ACTAS Dermo-Sifiliográficas 112 (2021) 843---844
CASE FOR DIAGNOSIS
Sudden appearance of a painful
bluish nodule on the hand夽
Aparición súbita de un nódulo azulado
doloroso en la mano
Patient History
A 40-year-old woman presented with sudden onset of a
painful nodule on the palmar aspect of the left third digit,
non-dominant hand. The nodule had been present for 4 days.
No previous local trauma or Raynaud’s phenomenon were
found in the past history, which was also unremarkable for
smoking, drug intake or other comorbidities.
Physical Examination
A bluish-violet nodule of 4 mm was observed on the palmar
side of the third digit, at the level of the proximal interpha-
langeal (PIP) joint (Fig.1). The nodule was highly sensitive on
compression and it was fixed to the subcutaneous structures.
No color change on the tip of the digit was present and pul-
sation at both the left radial and ulnar arteries was normal.
Physical examination was not otherwise remarkable. Figure 1 Bluish-violet nodule on the palmar side of the digit.
Complementary Tests
Dermoscopic examination of the lesion showed a blue struc-
tureless pattern (homogeneous blue pattern) (Fig. 2).
An excisional biopsy under intrathecal anesthesia was
performed.
Histological analysis revealed a severely ectatic venous
vascular structure with intraluminal congestion and an
organized thrombus in its interior. A scarce surrounding
inflammatory infiltrate containing lymphocytes and occa-
sional neutrophils was also observed (Fig. 3).
Laboratory studies including complete blood count,
prothrombin time, activated partial thromboplastin time,
proteins C and S, factor V Leiden, antithrombin III, anticar-
夽 Please cite this article as: Batista M, Brinca A, Vieira R. Aparición Figure 2 Dermoscopic examination: blue structureless pat-
tern.
súbita de un nódulo azulado doloroso en la mano. Actas Dermosifil-
iogr. 2021;112:843---844.
1578-2190/© 2021 Published by Elsevier España, S.L.U. on behalf of AEDV. This is an open access article under the CC BY-NC-ND license
([Link]
CASE FOR DIAGNOSIS
than dorsal veins, these seems to be more vulnerable to triv-
ial trauma.5 Such injuries are presumably unrecognized and
repetitive. As the majority of the cases our patient could
not recall a directly preceding traumatic event. However, it
should be noted that she is a dermatologic surgeon. There-
fore, minor trauma may have contributed.
It has also been suggested that hypercoagulable states
may play a role. However an association between digital pal-
mar vein thrombosis and hemostatic abnormalities has been
difficult to prove.3,6 Nevertheless, evaluation of the hemo-
static profile may be considered but has not been proved to
contribute to either the diagnosis or the management.
The differential diagnosis should include varices with no
thrombosis, hemangiomas, epidermal inclusion cysts, giant-
Figure 3 Hematoxylin-eosin, ×100. cell tumors, ganglions, lipomas, blue nevi, and melanoma
metastasis.6
diolipin antibodies and lupus anticoagulant did not showed Conservative management such as massaging the lesion,
relevant data. applying hot compresses or compression bandages and tak-
ing aspirin seems to be effective in relieving of symptoms.3
Surgical excision is indicated when the clinical diagnosis is
Diagnosis in doubt or if symptoms persist.
This case highlights the importance to consider palmar
Based on the clinical and histological findings, the patient digital vein thrombosis in the differential diagnosis of a
was diagnosed with thrombosis of palmar digital vein. painful, firm, blue nodule located at or in close proximity
to one of the flexion crease of a finger.
Course and Treatment
Conflicts of Interest
After surgical excision symptoms completely resolved and
recurrence of the lesion did not occur. The authors declare no conflicts of interest.
Comments References
Thrombosis of the palmar digital veins was first described in 1. Jadassohn W. Ein fall von thrombosen in den fingervenen. Schweiz
1936 by Jadassohn.1 Given the scarcity of cases reported in Med Wochenschr. 1936;66:549.
the literature digital vein thrombosis seems to be a relatively 2. Kim HY, Cho EB, Youn SH, Park EJ, Kwon IH, Kim KH, Kim KJ. Two
rare condition.2 cases of thrombosis of the palmar digital vein. Ann Dermatol.
It is observed most often in females between 35 and 2012;24:351---4.
65 years although it can occur at any age.3 Typically it 3. van Rossum M, van der Lei B, van Wingerden J. Thrombosis of
the palmar digital veins: a report of 6 cases and a review of the
presents as one or more hard painful nodules on the pal-
literature. Ann Plast Surg. 2005;55:629---32.
mar or lateral side of the fingers, with a bluish-black or 4. Gargan TJ, Slavin SA. Varix of the digit. Plast Reconstr Surg.
erythematous discoloration. The fourth digit is most often 1988;81:590---3.
affected, sometimes but not always associated with local 5. Lanzetta M, Morrison WA. Spontaneous thrombosis of palmar dig-
trauma like wearing a ring.3 Typically, as in our patient, the ital veins. J Hand Surg Br. 1996;21:410---2.
nodule is located around the PIP joint, but nodules have also 6. Vildósola S, Manrique P, Artola JL, Bilbao I, Morillo V, Zabalza I.
been located over the middle or proximal phalanx or at the Bluish nodule in the hand. Actas Dermosifiliogr. 2007;98:497---8.
level of the distal interphalangeal joint.
Although the etiology is still to be completely under- M. Batista,a,∗ A. Brinca,a R. Vieiraa,b
stood several factors have been implicated, namely the a
Department of Dermatology, Centro Hospitalar e
uniqueness of the anatomic characteristics of the palmar
Universitário de Coimbra, Coimbra, Portugal
digital veins. Different from dorsal veins, these vessels are b
Faculty of Medicine, University of Coimbra, Coimbra,
surrounded by a sheath of fine connective tissue and fat
Portugal
cushions.4 If this supporting structure deteriorates through
aging these veins become more prone to collapse leading ∗
Corresponding author.
to thrombosis. Furthermore, because of their localization E-mail address: sousabatistamariana@[Link]
at the flexion creases of the fingers and the fact that pal- (M. Batista).
mar veins are smaller in diameter and contain more valves
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