Changes

April 2025 — reviewed.  A literature search was conducted in March 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. There have been minor structural changes to the topic, including minor additions and clarifications for the recommendations, to align with current evidence on Dupuytren's disease.

Update

Goals

To support primary healthcare professionals to:

• Recognize and make a diagnosis of Dupuytren's disease.
• Offer appropriate management in primary care.
• Refer appropriately to secondary care.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

What is it?

• Dupuytren's disease is a benign, progressive fibroproliferative disorder of the fascia of the hands and fingers, which can lead to disabling contractures.
• The typical features of Dupuytren’s disease include thickening of the connective tissue in the hand to form nodules (usually in the palm of the hand), and development of cords that extend towards the fingers. 
  • Over months to years, the cords can thicken and contract, leading to a permanent flexion deformity of the fingers. When the fingers cannot be straightened, this is called Dupuytren’s contracture. 
  • Dupuytren’s disease often affects both hands, although one is usually more severely affected than the other.
• Dupuytren's disease belongs to a group of fibromatoses that also includes plantar fibromatosis (Ledderhose disease), penile fibromatosis (Peyronie's disease), and fibromatosis of the dorsum of the proximal interphalangeal joints (Garrod's knuckle pads).

[Van Dijk, 2013; NICE, 2016; BMJ Best Practice, 2023; Layton, 2023; Tomac, 2023; Khaliq, 2024]

What causes it?

• The cause of Dupuytren's disease is unknown, although several hypotheses have been proposed. 
  • Growing evidence supports that it develops through a complex interplay between genetic and environmental factors.
  • One working theory is that a compensatory inflammatory response to mechanical forces may be responsible. 
• Environmental triggers in genetically predisposed individuals appear to alter molecular pathways which contribute to the release of inflammatory cytokines, alter fibroblast gene expression, downregulate genes encoding for extracellular matrix, and disrupt the normal wound healing process.
  • There is myofibroblast proliferation at the affected palmar fascia, resulting in increased type III collagen that replaces normal type I collagen.
  • Nodules form as a result of myofibroblast influx and increased type III collagen deposition. This can progress to pathologic cord formation, which may ultimately lead to symptomatic contractures.
• Dupuytren's disease is an inherited condition that is autosomal dominant with variable penetrance.
  • One twin study of the genetic and environmental influences on Dupuytren’s disease indicated that heritability was approximately 80%, suggesting that genetic factors play a major role in the development of the condition.

[Larsen, 2015; Dutta, 2020; BMJ Best Practice, 2023; Layton, 2023; Khaliq, 2024]

What is the natural history of Dupuytren's disease?

• Dupuytren's disease is a progressive disease comprising the following: 
  • Skin thickening and pitting
    • In the early stages of Dupuytren’s disease, the skin of the palm (usually distal to the distal palmar crease) and underlying tissue becomes thickened.
    • Vertical fibres attach the skin to the palmar fascia, and shortening of these fibres causes pits or dimples to form in the skin. 
  • Nodule formation
    • Small firm nodules (usually painless) develop in the palm or fingers (most commonly near the distal palmar crease). Nodules are fixed to the underlying aponeurosis and the skin.
  • Cord formation
    • Dupuytren’s disease spreads from the nodules up the fascia and into the fingers, forming a cord. Cords may be attached to the skin.
  • Contracture development
    • As the cords mature and thicken, they become more prominent and rigid. In some people, shortening of the cords eventually forces the digits to bend towards the palm, forming a contracture.
    • Cords in the palm cause contractures at the metacarpophalangeal (MCP) joints. 
    • Cords in the digits cause contractures at the proximal interphalangeal (PIP) joints. 
    • Contractures most commonly affect the fourth and fifth fingers. The thumb and index finger are least likely to be affected.
  • Bilateral involvement
    • Most people with Dupuytren’s contracture are affected in both hands, although one hand is usually more severely affected.
    • In unilateral cases, the right side is more typically affected than the left.
    • Handedness does not appear to be a predictor of which hand is most severely affected.
• Dupuytren’s diathesis describes a tendency to develop more severe disease. It is linked to younger age at onset, a strong family history, bilateral disease, and ectopic disease. 
  • Ectopic disease can occur on the dorsum of the hands (Garrod’s knuckle pads — dorsal fibromatosis of the PIP joints), soles of the feet (Ledderhose disease — plantar fibromatosis) and penis (Peyronie’s disease — penile fibromatosis). 

[NICE, 2004; Van Dijk, 2013; NICE, 2016; Mella, 2018; Dutta, 2020; Ruettermann, 2021; BMJ Best Practice, 2023; Khaliq, 2024]

How common is it?

