Palmar plantar erythrodysesthesia differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mandana Chitsazan, M.D. [2]

Overview

PPE must be differentiated from Graft-Versus-Host Disease (GVHD).

Disease	Clinical manifestation	Histopathology	Additional diagnostic clues
Palmar plantar erythrodysesthesia	The areas of well-defined intense erythema and edema	A variable degree of epidermal (keratinocytes) necrosis Vacuolar degeneration of the basal cell layer of epidermis Spongiosis Hyperkeratosis Lymphohistiocytic infiltrates Superficial perivascular infiltration of dermis by lymphocytes and eosinophils Papillary dermal edema Neutrophilic eccrine hidradenitis Eccrine squamous syringometaplasia, in severe PPE (WHO grades 3 and 4)	History of chemotherapeutic agent use
Graft-versus-host disease	A diffuse macular erythema whihich may form papules	Histologic features of Graft-versus-host disease and palmar plantar erythrodysesthesia are identical in early stages and serial biopsies may be needed to distinguish these two entities. Features suggestive of Graft-versus-host disease: Degenerate keratinocytes at all levels of the epidermis Adjacent lymphocytes (satellite cell necrosis)	Extracutaneous manifestations of AGVHD, including: Gastrointestinal symptoms such as diarrhea and abdominal pain Elevated liver enzymes
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