Knuckle Pads 

  • Author: Cheryl J Barnes, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 17, 2012
 

Background

Knuckle pads are benign, asymptomatic, well-circumscribed, smooth, firm, skin-colored papules, nodules, or plaques, located in the skin over the dorsal aspects of the metacarpophalangeal (MCP) and interphalangeal (IP) joints. A history of repetitive trauma related to sports or occupation is often present.

Garrod first described knuckle pads in the medical literature in 1893,[1] but knuckle pads have been observed since the Renaissance era. Allison et al shows a photo of Michelangelo's statue of David displaying knuckle pads (Florence, Italy) as well as his statue of Moses (Rome, Italy), Victory (Florence, Italy), and Giuliano de Medici (Rome, Italy).[2] The name knuckle pad seems to be a misnomer because in most reported cases, lesions occur over the proximal interphalangeal (PIP) joint, not over the knuckles.

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Pathophysiology

Knuckle pads may be idiopathic, genetic, acquired as a response to repetitive trauma, or associated with several other acquired conditions.

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Epidemiology

Frequency

United States

Knuckle pads are a common occurrence. Measurement of prevalence of knuckle pads is difficult because patients are asymptomatic and do not seek medical attention for them.

International

Knuckle pads were noted in about 9% of subjects in one survey. Patients with Dupuytren contracture are 4 times as likely as the general population to have knuckle pads.

Mortality/Morbidity

Little morbidity is associated with knuckle pads. Patients typically are asymptomatic, but some patients experience pain and difficulty with hand functioning, including writing, as a result of their condition. Cosmetic issues drive most patients to seek attention for knuckle pads.

Race

No racial predilection is associated with knuckle pads.

Sex

Prevalence of knuckle pads is equal for men and women. Even in the presence of Dupuytren contracture, the prevalence of knuckle pads remains equal.

Age

Knuckle pads can present at any age. They have been reported in young children who bite and suck their fingers.[3] More commonly, knuckle pads are observed in adults older than 40 years.

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Contributor Information and Disclosures
Author

Cheryl J Barnes, MD  Dermatologist, McIntosh Clinic, PC

Cheryl J Barnes, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Loretta Davis, MD  Professor, Department of Internal Medicine, Division of Dermatology, Medical College of Georgia

Loretta Davis, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Gregory J Raugi, MD, PhD  Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle School of Medicine; Chief, Dermatology Section, Primary and Specialty Care Service, Veterans Administration Medical Center of Seattle

Gregory J Raugi, MD, PhD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Edward F Chan, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. Garrod AE. On an unusual form of nodule upon joints of the fingers. St. Bartholomew's Hosp Rep. 1893;29:157-161.

  2. Allison JR Jr, Allison JR Sr. Knuckle pads. Arch Dermatol. Mar 1966;93(3):311-6. [Medline].

  3. Paller AS, Hebert AA. Knuckle pads in children. Am J Dis Child. Sep 1986;140(9):915-7. [Medline].

  4. Richards TB, Gamble JF, Castellan RM, Mathias CG. Knuckle pads in live-chicken hangers. Contact Dermatitis. Jul 1987;17(1):13-6. [Medline].

  5. Cohen PR, Eliezri YD, Silvers DN. Athlete's nodules. J Am Acad Dermatol. Feb 1991;24(2 Pt 1):317-8. [Medline].

  6. Kanerva L. Knuckle pads from boxing. Eur J Dermatol. Jul-Aug 1998;8(5):359-61. [Medline].

  7. Swift S. Surfers' "Knots". JAMA. Apr 19 1965;192:223-4. [Medline].

  8. Wynn DR, Martin MJ. A physical sign of bulimia. Mayo Clin Proc. Oct 1984;59(10):722. [Medline].

  9. Bart RS, Pumphrey RE. Knuckle pads, leukonychia and deafness. A dominantly inherited syndrome. N Engl J Med. Jan 26 1967;276(4):202-7. [Medline].

  10. Stankler L. Pseudoxanthoma elasticum with a knuckle pad on the thumb. Acta Derm Venereol. 1967;47(4):263-6. [Medline].

  11. Codispoti A, Colombo E, Zocchi L, et al. Knuckle pads, in an epidermal palmoplantar keratoderma patient with Keratin 9 R163W transgrediens expression. Eur J Dermatol. Mar-Apr 2009;19(2):114-8. [Medline].

  12. Du ZF, Wei W, Wang YF, Chen XL, Chen CY, Liu WT, et al. A novel mutation within the 2B rod domain of keratin 9 in a Chinese pedigree with epidermolytic palmoplantar keratoderma combined with knuckle pads and camptodactyly. Eur J Dermatol. Sep-Oct 2011;21(5):675-9. [Medline].

  13. Lagier R, Meinecke R. Pathology of "knuckle pads". Study of four cases. Virchows Arch A Pathol Anat Histol. 1975;365(3):185-91. [Medline].

  14. Mikkelsen OA. Knuckle pads in Dupuytren's disease. Hand. Oct 1977;9(3):301-5. [Medline].

  15. Wooldridge WE. Four related fibrosing diseases. When you find one, look for another. Postgrad Med. Aug 1988;84(2):269-71, 274. [Medline].

  16. Ritter SB, Petersen G. Esophageal cancer, hyperkeratosis, and oral leukoplakia. Occurrence in a 25-year-old woman. JAMA. Apr 19 1976;235(16):1723. [Medline].

  17. Leonard NJ, Krol AL, Bleoo S, Somerville MJ. Sensorineural hearing loss, striate palmoplantar hyperkeratosis, and knuckle pads in a patient with a novel connexin 26 (GJB2) mutation. J Med Genet. Jan 2005;42(1):e2. [Medline].

  18. Koba S, Misago N, Narisawa Y. Knuckle pads associated with clubbed fingers. J Dermatol. Dec 2007;34(12):838-40. [Medline].

  19. Pierard GE, Lapiere CM. Phenytoin dependent fibrosis in polyfibromatosis syndrome. Br J Dermatol. Mar 1979;100(3):335-41. [Medline].

  20. Glicenstein J, Costa R. [Pachydermodactyly: a report of two cases]. Chir Main. Aug 2004;23(4):205-7. [Medline].

  21. Verbov J. Letter: Pachydermodactyly: a variant of the true knuckle pad. Arch Dermatol. Apr 1975;111(4):524. [Medline].

  22. Bettoni L, Bani L, Airò P. Rheumatoid nodules: the importance of a correct differential diagnosis. Eur Ann Allergy Clin Immunol. Jun 2011;43(3):95-6. [Medline].

  23. Weiss E, Amini S. A novel treatment for knuckle pads with intralesional Fluorouracil. Arch Dermatol. Nov 2007;143(11):1458-60. [Medline].

  24. Quinn KJ. Silicone gel in scar treatment. Burns Incl Therm Inj. Oct 1987;13 Suppl:S33-40. [Medline].

  25. Addison A. Knuckle pads causing extensor tendon tethering. J Bone Joint Surg Br. Jan 1984;66(1):128-30. [Medline].

 
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Knuckle pad over the proximal interphalangeal joint.
Multiple knuckle pads on various joints of the hand.
 
 
 
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