Palmar Xanthoma

What Is A Palmar Xanthoma?

A palmar xanthoma is a flat or slightly raised yellow-orange deposit in the creases of the palms and fingers. It’s made of immune cells packed with fat, and it usually points to a problem with how the body handles blood fats.

Xanthomas are local deposits of lipid that are usually benign in themselves but often signal a condition elsewhere in the body.^[1] When they appear in the palm and finger creases, doctors call them palmar xanthomas, palmar crease xanthomas, palmar striated xanthomas or, in the older Latin name, xanthoma striatum palmare. They belong to the plane (flat) group of xanthomas, which favor the palm creases, the bends of the fingers and other skin folds.^[1]

What makes them stand out from other xanthomas is how closely they’re tied to one condition. Palmar crease xanthomas can be pathognomonic for familial dysbetalipoproteinemia, also called type III hyperlipoproteinemia, meaning that when a doctor sees them, that diagnosis jumps to the top of the list.^[1] Our guides to what a xanthoma is and the xanthoma definition cover the wider family.

What Do Palmar Xanthomas Look Like?

They look like yellow, orange or brownish lines running along the natural creases of the palm and fingers, as if the creases had been tinted. They’re usually flat or barely raised, painless and easy to overlook.

A large lipid clinic study described them as flat deposits under the skin that give the palm and finger creases a yellow to brownish or orange tint, and noted that they’re easily missed.^[3] Most people notice them by chance, often when washing their hands or when someone else points them out. They don’t itch or hurt, and they tend to appear on both hands.

The palms can also carry a second, bumpier type. Tuberous and tuberoeruptive xanthomas are firmer, red to yellow papules that can join together, and they have a liking for the elbows and palms.^[1] Both types can show up together in dysbetalipoproteinemia.^[2] For the raised kind, see our guide to tuberous xanthoma, and for the flat kind elsewhere on the body, plane xanthoma.

What Causes Palmar Xanthomas?

They form when too many fat-carrying particles circulate in the blood, leak out of small vessels into the skin, and are swallowed by immune cells that become stuffed with fat. In the palms, the particles involved are usually cholesterol-rich “remnants”.

When blood fats are high, lipoproteins seep through the lining of small blood vessels into the skin and tendons. Tissue macrophages engulf the lipid and turn into foam cells, the fat-filled cells that make up every xanthoma.^[1]

Palmar xanthomas are linked with a particular kind of particle. The researchers behind the largest study of them concluded that they most likely reflect a buildup of triglyceride-rich remnant lipoproteins, the partly broken-down leftovers of fat-carrying particles. These remnants are thought to trigger inflammation and foam cell formation and to leak through capillary walls.^[3] The same team suggested that the small, repeated pressure our palms take every day may explain why the deposits gather there.^[3] That fits with a wider observation that xanthomas can form at sites of frequent mechanical trauma, where injury makes vessels leakier.^[1]

Diabetes, an underactive thyroid and kidney disease (nephrotic syndrome) can also push blood fats up and lead to xanthomas.^[1] Our guide to xanthomatosis explains what happens when many xanthomas appear at once.

What Is Dysbetalipoproteinemia?

Dysbetalipoproteinemia, or type III hyperlipoproteinemia, is an inherited disorder in which cholesterol-rich remnant particles build up in the blood. It’s usually caused by inheriting two copies of the APOE2 gene variant plus a second trigger such as weight gain, diabetes or an underactive thyroid.

Apolipoprotein E helps the liver clear remnant particles from the blood. Most cases of familial dysbetalipoproteinemia come from being homozygous for the APOE2 variant (the E2/E2 genotype), which clears remnants less well. Rarer variants cause the condition too, and about 10% of cases are inherited in a dominant pattern.^[2]

The gene alone usually isn’t enough. Most people with E2/E2 actually have normal or low blood fats; the disorder only shows itself when a second genetic or acquired factor is added, such as insulin resistance, obesity, type 2 diabetes, an underactive thyroid or metabolic syndrome.^[2] Men and women after menopause are more prone than younger women, because estrogen helps clear these particles.^[2]

How common it is depends on the definition used. One study that combined the E2/E2 genotype with high cholesterol put it at about 1 in 1,000 people, rising to about 1 in 825 when dominant cases were counted.^[2]

