What Dupuytren’s contracture is, how to tell it from a callus or trigger finger, how it is diagnosed in the UK, and when radiotherapy is an option.
Dupuytren’s contracture is a benign thickening of the palmar fascia, the connective tissue under the skin of the palm. It forms firm nodules that can develop into cords, gradually pulling one or more fingers towards the palm.
At first a small firm lump appears in the palm, usually below the ring or little finger, and the obvious explanations come first: a callus, a cyst, a trapped tendon. It stays there for months and does not hurt. Then you notice that you have another lump, it’s growing into the fingers, or your fingers are starting to feel tight.
If that is where you are, you may be asking: Is it going to get worse, and is there anything worth doing now rather than waiting for surgery?
This guide covers what it is, how it is diagnosed in the UK, and the options at each stage, including low-dose radiotherapy for Dupuytren’s contracture, which we provide at Theralife. This is general information, not advice about your own hand.
The palmar fascia is the layer underneath the skin of the palm. There are cells in the palmar fascia called fibroblasts that lay down scar tissue in normal healing. But in Dupuytren’s they lay down too much scar tissue which forms a lump in the palm. Eventually the lump becomes a line of tissue called a cord which makes the area feel tight. The tendons themselves are healthy and not affected.
It usually begins as a firm nodule in the palm, in line with the ring or little finger, and the skin above it may be pulled and form a dimple. Over months or years, these nodules form cords: rope-like bands running into the finger. As a cord shortens, it draws the finger towards the palm, and that is what a contracture is.
Specialists stage it by how far the finger is bent in a fixed position. Stage N is where there are nodules with no fixed bending, N/I is bending of 1 to 10 degrees, and stage I is 11 to 45 degrees. The treatment options are different depending on how bent the finger is.
The cause is not fully known. It runs in families and is markedly more common in people of Northern European descent, which is why it is sometimes nicknamed Viking disease. Other associations include age over 50, being male, manual work, diabetes, smoking and high alcohol intake, though age and family history are the most important factors. Women develop it later and it may be milder.
People with Dupuytren’s may also have a similar condition on the soles of the feet (Ledderhose disease) and the penis (Peyronie’s disease).
To make the diagnosis – the doctor or other healthcare professional feels the palm for nodules and cords and tests how well the fingers move. Scans are not needed.
If you have nodules and cords in the palm but you are still able to fully (or almost) straighten your fingers then you will be advised to monitor the situation or consider radiotherapy to stop it getting worse.
Sometimes patients already have a significant contracture (fixed bending of the fingers). In this case they will have a positive tabletop test and this may prompt referral to a hand surgeon to discuss how to release the contracture.
If you have a lump in your palm then you may be asking a number of questions: Is this going to get worse? Is there anything that I can do about it now? We can help you answer these questions, so you leave knowing where things actually stand and what makes sense for your hand.
No. Some people live with nodules in their palm for years and it never worsens and their finger never bends. Some people have a more active course and they find that it gets worse and causes a contracture within months or a few years. This can happen at any age, but it is more likely if the condition starts before the age of 50, where there is a strong family history, involvement of both hands, and where there is also disease in the feet.
Timing is really important. The Royal College of Radiologists guidance recommends radiotherapy only where disease has changed in the last 6 to 12 months, since treating stable disease risks treating something that was never going to progress.
There are different treatments that depend on which stage you are in your Dupuytren’s disease journey.
At this stage it is a choice between observation and radiotherapy treatment.
Low-dose radiotherapy directs low-energy X-rays at the nodules and cords to stop them getting worse and forming a contracture. The Royal College of Radiologists guidance, updated in March 2023 and co-authored by our Chief Medical Officer, Dr Richard Shaffer, states it is effective in early disease, where there is no contracture or a contracture of up to ten degrees. That is a Grade B rating, resting on well-conducted studies rather than randomised trials. The course is 30 Gy in 10 short sessions, in two blocks of five treatments, six to twelve weeks apart.
