AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Diffuse Hereditary PPK
• Focal Hereditary PPK
• Punctate Hereditary PPK
• Acquired PPK
• Syndromes With PPK as an Associated Feature
• Treatment
• Acknowledgments
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Diffuse Hereditary PPK
• Focal Hereditary PPK
• Punctate Hereditary PPK
• Acquired PPK
• Syndromes With PPK as an Associated Feature
• Treatment
• Acknowledgments
• References

Palmoplantar keratoderma (PPK) constitutes a heterogeneous group of disorders characterized by thickening of the palms and the soles of individuals who are affected. In recent years, speculation has arisen that a molecular genetic classification system will replace the traditional, clinically based, descriptive systems. Consequently, the authors of this review present each disorder according to traditional schemes and offer molecular and genetic insights into each.

The PPKs can initially be divided based on whether they are inherited or acquired. Focusing on the inherited PPKs, initial classification is into 3 distinct clinical patterns of epidermal involvement.

The first is diffuse PPK, which is uniform involvement of the palmoplantar surface. This pattern is usually evident within the first few months of life. The second is focal PPK, which consists of localized areas of hyperkeratosis located mainly on pressure points and sites of recurrent friction. The third is punctate keratoderma, which features multiple small, hyperkeratotic papules, spicules, or nodules on the palms and soles. These tiny keratoses may involve the entire palmoplantar surface or may be restricted to certain locations (eg, palmar creases).

The keratodermas can then be further subdivided based on whether only an isolated keratoderma is present or whether other skin findings are present and/or other organs are involved.

The first subclassification is simple keratoderma, which is isolated PPK. The second is keratodermas with associated features such as lesions of nonvolar skin, hair, teeth, nails, or sweat glands and/or with abnormalities of other organs.

Acquired forms are divided into keratoderma climactericum, keratoderma associated with internal malignancy, PPK due to inflammatory and reactive dermatoses, PPK caused by infections, drug-related PPK, and systemic disease–associated PPK.

DIFFUSE HEREDITARY PPK

Section 3 of 10  

• Authors and Editors
• Introduction
• Diffuse Hereditary PPK
• Focal Hereditary PPK
• Punctate Hereditary PPK
• Acquired PPK
• Syndromes With PPK as an Associated Feature
• Treatment
• Acknowledgments
• References

