Green Pigmentation on the Palms and Soles

Abstract

A man in his 50s presented with abrupt-onset asymptomatic green and brown pigmented lesions on both his palms and soles (Figure, A). He had had progressive jaundice for a month and was recently diagnosed as having advanced intrahepatic cholangiocarcinoma. The cutaneous eruption developed 3 days after a high-grade fever during admission for palliative endoscopic retrograde cholangiopancreatography with metallic stent insertion. The investigation for cause of fever showed influenza A infection. He denied history of contact with any greenish substances on his palms and soles during admission. His sweat was colorless.Physical examination revealed generalized marked jaundice and bilateral symmetrical greenish brown macules and patches on hyperkeratotic palms and soles. The potassium hydroxide examination and Gram stain results were negative for any organisms. Laboratory tests showed a total to direct bilirubin level of 32.7/ 25.5 mg/dL; aspartate aminotransferase level of 93 U/L; alanine aminotransferase level of 82 U/L; and alkaline phosphatase level of 973 U/L. (To convert bilirubin to micromoles per liter, multiply by 17.104; to convert asparatate aminotransferase, alanine aminotransferase, and alkaline phosphatase to microkatals per liter, multiply by 0.0167.) Figure, B, shows the dermatoscopic finding of peeling skin. An incisional biopsy specimen from a nondesquamated greenish brown patch on the left palm, 1 day after the appearance of lesions, was stained with hematoxylin-eosin (Figure, C).

Green palmoplantar vesicular eruption in a patient with hyperbilirubinemia

“…Hair and nails can become green from the deposition of copper or from Pseudomonas infection. A greenish-black discoloration of the palms and soles, as seen in our case, is also rare 1, 2, 3…”

“…In any patient with hyperbilirubinemia and palmoplantar vesicles, the differential diagnosis should include eccrine chromhidrosis, a rare condition in which pigment from dyes or medications are excreted via the eccrine sweat glands 1, 2, 3. Histopathology of eccrine chromhidrosis finds hyperkeratosis, diffuse acanthosis, and increased number and size of intraepidermal eccrine ducts surrounded by homogenous eosinophilic materials, which can sometimes be seen in the stratum corneum 1, 2, 3.…”

“…Histopathology of eccrine chromhidrosis finds hyperkeratosis, diffuse acanthosis, and increased number and size of intraepidermal eccrine ducts surrounded by homogenous eosinophilic materials, which can sometimes be seen in the stratum corneum 1, 2, 3. In addition to these features, intraepidermal spongiosis and vesiculation can be seen when eccrine chromhidrosis presents as pompholyx, 1 as seen in our case.…”

“…Green pigmentation on the palms and soles in patients with hyperbilirubinemia is a rare entity 1, 2, 3. Eccrine chromhidrosis is an unusual form of green acral pigmentation characterized by the secretion of colored sweat from the eccrine glands 1, 2, 3.…”

“…Eccrine chromhidrosis is an unusual form of green acral pigmentation characterized by the secretion of colored sweat from the eccrine glands 1, 2, 3. Rarely, eccrine chromhidrosis can mimic an eczematous process leading to misdiagnosis 1 .…”