In the longest follow-up study cited, 62% of those who chose observation progressed, and 30% went on to surgery, against 20% and 8% among those treated with 30 Gy. People were not allocated by chance in that study, and some people have criticised the study for this reason.
For some people it’s too early to need radiotherapy treatment and in that case main option is watchful waiting. One of our doctors can give you firm guidelines as to how to do that and not miss the window of opportunity for radiotherapy treatment.
Hand therapy, splinting, steroid injections and other injections are sometimes used for tender nodules, but none has been shown to stop things getting worse. Massage, vitamin E, and compression gloves have no strong evidence behind them.
The most standard option is open surgery (fasciectomy) to release the contracture and remove the diseased tissue. There is also another option called a needle fasciotomy, or a needle aponeurotomy, where the surgeon inserts a needle through the skin to divide the cord and release the contracture.
Surgery is the more invasive option and generally you can’t use your hand properly for at least 6 to 8 weeks. Needle fasciotomy is less invasive and you can generally get back to normal activities within a week.
Surgery gives a better chance of the contracture not coming back than needle aponeurotomy, where there is about a 60% chance of recurrence within three years.
Radiotherapy is not an effective treatment at this stage.
NICE assessed radiotherapy in 2016, found no major safety concerns, but judged the evidence on how well it works inadequate, and restricted it to special arrangements for clinical governance, consent, and audit or research. The Royal College of Radiologists 2023 recommendations state that: “RT is effective in the early stages of Dupuytren’s disease, where there is no contracture (stage N) or a contracture of up to ten degrees (N/I) (Grade B).”
The long-term concern is a small rise in skin cancer risk. There is about a 10% chance of getting a skin cancer from the sunlight, and radiotherapy adds only a 0.1% extra risk on top of this; so the risk is very tiny, but not zero. Skin effects are likelier but milder. In one follow-up of 176 hands, 25% had reduced sweating and 8.5% thinner skin.
Based at Alderley Edge in Cheshire, Theralife is a self-pay clinic specialising in low-dose radiotherapy for Dupuytren's disease and other benign conditions. Book an initial consultation, and one of our specialist consultants will talk you through exactly where things stand and whether low-dose radiotherapy could be right for you.
Usually not. Nodules can feel tender when they first appear, and that tenderness tends to settle after a couple of months. The main problem is tightness of the fingers, which also affects grip and daily tasks, and can eventually stop the fingers from straightening properly.
Sometimes the nodules can appear and then become a bit smaller by themselves, but an established contracture does not reverse on its own. Nodules can sometimes stay unchanged for years without ever forming a cord, so a lump in the palm does not mean a bent finger is inevitable. NICE notes that not everyone with the condition progresses.
Royal College of Radiologists guidance states it is effective in early-stage disease, where there is no contracture, or a contracture of up to ten degrees. In the longest follow-up study cited, 20% of those treated progressed, compared with 62% of those not treated. That study was not a randomised controlled trial, and for this reason NICE takes a more cautious view of the evidence.
Rarely, and it varies by area. There have been some hospitals that have offered this treatment but generally the funding for the treatment has been withdrawn. Most people in the UK pay privately for this treatment.
There is a small theoretical risk, and you should be told about it before you consent. There is about a 10% chance of getting a skin cancer from the sunlight, and radiotherapy adds only a 0.1% extra risk on top of this; so the risk is very tiny, but not zero. The risk is higher for younger patients and lower for older ones. No case of cancer caused by radiotherapy for Dupuytren’s has been reported in the literature.
No. Arthritis affects joints and their cartilage. Dupuytren’s affects the fascia (layer underneath the skin) in the palm, and the joints are not affected.
Genetics tends to be the cause in most people. However, there are certain trigger factors that can make this get worse more quickly. We know that manual workers and people who use vibrational tools get this condition more and it can get worse more quickly. For this reason we tell people to protect their hands well if they are doing very heavy work.
Radiotherapy will make it much less likely that the condition will continue to worsen over time, but like with every medical treatment there are no 100% guarantees, and despite the best care the condition continues to worsen over time in about 20% of people, and a contracture will form in 8% of people.