Diffuse types without associated features

• Epidermolytic PPK (Vorner PPK)
• • Synonyms for epidermolytic PPK (EPPK) include diffuse Vorner disease and PPK cum degeneratione granulosa. In some ethnic groups, this form is the most common type of hereditary PPK. It has an estimated prevalence of at least 4.4 cases per 100,000 population in Northern Ireland. It is inherited in an autosomal dominant fashion. Onset occurs in the first few months of life, but the disease is usually well developed by age 3-4 years.
  • Clinical features are very similar to diffuse nonepidermolytic PPK (NEPPK). A well-demarcated, thick, yellow hyperkeratosis is present over the palms and soles. An erythematous band is frequently present at the periphery of the keratosis. The surface is often uneven and verrucous. Finally, it is usually nontransgredient, with a sharp demarcation of the lesions at the wrists.
  • Histologically, keratinocytes show epidermolysis, hyperkeratosis, acanthosis, and papillomatosis. Perinuclear vacuolization and large keratohyalin granules are seen. Cellular breakdown in the spinous and granular cell layers sometimes leads to blister formation. Several biopsy specimens may be required to confirm the changes because they may be subtle and patchy.
  • Keratin 1 and keratin 9 mutations have been reported. The keratin 1 mutations appear to be associated with a milder form of EPPK.¹
  • Treatment includes salicylic acid, 50% propylene glycol in water under plastic occlusion several nights per week, and lactic acid– and urea-containing creams and lotions; all have been shown to be helpful. Mechanical debridement with a blade also may be useful. Oral retinoid therapy has had variable effects and may not benefit patients with certain genotype profiles, such as K1 mutations.
• Nonepidermolytic PPK (Unna-Thost PPK)
• • Synonyms include diffuse Unna-Thost disease and PPK diffusa circumscripta. Diffuse NEPPK is inherited in an autosomal dominant fashion. The condition may manifest in the first few months of life but is usually well developed by age 3-4 years. It is another common type of hereditary PPK.
  • Clinically, even, waxy, thick, well-demarcated hyperkeratosis is present over the palms and soles. A red band is frequently present at the periphery of the keratosis. It is usually nontransgredient, with a sharp demarcation of the lesions at the wrists. Aberrant keratotic lesions may appear in the dorsum of the hands, feet, knees, and elbows. The dorsa of the fingers may be involved with a sclerodermalike thickening of the distal digit. A cobblestone hyperkeratosis of the knuckles may be seen. Nails may be thickened.
  • Although not always distinguishable, some clinical features may help differentiate EPPK from NEPPK. NEPPK may have a waxy appearance, compared with the dirty appearance of EPPK. Hyperhidrosis and pitted keratolysis may be present with NEPPK. Finally, with NEPPK, secondary dermatophyte infections, resulting in maceration and peeling, are common.
  • Histologic findings include orthokeratotic hyperkeratosis associated with hypergranulosis or hypogranulosis and moderate acanthosis. Changes are nonspecific and common to many varieties of keratoderma. An absence of epidermolysis differentiates it from EPPK.
  • Molecular biology features include linkage to type II keratin locus on band 12q11-13, corresponding to a keratin 1 gene mutation.
  • Treatment includes salicylic acid, 50% propylene glycol in water under plastic occlusion several nights per week, and lactic acid– and urea-containing creams and lotions; all have been shown to be helpful. Mechanical debridement with a blade may also be useful. Oral retinoid therapy has had variable effects. Treatment with an antifungal agent is beneficial if dermatophyte infection coexists with the NEPPK.
• Mal de Meleda²
• • A synonym is keratosis extremitatum hereditaria trangrediens et progrediens. Mal de Meleda is an autosomal recessive disease. Onset occurs in early infancy, but the condition is rare. The prevalence is 1 case per 100,000 population. Initially, it was described in inhabitants of the Adriatic Island of Meleda.
  • Clinical features include diffuse, thick keratoderma with a prominent erythematous border. Lesions spread onto the dorsa of the hands and the feet (transgredient). Constricting bands are present around the digits and can result in spontaneous amputation. Well-circumscribed psoriasislike plaques or lichenoid patches may be present on the knees and the elbows. Patients may have severe hyperhidrosis, possibly accompanied by malodor. Secondary bacterial and fungal infections are common. Perioral erythema; periorbital erythema and hyperkeratosis; nail changes (eg, koilonychia, subungual hyperkeratosis); and lingua plicata, syndactyly, hair on the palms and the soles, high-arched palate, and left-handedness are other clinical features.
  • Histologic findings include orthokeratosis and normogranulosis without epidermolysis.
  • Molecular biology features include mutations in the gene encoding SLURP-1 found on band 8q24.3. Proteins of the SLURP family have been implicated in transmembrane signal transduction, cell activation, and cell adhesion.
  • Treatment is with oral retinoid therapy.
• Nagashimi-type PPK³
• • This condition is inherited in an autosomal recessive fashion. Onset of disease occurs between birth and age 3 years. To date, all 19 cases have been reported in Japan.
  • Clinically, the disease was initially described as a milder form of mal de Meleda. Some classify this keratosis as its own distinct entity, with involvement of other sites, including the elbows and knees, being common. Hyperhidrosis and tinea pedis infection are associated features.
  • Molecular biology studies in one case did not find any mutations in the gene encoding SLURP-1.
• Progressive PPK (Greither disease)
• • A synonym is transgrediens et progrediens PPK. This is inherited in an autosomal dominant fashion. Onset occurs in early infancy but may occur later in childhood.
  • Clinically, diffuse PPK extends onto the dorsa of the hands and the feet (trangredient), with characteristic involvement of the Achilles tendon. Scaly plaques may be found on the elbows, knees, and flexural areas. Hyperhidrosis and intrafamilial phenotypic variation are common. Pseudoainhum formation with amputation of the digits has been described.
  • Histologic features include epidermolysis of the granular cell layer. Lipid-laden corneocytes may be seen.
  • Molecular biology features include mutations in the gene encoding keratin 1.⁴
  • Treatment includes emollients, topical retinoids, keratolytics, and topical steroids.