• Dupuytren's disease is a common condition.
  • The overall prevalence of the disease in the UK is about 4%, rising to about 20% in those aged over 65 years. In the UK, more than 2 million people are thought to have Dupuytren’s disease. 
  • Reported prevalence varies widely between geographic areas due to differences in reporting techniques (such as coding in general practice) and local genetic and environmental factors (such as smoking, alcohol intake, and trauma).
  • One prospective survey of over 500,000 general practice consultations over a 12-month period identified an incidence of 34.3 per 100,000 men. 
• Dupuytren's disease is most often seen in people of northern European descent. 
  • In most studies, individuals in northern Scotland, Iceland, and Norway have the highest prevalence of Dupuytren's contracture.
• Dupuytren's disease is up to seven times more common in men than in women. 
• The prevalence of Dupuytren's disease increases with age. 
  • Incidence is highest in men older than 50 years of age (mean age 55 years) and in women older than 60 years of age.
  • The estimated incidence per 10,000 population rises from 5 (aged younger than 50), to 15 (50 to 59 years), 30 (60 to 69 years), and 40 (aged 70 to 79 years).

[Hindocha, 2009; Van Dijk, 2013; Salari, 2020; Ruettermann, 2021; Khaliq, 2024]

What are the risk factors?

• The main risk factors for Dupuytren's disease are:
  • Increasing age — it predominantly affects people aged over 40 years. The severity of Dupuytren’s disease is also linked to advancing age. 
  • Male sex.
  • A positive family history of Dupuytren's disease — Dupuytren's disease is an inherited condition that is autosomal dominant with variable penetrance.
  • Northern European descent.
• Other risk factors include:
  • Diabetes mellitus. 
    • A systematic review and meta-analysis found that the average prevalence of Dupuytren's disease in people with diabetes mellitus is 31% and that it is equally common in type 1 and type 2 diabetes.
    • Several studies have found that people who have had diabetes mellitus for a longer duration are more likely to develop Dupuytren’s disease.
    • People with diabetes tend to have a mild form of the disease with slow progression. 
  • Smoking. 
    • The association between Dupuytren's disease and smoking follows a dose-response relationship.
    • The prevalence of Dupuytren’s disease has been reported to be up to three times higher in smokers, possibly due to microvascular changes in the hand.
  • High alcohol consumption. 
    • Alcohol consumption is associated with Dupuytren's disease. 
    • A large cohort study in France (n = 13,587) identified a dose-dependent association between alcohol consumption and Dupuytren’s disease in men.
  • Epilepsy.
    • There is some evidence of an association between epilepsy and Dupuytren's disease, however, the precise relationship remains unclear, but antiseizure medications may be the trigger.
• Other associations that have been reported include:
  • Elevated serum lipids.
    • In a systematic review that evaluated the association between hyperlipidaemia and Dupuytren's disease, three studies found no association and two studies showed a significant association. 
  • Hand trauma (such as from manual work or exposure to vibration or surgery).
    • A systematic review and meta-analysis that assessed the role of occupational vibration exposure in Dupuytren's disease found a significantly increased incidence among people with vibration exposure compared with controls.
  • Liver disease.
    • A systematic review and meta-analysis described an approximate two-fold increase in Dupuytren's disease among those with liver disease.

[Broekstra, 2018; Alser, 2020a; Mathieu, 2020; Ruettermann, 2021; BMJ Best Practice, 2023; Khaliq, 2024]

What is the prognosis?

• Dupuytren's disease is a progressive and incurable condition — 75% of people develop features of more advanced stages of the disease.
  • A population-based Scandinavian study found that 35% of people with nodules or cords progressed to contracture during an 18-year follow-up period.
  • The rate of progression varies from person to person.
    • Progression may be more rapid among men, people aged under 50 years, and those with a strong family history of the disease. 
    • Although most people will progress in severity, about 10% will regress. 
  • Contractures of the hands and fingers can cause significant disability.
  • Early-onset (before age 40 years), bilateral involvement, radial digit involvement, and involvement in other sites (such as the feet or penis) are associated with aggressive disease (Dupuytren’s diathesis). 
• Surgical correction does not stop the disease process.
  • Surgery can improve hand functionality, but it will not eradicate the disease. 
  • There remains a risk of disease recurrence at the same site or elsewhere in the hand.
  • The 10-year risk of reoperation on the same hand varies depending on the surgical technique used, and is around 20% following either limited fasciectomy or dermofasciectomy, and around 33% following percutaneous needle fasciotomy.
    • The National Institute for Health and Care Excellence (NICE) states that the recurrence rate for needle fasciotomy is approximately 50% at 3–5 years and seems to depend on the severity of the disease. 
  • Recurrence appears to be most common for people with proximal interphalangeal (PIP) joint contractures, a diseased little finger or multiple affected digits, and recurrence risk likely increases with contracture severity.
  • Hand function is significantly improved in most people after surgery, but not to pre-morbid levels. 
  • Men have a slightly lower rate of reoperations than women. 

[NICE, 2004; Mella, 2018; Alser, 2020b; Dutta, 2020; BMJ Best Practice, 2023; Khaliq, 2024]

When should I suspect Dupuytren’s disease?

