Management of Chronic Palmoplantar Excoriation

Contact Dermatitis

Chronic allergic or irritant contact dermatitis of the palms and soles presents with dryness, lichenification, and fissuring that provoke scratching; patch testing should be offered for persistent cases to identify the offending allergen【1】.
Repeated exposure to detergents, organic solvents, soaps, or low‑humidity irritants can cause cumulative irritant contact dermatitis, contributing to chronic excoriation【1】.
Allergic contact dermatitis has a poorer prognosis unless the specific allergen is identified and avoided【1】.

Iron deficiency is a frequent systemic cause of generalized pruritus that may involve the palms and soles; checking a full blood count and ferritin (threshold < 15–25 µg/L) is recommended in all chronic pruritus patients【2】.
Oral iron replacement can lead to rapid cessation of pruritus in many patients【2】.

Hepatic cholestasis, uraemia, malignancy, haematologic disorders, endocrine disease, and infections can produce generalized pruritus with possible palm‑plantar excoriation【2】.
HIV infection may present with pruritus, often in advanced disease but occasionally as an initial manifestation【4】.

Small‑fiber neuropathy can cause localized or generalized pruritus affecting the palms and soles, frequently accompanied by burning, paraesthesia, stinging, or tingling sensations【3】.
Systemic diseases such as diabetes mellitus, HIV, sarcoidosis, and Guillain‑Barré syndrome are associated with neuropathic pruritus of the extremities【3】.
When small‑fiber neuropathy is suspected, skin biopsy may be required because clinical and electrophysiological findings can be subtle【3】.

Acute stress, strong emotions (e.g., rage, fear, embarrassment), and major life events can trigger or exacerbate pruritus through activation of hippocampal and subcortical neural circuits【5】.
Chronic pruritus is commonly observed in patients with depression, anxiety disorders, obsessive‑compulsive disorder, substance abuse, and delusional infestation【5】.

A thorough physical evaluation should precede any psychogenic labeling; clinicians must prioritize identification of dermatologic, systemic, or neuropathic etiologies【5】【6】.
Detailed history taking should include travel, sexual exposure, intravenous drug use, occupational hazards, and personal care products to uncover potential triggers【1】.
For suspected contact dermatitis, review of workplace health‑and‑safety data sheets is advised to pinpoint irritant or allergen exposure【1】.

Attributing chronic palm‑plantar excoriation solely to psychiatric causes without comprehensive investigation is a major error; up to one‑third of patients with chronic pruritus develop secondary anxiety or depression, which are consequences rather than primary causes【5】【4】.