Diffuse types with associated features

• Mutilating PPK (Vohwinkel syndrome)
• • Synonyms include PPK mutilans and keratoderma hereditaria mutilans. Mutilating PPK is inherited in an autosomal dominant fashion. Onset occurs in infancy.
  • Clinically, this condition manifests in infants as a honeycomblike keratosis of the palms and the soles. It becomes transgredient during childhood. Later-forming, constricting, fibrous bands appear on the digits and can lead to progressive strangulation and autoamputation. Starfish-shaped keratosis may occur on the knuckles of the fingers and toes, which is a characteristic feature of this disorder. Alopecia, hearing loss, spastic paraplegia, myopathy, ichthyosiform dermatosis, and nail abnormalities are associated. Cases of epithelioma cuniculatum have been reported.
  • Histologic findings include hyperkeratosis, acanthosis, and a thickened granular cell layer with retained nuclei in the stratum corneum.
  • Molecular biological studies have confirmed that the most common mutation found in Vohwinkel syndrome involves the gene encoding connexin 26. This subtype is associated with hearing loss. In contrast, a mutation in the gene for loricrin is associated with mutilating keratoderma and ichthyosis but not deafness.
  • Treatment includes oral retinoids.
  • Also see Vohwinkel Syndrome. 
• Bart-Pumphrey syndrome 
• • A synonym is PPK with knuckle pads, leukonychia, and deafness. It is inherited in an autosomal dominant fashion. Onset occurs in infancy.
  • Clinically, all neonates are hearing impaired from birth and develop diffuse PPK in childhood. Leukonychia and hyperkeratoses over the joints of the hand also appear.
  • Molecular biological studies include a new mutation in the gene that encodes connexin 26, which explains the clinical overlap with Vohwinkel syndrome.
• Diffuse NEPPK and sensorineural deafness
• • This condition is inherited in an autosomal dominant fashion.
  • Clinical features include diffuse palmoplantar hyperkeratosis in association with slowly progressive, bilateral, high-frequency hearing loss (onset in early childhood). Deafness precedes the skin changes (onset in mid childhood).
  • Molecular biology features include a connexin 26 mutation (different domains than those mutated in Vohwinkel syndrome). In addition, a mitochondrial point mutation has been demonstrated as the cause of this phenotype, making this the only type of keratoderma associated with a mutation in mitochondrial DNA (serine tRNA).
• PPK with sclerodactyly (Huriez syndrome)
• • PPK with sclerodactyly is inherited in an autosomal dominant fashion. Onset occurs in infancy.
  • Clinical features include red, atrophic skin on the dorsal hands and feet at birth. Diffuse, mild keratoderma is more marked on the palms than the soles. Other clinical features are sclerodactyly and nail abnormalities (hypoplasia, fissuring, ridging, koilonychia). PPK with sclerodactyly is also associated with aggressive squamous cell carcinoma in areas of atrophic skin.
  • Histologic findings include acanthosis, accentuation of the granular layer, and orthokeratosis; Langerhans cells are almost completely absent in the affected skin. Under electron microscopy, dermoepidermal junctions and desmosomes are normal; however, dense bundles of tonofilaments are seen in the epidermal layer. The granular layer shows large, coarse, clumped keratohyalin.
  • Molecular biologic findings include a mutation in the gene mapped to 4q23.
• Hidrotic ectodermal dysplasia (Clouston syndrome)
• • This syndrome is an autosomal dominant disorder.
  • Clinical features include diffuse papillomatous PPK (especially over pressure points of the palms and soles), dystrophic nails, and hypotrichosis. Thickened, hyperpigmented skin may also appear over the small and large joints, including the knuckles, elbows, and knees. Thickened, severely dystrophic nails develop, but they may be normal at birth. Universal sparsity of hair involves the scalp, eyebrows, eyelashes, and axillary and genital regions. Sensorineural deafness, polydactyly, syndactyly, clubbing of fingers, mental retardation, dwarfism, photophobia, and strabismus are associated.
  • Clouston syndrome is mapped to 13q11. One form can be caused by mutation in the gene encoding connexin 30. Ultrastructural studies of the hair of these patients demonstrate disorganization of hair fibrils with loss of the cuticular cortex.
• Mutilating PPK with periorificial keratotic plaques (Olmsted syndrome)
• • Most cases of this condition are sporadic, with the exception of one report of an autosomal dominant pattern of inheritance. Onset occurs in the first year of life.
  • Clinically, PPK begins focally in infancy and then becomes diffuse and severe. Later findings include flexion deformities and constriction of the digits, sometimes leading to spontaneous amputation. Progressive, well-defined perioral, perianal, and perineal hyperkeratotic plaques are present, as is onychodystrophy. Alopecia, deafness, nail dystrophy, and dental loss may be associated. Squamous cell carcinoma and malignant melanoma have developed in the areas of PPK.
  • Histologic findings include hyperkeratosis without parakeratosis and mild acanthosis.
  • Abnormal expression of keratin 5 and 14 has been reported.
  • Treatment includes oral and topical retinoids. Full-thickness excision and skin grafting has also been reported to result in clinical improvement.
• PPK with periodontitis (Papillon-Lefèvre syndrome)
• • This condition is inherited in an autosomal recessive fashion. The frequency of PPK with periodontitis is 4 cases per 1 million population. The male-to-female ratio is equal. Onset occurs between the first and fifth years of life. A variant, Haim-Munk syndrome, features, in addition to PPK and periodontitis, arachnodactyly, acroosteolysis, and onychogryphosis.
  • Clinically, diffuse transgredient PPK may be observed, typically developing within the first 3 years of life. Punctiform accentuation, particularly along the palmoplantar creases, may be seen. Unless treated, periodontosis results in severe gingivitis and loss of teeth by age 5 years. No significant correlation has been demonstrated between the level of periodontal infection and the severity of skin affections, which supports the concept that these major components of this syndrome are unrelated to each other. Patients exhibit increased susceptibility to cutaneous and systemic infections. Scaly, psoriasiform lesions are often observed over the knees, elbows, and interphalangeal joints. Finally, patients may have malodorous hyperhidrosis. Reports from 2008 indicate a high prevalence of malignant melanoma in Japanese patients with Papillon-Lefèvre syndrome.⁵
  • Histologic findings include hyperkeratosis with irregular parakeratosis and moderate perivascular infiltration. Electron microscopic features include lipidlike vacuoles in corneocytes and granulocytes, a reduction in tonofilaments, and irregular keratohyalin granules.
  • Molecular biology findings include mutations in the gene for cathepsin C, mapping to 11q14-q21, which are responsible for this syndrome.⁶ Cathepsin C is a lysosomal protease known to activate enzymes that are vital to the body's defenses.
  • Treatment includes oral retinoids for the PPK. Elective extraction of involved teeth may prevent excess bone resorption. Appropriate antibiotic therapy may be required for periodontitis and recurrent cutaneous and systemic infections. Treatment with acitretin starting at an early age shows promise towards allowing patients to have normal adult dentition.
• Diffuse NEPPK with woolly hair and arrhythmogenic cardiomyopathy (Naxos disease)
• • This condition is inherited in an autosomal recessive fashion.
  • Clinically, a diffuse, nontransgredient keratoderma with an erythematous border appears during the first year of life. Woolly (dense, rough, and bristly) scalp hair is present at birth. Cardiac disease, manifested by arrhythmias, heart failure, or sudden death, becomes evident during and after late puberty. Other cutaneous manifestations include acanthosis nigricans, xerosis, follicular hyperkeratosis over the zygoma, and hyperhidrosis.
  • Histologic findings include hyperkeratosis, hypergranulosis, and acanthosis.
  • Molecular biology findings include a mutation in the plakoglobin gene, mapping to 17q21, which is responsible for Naxos disease. Plakoglobin is an important component of cell-to-cell and cell-to-matrix adhesion complexes of many tissues, including the skin and cardiac junctions. It also plays a role in signaling in the formation of desmosomal junctions. Mutations in the plakoglobin gene may lead to detachment of the cardiac myocytes, resulting in myocyte death. Plakoglobin mutations may also lead to desmosomal junction fragility in hair shafts, explaining the clinical phenotype of woolly hair.
  • The Medscape CME course Mechanisms of Disease: Molecular Genetics of Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy may be of interest.

