*[[Chronic (medical)|Chronic:]]


==Differential diagnosis==
:* Predominance of parakeratosis and acanthosis with minimal or no spongiosis and a [[dermal]] [[Lymphocyte|lymphocytic]] infiltrate
The problem arises in patients after [[bone marrow transplant|bone marrow transplants]], as the clinical and histologic features of PPE can be similar to cutaneous manifestations of acute (first 3 weeks) [[graft-versus-host disease]]. It is important to differentiate PPE, which is benign, from the more dangerous graft-versus-host disease. As time progresses, patients with graft-versus-host disease progress to have other body parts affected, while PPE is limited to hands and feet. Serial biopsies every 3 to 5 days can also be helpful in differentiating the two disorders (Crider et al, 1986).
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Intensely [[Pruritis|pruritic]]
* History of recurrence
|-
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" | '''[[Pustulosis palmaris et plantaris|Palmoplantar pustulosis]]'''
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Multiple [[pustules]] on the [[Hand|palms]] and/or [[Sole (foot)|soles]], with surrounding [[erythema]] and [[hyperkeratosis]]
*[[Fissure|Fissures]]
*[[Nail changes]]
* Brown [[macules]] at the site of resolving [[pustules]]
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Parakeratosis
* Loss of [[granular layer]]
* Psoriasiform epidermal hyperplasia
* Spongiosis
*[[Pustules]] filled with [[Neutrophil|neutrophils]] and [[eosinophils]] in the upper [[Epidermis (skin)|epidermis]]
*[[Mast cell]] and [[eosinophil]] infiltration in the upper [[dermis]]
* Mixed perivascular and diffuse infiltrate in the [[dermis]] ([[Lymphocyte|lymphocytes]], [[neutrophils]], [[eosinophils]], and [[Mast cell|mast cells]])
| style="background: #DCDCDC; padding: 5px; text-align: left;" valign="top" |
* Non-[[pustular psoriasis]]-like eruptions may be seen in other areas
*[[Nail changes]] may be seen
*[[Arthralgia]] or unspecified [[arthritis]] may be seen in some [[Patient|patients]]
|-
|}


==References==
==References==
{{reflist|3}}
{{reflist|3}}
[[Category:Up-To-Date]]
[[Category:Oncology]]
[[Category:Medicine]]

Latest revision as of 19:32, 5 August 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mandana Chitsazan, M.D. [2]

Overview

Palmar plantar erythrodysesthesia (PPE) must be differentiated from other skin disorders that involve palms and/or soles, such as Graft-versus-host disease, contact dermatitis, palmoplantar plaque psoriasis, dyshidrotic eczema, and palmoplantar pustulosis.

Differentiating Palmar Plantar Erythrodysesthesia from other Diseases

Palmar plantar erythrodysesthesia (PPE) must be differentiated from other skin disorders that involve palms and/or soles, such as Graft-versus-host disease, contact dermatitis, palmoplantar plaque psoriasis, dyshidrotic eczema, and palmoplantar pustulosis.

Disease Clinical manifestation Histopathology Additional diagnostic clues
Palmar plantar erythrodysesthesia
Graft-versus-host disease (GVHD)
Allergic contact dermatitis[4]
Palmoplantar plaque psoriasis
Dyshidrotic eczema
  • Intraepidermal spongiotic vesicles or bullae that do not involve the intraepidermal portion of the eccrine sweat duct (acrosyringium)
  • A sparse, superficial perivascular infiltrate of lymphocytes
  • Predominance of parakeratosis and acanthosis with minimal or no spongiosis and a dermal lymphocytic infiltrate
  • Intensely pruritic
  • History of recurrence
Palmoplantar pustulosis

References

  1. Fitzpatrick JE (1993). "The cutaneous histopathology of chemotherapeutic reactions". J Cutan Pathol. 20 (1): 1–14. PMID 8468414.
  2. 2.0 2.1 Valks R, Fraga J, Porras-Luque J, Figuera A, Garcia-Diéz A, Fernändez-Herrera J (1997). "Chemotherapy-induced eccrine squamous syringometaplasia. A distinctive eruption in patients receiving hematopoietic progenitor cells". Arch Dermatol. 133 (7): 873–8. PMID 9236526.
  3. Sale GE, Lerner KG, Barker EA, Shulman HM, Thomas ED (1977). "The skin biopsy in the diagnosis of acute graft-versus-host disease in man". Am J Pathol. 89 (3): 621–36. PMC 2032260. PMID 23008.
  4. Goldsmith, Lowell (2012). Fitzpatrick's dermatology in general medicine. New York: McGraw-Hill Medical. ISBN 978-0-07-166904-7.