How to Find the Cause of Itchy Palms and Soles

Diagnosis of Palmoplantar Pruritus: Guidelines for Doctors, Patients

Mar 11, 2009 Hanish Babu

Finding the cause of itchy palms and soles involves detailed history taking, meticulous clinical examination and carrying out relevant laboratory tests.

Itchy palms and soles, especially without any evident skin changes, is a challenge for both the treating physician as well as patients.

To find the most effective remedy for the itchy palms and soles, it is important to find the exact cause of the palmoplantar pruritus. When skin rashes are present, the diagnosis is somewhat easy. Skin rashes most often affect the palms and soles only, but in many cases, can involve the back of the hands and feet as well as other areas of the body.

There are two phases in finding the cause of itchy palms and soles: during the initial visit of the patient and during the subsequent visit, say, after a period of two weeks.

Finding the Cause of Itchy Palms and Soles: Initial Visit

Detailed history of the itching of palms and soles or hands and feet.
- Are there any skin rashes? Itchy palms and/or soles without skin changes may be due to internal systemic causes, ingested allergens, or psychogenic.
- Did the skin rashes appear before or after the itching started? Contact dermatitis causing hand and foot eczema can cause itching even before the signs dermatitis appear. The itching of Tinea manum (ringworm of hand) or Tinea pedis (ringworm of foot) usually start after the appearance of the skin rashes. Itching of scabies may be preceded by the appearance of burrows and bumps in between the finger webs and elsewhere on the body.
- When is the itching of the hands and feet more? Does it keep the patient awake? Itching in scabies is more during night. The psychogenic itching is more when the patient is sitting idle or when stressed.
Skin examination to rule out or confirm skin conditions causing the itching of palms and soles.
- The rashes of palmoplantar psoriasis, ring worm, hand eczema, pompholyx, lichen planus, dry skin, scabies etc are typical enough to make an on the spot diagnosis. Typical rashes in other areas of the body will clinch the diagnosis. Ide eruptions and pompholyx with severe itching of palms and soles can occur following infectious foci elsewhere on the body, like ring worm infestation, infected eczema, herpes simplex infection etc.
Clinical tests
- Stroking the skin firmly with a blunt object produces wheals in urticaria (dermographism), while it produces blanching or white dermographism in atopic dermatitis. Application of water on the skin for 2-5 minutes produces itching and rashes in aquagenic pruritus and aquagenic urticaria.
General systemic examination.
- General physical examination including lymph nodes, respiratory system, liver, spleen and abdominal examination.
Repeat history taking relevant to the initial findings.
- Does the patient have any constitutional symptoms like fever, weight loss, loss of appetite, fatigue etc?
- Any history of recent medications?
Baseline laboratory investigations to rule out the common causes.
- Random blood sugar, hemoglobin to rule out anemia.
- Scraping the scales for fungus and the finger web burrows for scabies mite and examination under microscope.
Provide a treatment schedule for the itchy palms and soles based on the findings
- A long acting antihistamine (like cetrizine), plus a short acting sedating antihistamine (hydroxyzine) will provide symptomatic relief. Most temporary allergies to food, medications will get relieved. Specific therapies for scabies, ring worm, eczema, psoriasis or lichen planus is given according to the diagnosis made.
Appointment for the next visit.
- An appointment for follow up review is given after two weeks

Finding the Cause of Itchy Palms and Soles: Subsequent Visit or Visits

Review the effect of treatment advised for the itchy palms and soles during the first visit.
If no relief or actual worsening of the itching of palms and soles with the treatment provided, carry out a detailed review of history, skin and systemic examination again.
Laboratory tests: Complete blood counts (CBC), erythrocyte sedimentation rate, peripheral blood smear for opinion, fasting and post meal blood sugar, liver and kidney function tests, Hepatitis A, B and C tests, thyroid tests, stool for occult blood and parasites, herpes virus antigen tests, x ray chest etc are the basic tests laboratory investigations to be carried out in persistent itchy palms and soles where no evident skin or systemic disease could be identified.
If diagnosis reached already: proceed with specific treatment for the itchy palms and soles depending upon the cause.
If still no diagnosis, what to do? This calls for multidisciplinary referrals including psychiatry and gastroenterology for a review of all systems to find the possible cause. In females a full pelvic examination and PAP smear should be carried out.

Finding the exact cause is thus of paramount importance in getting rid of the itchy palms and soles.

Reference

Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology, Fifth Ed, 2005

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