Diagnosis and Management of Itching Palms and Soles with Lacerative Lesions

Immediate Life-Threatening Exclusions

The American College of Physicians and the Centers for Disease Control and Prevention recommend treating empirically with doxycycline immediately for Rocky Mountain spotted fever if fever, headache, or systemic symptoms are present with recent tick exposure, as it presents with maculopapular rash involving palms and soles 2-4 days after fever onset and carries 5-10% mortality if untreated 3, 1
The Centers for Disease Control and Prevention advise not to wait for the classic triad (fever, rash, tick bite) before treating suspected RMSF—only a minority present with all three initially, and delayed treatment increases mortality 1
The American College of Obstetricians and Gynecologists recommends measuring serum bile acids to exclude intrahepatic cholestasis of pregnancy if pregnant with pruritus, which predominantly affects palms and soles, is worse at night, and confers risk of stillbirth 4

The American Academy of Dermatology notes that palmoplantar psoriasis is one of the most common causes, presenting with well-demarcated erythematous plaques with thick silvery scale and hyperkeratosis, affecting 40% of cases 2, 1
The American Academy of Dermatology also states that hyperkeratotic hand-foot eczema is another common cause, presenting with vesicles, scaling, erythema, and fissuring with yellow-white scaling on dermoscopy, affecting 31% of cases 2

The American Academy of Dermatology recommends including occupational exposures to irritants or allergens in the patient history, as frequent hand washing, chemicals, or wet work can exacerbate symptoms 2
The Centers for Disease Control and Prevention advise including recent tick exposure or travel in the patient history to consider RMSF 3, 1
The American College of Obstetricians and Gynecologists recommends including pregnancy status in the patient history to consider cholestasis 4

The American Academy of Dermatology recommends initiating topical therapy with clobetasol propionate 0.05% cream or ointment twice daily to affected areas for palmoplantar psoriasis or hyperkeratotic eczema 2
The American Academy of Dermatology also recommends using urea 10% cream three times daily to all affected areas, including after hand washing, for humectant and keratolytic effects 2
The American Academy of Dermatology suggests using the "soak and smear" technique: soaking hands in plain water for 20 minutes, then applying moisturizer to damp skin to enhance penetration 2

The American Academy of Dermatology recommends referring for topical PUVA (psoralen plus UVA) therapy 2-3 sessions weekly if no response after 4 weeks of topical therapy, which achieves clearance or considerable improvement in 58-81% of dyshidrotic eczema and 50-67% of hyperkeratotic eczema 2
The Journal of the American Academy of Dermatology suggests using 308-nm excimer laser for targeted phototherapy as an alternative 5

The American Academy of Dermatology recommends initiating acitretin 25 mg daily for severe palmoplantar psoriasis, which demonstrates significant improvement in scaling, thickness, and erythema within 2 months 5, 2
The American Academy of Dermatology notes that monitoring lipid panels is necessary, as elevations in triglycerides and cholesterol are common but manageable with fibrates or statins 5, 2

The Centers for Disease Control and Prevention warn never to dismiss fever with palmar rash as simple dermatitis—RMSF mortality increases dramatically with delayed doxycycline treatment 3, 1
The American College of Obstetricians and Gynecologists advises not to confuse excoriations from scratching with primary rash—cholestasis in pregnancy has no primary rash, only secondary excoriations 4