1. The blood picture. Total cholesterol and triglycerides are both raised, often to similar levels somewhere between 300 and 1,000 mg/dL.^[2]
2. The skin signs. About half of people with the disorder develop xanthomas, most often palmar crease or eruptive ones, and palmar and tuberous xanthomas are more likely when levels pass about 1,000 mg/dL.^[2]
3. The risk. Remnant particles are strongly linked with hardening of the arteries, which is why finding the disorder matters so much (see below).^[2]

Can Palmar Xanthomas Mean Something Other Than Dysbetalipoproteinemia?

Read moreHow Does Xanthelasma Form

Yes. About 1 in 10 people with them don’t have dysbetalipoproteinemia. Other causes include partial lipoprotein lipase deficiency, familial hypercholesterolemia, cholestatic liver disease such as primary biliary cholangitis, and, rarely, a blood protein disorder with normal blood fats.

A study of 3,382 adults at a Canadian lipid clinic found palmar xanthomas in 5.1% overall. They were present in 18.8% of people with dysbetalipoproteinemia and 14.1% of those with partial lipoprotein lipase deficiency, and in all eight people with the rare homozygous form of familial hypercholesterolemia, but in only 2.5% of those with the common heterozygous form. About 10% of people with palmar xanthomas didn’t meet the criteria for dysbetalipoproteinemia.^[3] The authors’ conclusion was that palmar xanthomas can appear across a wide range of lipid disorders that share a buildup of remnant particles.^[3]

• Familial hypercholesterolemia. An inherited condition affecting about 1 in 250 to 1 in 500 people. It’s best known for tendon xanthomas, including on the hands, and for xanthelasma.^[4] Palmar xanthomas are much rarer in the common form.^[3] See our guide to tendon xanthomas.
• Cholestatic liver disease. Flat xanthomas in the palm creases are often seen with biliary cirrhosis,^[1] the condition now called primary biliary cholangitis, in which bile flow is blocked and an unusual particle, lipoprotein X, drives cholesterol up.
• Blood protein disorders. Flat xanthomas can occur with normal blood fats in people with a paraprotein in the blood,^[1] and diffuse plane xanthoma with normal lipids has been linked with monoclonal gammopathy.^[5]

Are Palmar Xanthomas Dangerous?

The deposits themselves aren’t dangerous: they don’t turn into cancer and they don’t harm the hands. What matters is the disorder behind them, which can raise the risk of heart attack, stroke, blocked leg arteries and, at very high triglyceride levels, pancreatitis.

Dysbetalipoproteinemia carries about a 10-fold higher risk of premature coronary artery disease than in the general population.^[2] In one European study of 305 people with the condition, 19% had coronary artery disease, 11% had peripheral artery disease (narrowed arteries in the legs) and 4% had cerebrovascular disease.^[2] Very high triglycerides can also bring on acute pancreatitis, and some people are first diagnosed after an attack.^[2]

Familial hypercholesterolemia carries its own risk: without management, about half of men have a coronary event by 50 and about 30% of women by 60.^[4] The researchers behind the palmar xanthoma study suggested these deposits might one day serve as a simple bedside marker of cardiovascular risk, though that needs more study.^[3] The good news is that the outlook with dysbetalipoproteinemia is good once it’s managed, and earlier diagnosis gives better results.^[2]

If you’ve found other yellow bumps on your skin, our guide to skin xanthomas describes the different types and what each one suggests.

Who Gets Palmar Xanthomas?

Mostly adults with a remnant-type lipid disorder, especially those who also carry extra weight, have type 2 diabetes or an underactive thyroid. In the largest study, two-thirds of people with palmar xanthomas were women.

