Puzzling palmar papules and pits

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Puzzling palmar papules and pits

J Fam Pract. 2005 March;54(3):227-230

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References

1. Rosen T, Martin S. Variants of normal skin in blacks. In: Atlas of Black Dermatology. 1st ed. Boston, Mass: Little, Brown; 1981;12-13.

2. Dilaimy MS, Owen WR, Sina B. Keratosis punctata of the palmar creases. Cutis 1984;33:394-396.

3. Rustad OJ, Vance JC. Punctate keratoses of the palms and soles and keratotic pits of the palmar creases. J Am Acad Dermatol 1990;22:468-476.

4. Kinsley-Scott TR, Young RJ, 3rd, Meffert JJ. Keratosis punctata of the instep. Cutis 2003;72:451-452.

5. Kong MS, Harford R, O’Neill JT. Keratosis punctata palmoplantaris controlled with topical retinoids: a case report and review of the literature. Cutis 2004;74:173-179.

6. Anderson WA, Elam MD, Lambert WC. Keratosis punctata and atopy. Report of 31 cases with a prospective study of prevalence. Arch Dermatol 1984;120:884-890.

7. Asadi AK. Type I hereditary punctate keratoderma. Dermatol Online J 2003;9:38.-

8. Weiss RM, Rasmussen JE. Keratosis punctata of the palmar creases. Arch Dermatol 1980;116:669-671.

9. Penas PF, Rios-Buceta L, Sanchez-Perez J, Dorado-Bris JM, Aragues M. Keratosis punctata of the palmar creases: case report and prevalence study in Caucasians. Dermatology 1994;188:200-202.

10. Del-Rio E, Vazquez-Veiga H, Aguilar A, Velez A, Sanchez Yus E. Keratosis punctata of the palmar creases. A report on three generations, demonstrating an association with ichthyosis vulgaris and evidence of involvement of the acrosyringium. Clin Exp Dermatol 1994;19:165-167.

11. Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 4th ed. St. Louis, Mo: Mosby; 2004.

12. Osman Y, Daly TJ, Don PC. Spiny keratoderma of the palms and soles. J Am Acad Dermatol 1992;26:879-881.

13. Betlloch I, Vergara G, Albares MP, Pascual JC, Silvestre JF, Botella R. Aquagenic keratoderma. J Eur Acad Dermatol Venereol 2003;17:306-307.

14. Gimenez-Garcia R, Sanchez-Ramon S, Cuellar-Olmedo LA. Palmoplantar pustulosis: a clinicoepidemiological study. The relationship between tobacco use and thyroid function. J Eur Acad Dermatol Venereol 2003;17:276-279.

15. Gunduz K, Inanir I, Turkdogan P, Sacar H. Palmoplantar lichen planus presenting with vesicle-like papules. J Dermatol 2003;30:337-340. 0

16. Vignale R, Yusin A, Panuncio A, Abulafia J, Reyno Z, Vaglio A. Cole disease: hypopigmentation with punctate keratosis of the palms and soles. Pediatr Dermatol 2002;19:302-306.

17. Kumar B, Saraswat A, Kaur I. Palmoplantar lesions in psoriasis. Acta Derm Venereol 2002;82:192-195.

Differential diagnosis

Punctate keratoses of the palms are fairly common frequently overlooked lesions. The differential diagnosis is extensive (Table), but there are several clinical features of KPPC that distinguish it from other hyperkeratotic conditions. The lesions of KPPC can be painful, have a predilection for jointcreases, and evolve into pits.³ KPPP is similar except not localized to the creases.⁴

Aquagenic keratoderma is a transitory condition afflicting young women and defined clinically by the appearance of palmar lesions accentuated after immersion in water. These lesions have a characteristic histological appearance (hyperkeratosis, dilated eccrine ducts).¹³

Palmoplantar pustulosis is characterized by chronically recurring sterile pustules on the palms and soles, usually found on an erythematous base, and a strong association with tobacco use.¹⁴Palmoplantar lichen planus may exhibit a variety of morphologic patterns including papules or plaques with pruritus, erythema, and compact hyperkeratosis.¹⁵

Cole disease is an uncommon disorder typified by distinctive cutaneous hyperpigmentation and punctate keratoses on the palms and soles. It is a congenital disease with an autosomal dominant inheritance pattern and phenotypic variability.¹⁶

Palmoplantar psoriasis is associated with manual labor in 50% of cases. Lesions are restricted to areas exposed to pressure. All patients with unilateral palmar lesions had them on their dominant hand. Biopsy may be necessary to differentiate hyperkeratotic eczema from psoriasis when just localized to the palms and soles.¹⁷

TABLE
Differential diagnosis of punctate keratoses of the hands and feet

Acquired keratoses	Classic clinical description	Associations
Arsenical	Round, verrucous, or acuminate keratotic papules most common on palms and soles. Typically occur decades after chronic arsenic ingestion	Angiosarcoma of the liver, nonmelanoma skin cancer, bronchial adenocarcinoma
Idiopathic filiform porokeratoses	Multiple thin spiny keratotic projections on palms and soles	Breast, renal, colon, and lung cancer
Keratosis punctata of the palmar creases	Discrete, sharply marginated, hyperkeratotic, conical, 1–5 mm depressions confined to flexural creases	Dupuytren’s contracture, striate keratoderma, knuckle pads
Hereditary keratoses	Classic clinical description	Associations
Keratosis punctata palmoplantaris (type I), Buschke-Fischer-Brauer disease	Multiple 1–2 mm punctate keratoses of the palms and soles	Longitudinal nail dystrophy, lichen nitidus, ichthyosis, atopy, recalcitrant warts. Increased risk of malignancy
Spiny keratoderma (type II)	Small keratotic spines over entire palmoplantar surfaces. Resembles the spines of an old-fashioned music box	No predisposition to malignancy
Acrokeratoelastoidosis lichenoids (type III)	2–4 mm round to oval papules on the borders of hands, feet and wrists. May be umbilicated and become confluent	Darier’s disease, Cowden’s disease
Adapted from Rustad et al 1990,⁵ Kong et al 2004,⁷ Asadi 2003,⁹ Habif 2004,¹¹ and Osman et al 1992.¹²