Why do I have knuckle pads despite taking treatment?

Question

Hello doctor,

My problem has been related to knuckle pads for two years.

I use Kerasol F (a topical Salicylic acid and urea preparation) and an intralesional corticosteroid, but there is no improvement.

What to do next?

I am really concerned.

Kindly help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I understand how frustrating it can be to live with persistent knuckle pads, especially when treatments tried over a long period have not shown improvement. Based on the image (attachment removed to protect patient identity) that you have shared in the history, you are having knuckle pads, which are also called subcutaneous fibroma or holoderma. They are usually painless, non-infectious, and not dangerous, but unfortunately, they are known to be notoriously treatment-resistant.

Knuckle pads are regarded as a kind of localized fibromatosis, which means that they consist of excessive formation of collagen and fibroblasts instead of inflammation. Therefore, it is clear why methods such as keratolytic treatment (topical Salicylic acid and Urea preparation) and injections of corticosteroids are inefficient, since corticosteroids reduce only inflammation and not fibrosis.

From a research and evidence-based perspective, treatment options can be divided into conservative, medical, procedural, and experimental approaches.

Among topical therapies, high-strength keratolytics such as Salicylic acid (20 to 40 percent), Urea (30 to 40%), or Lactic acid combinations may soften the surface but rarely reduce the size significantly. Topical retinoids (Tretinoin or Adapalene) can be tried for several months to reduce epidermal hyperplasia, but results are variable and usually modest. Silicone gel sheets used regularly may help flatten lesions slightly over long-term use by reducing collagen stimulation, though evidence is limited.

Regarding injectable therapies, intralesional corticosteroids (such as Triamcinolone) often fail, as you have already experienced. Some studies and case reports suggest that intralesional 5 Fluorouracil is helpful in selected cases, as it inhibits fibrous growth. Pain, ulceration, and recurrence are possible side effects.

Procedural options include cryotherapy, which generally has poor outcomes and may cause pigmentary changes or scarring.

Laser therapies (carbon dioxide or erbium yttrium aluminum garnet) have been used to debulk lesions, but recurrence is common because the fibrotic process persists beneath the surface.

Surgical excision is usually not recommended as a routine option because recurrence rates are high, and scarring over joints can cause stiffness or cosmetic dissatisfaction.

I would suggest you go for Intralesional 5 Fluorouracil injections on the knuckle pads, see the response, and then get it all done.

Another option for you, in my opinion, is a strong topical formulation called (a combination of Cantharidin, Podophyllin, and Salicylic acid). This is a powerful, topical, keratolytic compound used by professionals to treat recalcitrant warts and certain skin growths.

You can get it done on one knuckle pad to see the result.

It should be done only by a proper expert and not at home.
It has the highest cure rate so far for your issue.

Also, try to focus on eliminating aggravating factors. Repeated friction, pressure, or micro trauma over the knuckles can maintain or worsen the pads. This includes:

Resting knuckles on hard surfaces.
Gym activities involving gripping.
Manual work.
Unconscious rubbing.

If any such habit exists, consciously stopping it is crucial. In some patients, simply removing chronic trauma prevents further progression.

I hope you are satisfied with my answer. For further queries, you can consult me at iCliniq.

Thank you.