In the Canadian clinic study, 67.1% of people with palmar xanthomas were women, compared with 43.9% of those without them.^[3] They were also more common alongside obesity (7.6%), type 2 diabetes (8.2%), metabolic syndrome (6.9%) and an underactive thyroid (9.7%), and most common of all when dysbetalipoproteinemia was combined with type 2 diabetes (29.1%) or obesity (26.1%).^[3]

People with palmar xanthomas had higher total cholesterol, higher triglycerides and higher remnant cholesterol than other patients, but lower LDL (“bad”) cholesterol. That’s the reverse of what many people expect, and it’s why a standard cholesterol test can miss the disorder.^[3] Carrying at least one APOE2 gene copy was also far more common: 44.8% of people with palmar xanthomas compared with 25.6% without.^[3]

Because the disorder usually needs a second trigger, palmar xanthomas tend to appear in adulthood rather than childhood. The exception is homozygous familial hypercholesterolemia, which shows from an early age. Our guide to xanthoma covers who gets each type.

How Are Palmar Xanthomas Diagnosed?

A doctor usually recognizes them by looking. The real work is finding the cause: fasting blood fat tests, then specialist tests such as apolipoprotein B ratios and an APOE gene test, plus checks for diabetes, thyroid and liver problems.

A clinical examination is usually enough to identify a xanthoma, and the workup for the cause starts at the same time, with fasting triglycerides, total, LDL and HDL cholesterol, and blood sugar or HbA1c where needed. Specific patterns, palmar crease xanthomas among them, should prompt a search for their associated conditions.^[1]

1. Examination and history. Your doctor looks at your hands, elbows, knees, tendons and eyelids, and asks about family history, heart disease, diabetes, thyroid problems, alcohol and medicines.
2. Fasting lipid profile. Total cholesterol, triglycerides, LDL and HDL. In dysbetalipoproteinemia, cholesterol and triglycerides are often raised to a similar degree.^[2]
3. Specialist lipid tests. Blood fat numbers alone can’t tell dysbetalipoproteinemia apart from other disorders. Labs use ultracentrifugation or gel electrophoresis where available, or ratios based on apolipoprotein B, such as an apoB to total cholesterol ratio below 0.15 g/mmol.^[2]
4. APOE gene test. Diagnosis needs both the blood fat pattern and the APOE genotype, usually a test for E2/E2, with full gene sequencing for suspected dominant forms.^[2]
5. Checks for triggers and other causes. Thyroid function, blood sugar, kidney and liver tests, since an underactive thyroid, diabetes, kidney disease and cholestatic liver disease can all play a part.^[1][2]
6. Biopsy, rarely. A small skin sample is only needed if the diagnosis is in doubt; it shows the typical foam cells.^[1]

A lipid specialist (lipidologist) or an endocrinologist usually leads the workup, with a dermatologist involved if the skin diagnosis is unclear.

How Are Palmar Xanthomas Managed?

By managing the blood fat disorder behind them. That means diet changes, weight loss, cutting alcohol, controlling diabetes and thyroid problems, and usually cholesterol-lowering medicine, often a statin with a fibrate. The xanthomas then fade on their own.

Controlling the underlying condition is the main goal with any xanthoma; statins lower blood fats and may shrink the lesions.^[1] For dysbetalipoproteinemia specifically, the current approach looks like this:^[2]

• Food. Minimally processed, high-fiber, plant-based foods, less saturated fat, more unsaturated fats and fish, and fewer refined carbohydrates, because insulin resistance is common.
• Weight and exercise. Losing weight lowers triglycerides, and more activity helps. A dietitian can make a real difference.
• Alcohol. No more than one drink a day.
• Triggers. Check for and manage an underactive thyroid, type 2 diabetes and metabolic syndrome.
• Medicine. Statins and fibrates are the mainstay when diet isn’t enough; a statin alone often leaves cholesterol high, so a fibrate is added. Non-HDL cholesterol is the usual target.
• Side effects. Combining a statin and a fibrate raises the risk of muscle problems, so your doctor will explain what to watch for. PCSK9 inhibitor injections have an uncertain role but may help people who can’t take or don’t respond to the usual medicines.

For familial hypercholesterolemia, statins are the first-line medicine.^[4] For cholestatic liver disease or a blood protein disorder, the plan centers on that condition instead. A procedure to remove palmar xanthomas is rarely needed, because they fade with time once the cause is controlled.^[2]

Do Palmar Xanthomas Go Away?

Read moreCan Xanthelasma Go Away On Its Own

Usually, yes. Once blood fats are brought under control, palmar crease xanthomas resolve with time, typically over several months. They’re one of the most responsive kinds of xanthoma.

