A report describes a case of a 55-year-old female who complained of painful lesions over her palms for 3 days. Examination revealed multiple erythematous to violaceous, tender edematous plaques, and nodules of 1 × 2 to 2 × 3 cm2 dimensions over bilateral palms, sides of fingers, and fingertips. Some nodules and plaques showed vesiculation on the surface. Her hands were also swollen. The dorsum of the hands and the feet displayed no lesions. No systemic features like fever, joint pain, sore throat, or loose stool were present. No similar episode in the past or any relevant drug history was described. General, mucosal and systemic examinations showed no abnormality.

Differential diagnoses like palmoplantar eccrine hidradenitis (PEH), erythema multiforme, localized sweet′s syndrome, drug reactions, cutaneous vasculitis, secondary syphilis, Palisaded neutrophilic granulomatous dermatitis (PNGD) and Osler′s nodes were considered. Investigations showed hemoglobin of 10.4 gm%, total leukocyte count of 10,000/mm³ with 81% neutrophilia. Her erythrocyte sedimentation rate was found to be 72 mm in the first hour, and C-reactive protein was 98 mg/L (0-6 mg/L). Peripheral smear displayed normochromic normocytic anemia. Her urine analysis, liver and renal function tests, thyroid profile, and serology for HIV, HBs antigen, hepatitis C virus, and venereal disease research laboratory (VDRL) were normal and nonreactive, respectively. Rheumatoid factor and antinuclear antibody were also deemed negative. Chest X-ray, ultrasonography of abdomen and pelvis, and electrocardiogram showed no abnormalities. Stool examination for occult blood came out to be negative. Culture from the exudate of finger lesions revealed no growth. Histopathology of the lesion displayed dense aggregation of neutrophils in the dermis, with subepidermal vesicles. Leukocytoclasia along with endothelial swelling of blood vessels and extravasation of RBCs were located at some sites.

These clinicopathologic features prompted the diagnosis of neutrophilic dermatoses of dorsal hands (localized sweet′s syndrome). She was prescribed oral prednisolone 30 mg for 2 weeks, which was then tapered over 3 weeks. She showed a significant response after 2 weeks and no recurrence in the next 6-month follow-up.

Source: Sahu K. Isolated tender nodules on palms: a case report. Indian Dermatol Online J. 2021;12(4):624-7.