• Suspect Dupuytren’s disease if a person develops signs and symptoms, including:
  
  • Skin thickening, tethering, puckering, pitting, or dimpling on the palm. 
  • Reduced range of motion or loss of function in the hands or fingers.
  • Firm nodules fixed to the skin and deep fascia of the palm or fingers. 
    • Nodules can occur anywhere on the palm or fingers. The most common site is the distal palmar crease, in line with the ring or little finger.
    • Dupuytren’s diathesis can cause ectopic nodules on the knuckles and soles of the feet. 
  • Cords — longitudinal, linear thickenings in the palm that extend towards the fingers. 
  • Contractures of the cords, causing flexion deformity at the metacarpophalangeal (MCP) and proximal interphalangeal joints. Contractures usually start in the palm and progress distally.
    • Often, both hands are affected (this is more common in men), with one hand usually more severely affected than the other, though handedness does not appear to be a reliable predictor of severity. 
    • The fourth and fifth fingers are most commonly affected. The thumb and index are least likely to be affected.

How should I assess a person with Dupuytren's disease?

• Take a thorough history and ask about:
  • Risk factors for Dupuytren's disease. 
  • Loss of hand function, such as functional limitations affecting work or leisure activities (for example, face washing, combing hair, putting hands in pockets, putting on gloves, or grasping objects).
  • Pain or discomfort — Dupuytren's disease is not typically characterized by pain, but some people may experience tenderness or discomfort, particularly in the early stages of the condition.
  • Ectopic lesions, such as on the:
    • Dorsum of the hands — Garrod’s knuckle pads (dorsal fibromatosis of the proximal interphalangeal [PIP] joints).
    • Soles of the feet — Ledderhose disease (plantar fibromatosis).
    • Penis (if appropriate) — Peyronie’s disease (penile fibromatosis).
• Examine both hands and look for:
  • Thickening and pitting of the palmar skin. 
  • Firm, painless nodules fixed to the skin and palmar fascia. 
  • Cords (one or more).
  • Contracture causing flexion deformity of the metacarpophalangeal and/or PIP joints (distal interphalangeal joints are rarely affected).
    • Contractures most commonly affect the fourth and fifth fingers. The thumb and index finger are least likely to be affected. 
    • The ‘tabletop’ test can be used to identify contractures. If the person is unable to lay their palm and fingers flat on a tabletop, then contracture is present.
• Investigations are not usually necessary to diagnose Dupuytren’s disease.
  • However, if the history raises suspicion of diabetes mellitus or alcohol-related liver disease, or an alternative diagnosis is suspected, arrange appropriate investigations.
  • See the CKS topics on Diabetes - type 1, Diabetes - type 2, and Alcohol - problem drinking for further information.

What else might it be?

• Callus — common.
  • A thickened area of skin that develops in response to friction or pressure. 
• Epithelioid sarcoma — rare. 
  • A malignant soft tissue tumour of the palm. This appears as an enlarging indurated mass that may ulcerate.
  • It is seen in adolescents and young adults.
• Ganglion — the most common benign tumour of the hand. 
  • A fluid-containing mass, usually attached to a tendon sheath or connected with an underlying joint.
  • Often develops around the wrist, but can also develop at the base of the fingers.
• Giant cell tumour. 
  • Usually a painless, slow-growing, soft tissue mass. 
  • Typically presents in people aged 30–50 years, peaking in those aged 40–50 years.
  • Women are more commonly affected than men (3:2).
• Inclusion cyst. 
  • A fluid-filled mass, which usually develops (often years) after an injury. 
• Stenosing tenosynovitis (trigger finger). 
  • A tender nodule or mass may be palpable at the level of the metacarpal head in the palm. 
  • Characterized by intermittent locking or catching in a flexed position, and the finger can be fully extended with a notable click.
  • It is most commonly seen in women aged over 40 years. 
• Ulnar nerve palsy (for example claw hand).
  • Often presents with numbness and tingling alongside weakness in the hand, which are not observed in Dupuytren's disease.
• Post-trauma or infection — history of significant preceding trauma leading to injury of the interphalangeal joint, or infection. 
• Joint diseases. 
  • Rheumatoid arthritis — joints are usually enlarged and painful. For more information, see the CKS topic on Rheumatoid arthritis. 
  • Osteoarthritis of the metacarpophalangeal joint — for more information, see the CKS topic on Osteoarthritis. 
• Diabetic cheiroarthropathy — all of the digits are affected aside from the thumb. Skin is usually waxy in appearance. 
• Camptodactyly — an autosomal dominant disorder with contraction of the little finger. It is more often present in childhood and can be caused by a number of congenital syndromes. 
• Volkmann’s contracture — can manifest as a claw-like deformity caused by undiagnosed compartment syndrome of the forearm.

Scenario: Management of Dupuytren's disease

From age 18 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of Dupuytren's contracture.

Search dates

September 2020 - march 2025

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• Dupuytren Contracture/ or Dupuytren Contracture.mp.
• dupuytren$.tw.
• (palm$ adj3 fibromatosis).tw.
• ((palm$ adj3 fascia$) and contract$).mp.

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
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• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
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• First draft internal review
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Evidence exclusion criteria

Our policy

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Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
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  • Current interventions
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  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

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Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

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Competing interests declared for this topic:

None.