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Knuckle Pads

  • Author: Cheryl J Barnes, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Jul 14, 2016
 

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 four times as likely as the general population to have 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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Prognosis

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. Spontaneous resolution can occur, especially if an inciting repetitive injury is identified and eliminated. In most cases, knuckle pads persist indefinitely with little change.

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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

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

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, 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, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

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.

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. 1966 Mar. 93(3):311-6. [Medline].

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

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

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

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

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

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

  9. Bart RS, Pumphrey RE. Knuckle pads, leukonychia and deafness. A dominantly inherited syndrome. N Engl J Med. 1967 Jan 26. 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. 2009 Mar-Apr. 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. 2011 Sep-Oct. 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. 1977 Oct. 9(3):301-5. [Medline].

  15. Wooldridge WE. Four related fibrosing diseases. When you find one, look for another. Postgrad Med. 1988 Aug. 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. 1976 Apr 19. 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. 2005 Jan. 42(1):e2. [Medline].

  18. Almutawa F, Thusaringam T, Watters K, Gayden T, Jabado N, Sasseville D. Pachyonychia Congenita (K16) with Unusual Features and Good Response to Acitretin. Case Rep Dermatol. 2015 Aug. 7(2):220-6. [Medline].

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

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

  21. Hyman CH, Cohen PR. Report of a family with idiopathic knuckle pads and review of idiopathic and disease-associated knuckle pads. Dermatol Online J. 2013 May. 19(5):18177. [Medline].

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

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

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

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

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

  27. Addison A. Knuckle pads causing extensor tendon tethering. J Bone Joint Surg Br. 1984 Jan. 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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