Clinical guidance states that palmar crease xanthomas resolve over time once management of dysbetalipoproteinemia begins.^[2] The Canadian researchers noted they may regress and disappear after several months of lipid-lowering, which may be why they found them in 5.6% of people not on medicine but only 2.6% of those on medicine or of unknown status.^[3] More generally, small xanthomas often shrink or resolve with control of the underlying disease, and small xanthomas have been reported to clear after liver transplant or plasma exchange (plasmapheresis) in people with severe disease.^[1]

That fading is a useful sign that management is working. If palmar xanthomas come back, it’s often a clue that blood fats have crept up again or a trigger, such as weight gain or a thyroid problem, has returned. Thicker tuberous lesions on the palms or elbows tend to take longer to fade than flat crease deposits.

Should Your Family Be Checked?

Often, yes. The main causes of palmar xanthomas are inherited, so brothers, sisters, children and parents may carry the same gene variants and benefit from a blood fat test, even if they have no skin signs.

Most dysbetalipoproteinemia is recessive, meaning a person needs two copies of the APOE2 variant, one from each parent, while about 10% of cases follow a dominant pattern.^[2] Brothers and sisters of someone with E2/E2 have the highest chance of sharing it, though a second trigger is still needed for the disorder to show.^[2]

Familial hypercholesterolemia is dominant: each child of an affected parent has a 50% chance of inheriting it.^[4] Because it raises heart risk from birth, testing relatives early, a process called cascade screening, can make a big difference. Our guide on whether xanthelasma is genetic explains how inherited lipid disorders can show up on the eyelids too.

How Is A Palmar Xanthoma Different From Xanthelasma?

Xanthelasma sits on the eyelids and is linked with a lipid disorder in only about half of people. Palmar xanthomas sit in the hand creases and almost always point to a significant blood fat disorder, so they carry far more weight as a warning sign.

Xanthelasma palpebrarum affects about 1.1% of women and 0.3% of men, and about half of people with it have a primary or secondary lipid disorder; the rest have normal blood fats.^[6] Palmar xanthomas are much rarer and much more specific. Both are made of the same foam cells, but the location tells a doctor a lot about the likely cause.

If you were searching for the eyelid type, see our main xanthelasma guide, what xanthelasma looks like, the causes of xanthelasma and whether xanthelasma indicates raised cholesterol.

When Should You See A Doctor About Palmar Xanthomas?

As soon as you notice them. They’re not an emergency, but they’re a strong sign of a blood fat disorder that’s worth finding early. Seek urgent care for chest pain, sudden severe stomach pain or new pain in the legs when walking.

• Book a routine appointment for any yellow or orange lines in your palm creases, or yellow bumps on your elbows, knees or tendons.
• Mention your family history of high cholesterol, early heart attacks or strokes.
• Ask for a full lipid profile, and ask whether dysbetalipoproteinemia has been considered if cholesterol and triglycerides are both high.
• Ask about referral to a lipid clinic or endocrinologist for APOE testing.
• Get urgent help for chest pain, severe pain in the upper stomach (a possible sign of pancreatitis), or a sudden crop of many small yellow-red bumps, which can mean very high triglycerides.

Sudden crops of small, itchy yellow-red bumps are a different type, covered in our guide to eruptive xanthoma. Firm swellings over the heel cord are described in our Achilles tendon xanthoma guide.

What’s The Bottom Line On Palmar Xanthoma?

Palmar xanthomas are harmless yellow-orange deposits in the hand creases, but they’re one of the clearest skin signs of a blood fat disorder, most often dysbetalipoproteinemia. See a doctor, get the right blood tests, and expect them to fade once the cause is under control.

The deposits don’t need removing. What they need is someone to find out why they’re there, because the disorder behind them raises the risk of heart and artery disease and is very manageable once found. Diet, weight, alcohol, diabetes and thyroid control, and the right medicine usually bring blood fats down, and the palm creases clear over the following months. If you were looking for yellow plaques on the eyelids instead, our main xanthelasma guide explains that condition, and you can browse all our xanthelasma and xanthoma guides.

Common Questions About Palmar Xanthoma