Palmar erythema and pruritus
Question:
5/8/2023
I have a 73-year-old patient who endorses sensation of intense palmar erythema/pruritus for the past year when she eats "high histamine" containing foods during lunch but she can eat these foods during dinner without issue. If she eats what she deems "bland foods" during lunch she does not have issues. Oral antihistamines prn during these episodes provided some relief. I did food allergy IgE testing that was negative and did discuss that low histamine diets are not necessarily medically validated at this time. Is there any other work up you would recommend?
Answer:
There is a very wide differential diagnosis for palmar erythema, with or without itching.
Palmar erythema is typically not pruritic. Numerous disease states are associated with secondary palmar erythema including cirrhosis, abnormal serum estradiol levels, Wilson's disease, hereditary hemochromatosis, rheumatoid arthritis, thyrotoxicosis, and diabetes mellitus. Drug-induced palmar erythema has been associated with hepatic damage with use of amiodarone, gemfibrozil, and cholestyramine. Drug-induced palmar erythema with normal liver function has been associated with the use of topiramate and albuterol. Metastatic and primary brain neoplasms have been associated with palmar erythema. Erythema ab igne, caused by repeated exposure to direct heat or infrared radiation, can mimic palmar erythema. Smoking and chronic mercury poisoning are environmental causes of palmar erythema.
https://pubmed.ncbi.nlm.nih.gov/18039017/
Acute onset palmar itching, with minimal skin changes, has been associated with contact dermatitis, diabetes, reactions to medications, cirrhosis, and nerve disorders. Alcohol ingestion can cause transient hand itching.
If cetirizine 10 to 20 mg 1/2 hour prior to lunch mitigates the symptoms, then they are likely to be at least partially histamine mediated.
Eric Macy, MD, MS, FAAAAI