Eur J Plast Surg (2006) 28: 480–482
J. M. Smit
P. H. M. Spauwen
Painful ulcers on the fingertips in hereditary hemorrhagic
telangiectasia: a case report
Received: 22 March 2005 / Accepted: 10 August 2005 / Published online: 9 November 2005
# Springer-Verlag 2005
Abstract Hereditary hemorrhagic telangiectasia (HHT) is
an autosomal dominant trait characterized by epistaxis,
telangiectasia, visceral lesions, and a positive family his-
tory. A patient is presented with painful ulcers on the fin-
gertips secondary to HHT, causing impairments in daily
activities. The most affected sites were stripped of their
dermis and resurfaced with skin grafts. This treatment
proved to be a good therapeutic option, and stable long-
term results can hopefully be expected.
Keywords Hereditary hemorrhagic telangiectasia
A 43-year-old male presented with painful ulcers on the
fingertips, and they bled with minimal trauma (Fig. 1).
Because of the associated pain, the patient could not do his
job as a truck driver. He was diagnosed with hereditary
hemorrhagic telangiectasia (HHT) in 1989. He had a
positive family history for HHT, epistaxis since 1985, and
he underwent a medial lung lobectomy in 1990 because of
pulmonary hemorrhage. The ulcers on the fingertips were
present since 1995.
In another clinic, the ulcers were excised on several
occasions. However, they recurred following excision. As a
final therapeutic option, the patient was advised to let his
most affected fingertips (the index and middle fingers of
both hands) be amputated. The patient could not accept this
advice and came to our clinic for a second opinion.
The patient was advised to have the skin of the most
affected fingertips replaced by full-thickness skin grafts. It
was felt that smaller lesions could be excised and closed
directly. It was stressed that this treatment provided no
guarantee, and that the ulcers might return, and his finger-
tips might eventually have to be amputated. This was made
very clear to the patient.
Treatment took place in two sessions. In the first session,
the fingertips of the index and middle fingers of the left
hand were stripped of their dermis and resurfaced by grafts
taken from the groin. In the second session, the same
treatment was performed on the index and middle fingers
of the right hand.
Over a 2-year follow-up, the patient gradually went back
to live a normal life. The grafts are stable, and the patient is
free of complaints (Fig. 2). In the meantime, the patient
came back twice to our clinic for surgery. Both surgeries
involved ulcers located elsewhere on the hands; these
ulcers were eradicated.
Hereditary hemorrhagic telangiectasia, commonly referred
to as “Rendu–Osler–Weber” disease, is mainly diagnosed
by its clinical features. To give physicians more informa-
tion when considering the diagnosis HHT, Shovlin et al. 
presented the Curaçao criteria in 2000. In this model, the
diagnosis HHT is certain if three or more criteria are met.
The diagnosis is suspected if two criteria are met. The
criteria are epistaxis, telangiectasia, visceral lesions, and an
affected first-degree relative.
Epistaxis is the most frequently noticed symptom of
HHT and is found in 96% of the patients. In more than half
of the cases, it manifests itself before the age of 20. The
nosebleeds occur spontaneously or with minimal provoca-
tion . The frequency, duration, and severity differs per
patient and may increase with age .
Telangiectasia develops abruptly and tends to become
more numerous in time. About half of the patients present
before the age of 30. The most frequently affected sites are
the face, mouth, and hands/wrists; the incidence is 63, 48,
and 37% of cases, respectively .
J. M. Smit (*)
P. H. M. Spauwen
Department of Plastic Surgery (305),
UMCN St. Radboud,
P.O. Box 9101, 6500 Nijmegen, The Netherlands