FOCAL HEREDITARY PPK

Section 4 of 10  

• Authors and Editors
• Introduction
• Diffuse Hereditary PPK
• Focal Hereditary PPK
• Punctate Hereditary PPK
• Acquired PPK
• Syndromes With PPK as an Associated Feature
• Treatment
• Acknowledgments
• References

Focal PPK without associated features

• Focal EPPK
• • Synonyms include keratosis palmoplantaris nummularis and hereditary painful callosities. This condition is inherited in an autosomal dominant manner. Onset occurs within the first 2 years of life.
  • Clinical features include nummular keratotic lesions, mainly located on plantar pressure points. This condition is also painful.
  • Histologic features include local epidermolytic hyperkeratosis.
  • Molecular genetic findings have not yet been reported.
• Striate PPK
• • Synonyms include Brünauer-Fuhs-Siemens syndrome, Wachter-type focal NEPPK, and PPK areata/striata. Striate PPK is inherited in an autosomal dominant fashion. Onset occurs in infancy or in the first few years of life.
  • Clinical features include marked variability in phenotypic expression. Hands may show minimal callous formation, or, changes may be undetectable in individuals with sedentary occupations. Friction-associated trauma from manual labor results in a striate pattern of PPK over the palmar aspects of the digits (islands of linear hyperkeratosis). Increased skin fragility may lead to skin splitting following trauma. Nails and hair may be involved.
  • Histology demonstrates acanthosis and an increased granular layer.
  • Molecular biology findings include mutations in desmosomal proteins, which have been implicated in this disorder, including desmoglein 1 on 18q11-12 and the desmoplakin gene on 6p21. Desmosomal function is very important in areas prone to repeated friction. Mutations in keratin 1 and keratin 16 are also associated with striate PPK.
  • Treatment includes oral retinoids.

Focal type with associated features

• PPK associated with esophageal cancer (Howell-Evans syndrome)
• • Synonyms include tylosis esophageal cancer and focal NEPPK with carcinoma of the esophagus. This condition is inherited in an autosomal dominant fashion.
  • Clinically, focal PPK develops at age 5-10 years. The PPK is limited to the pressure points on the balls of the feet, with later mild involvement on the palms. Patients have an increased susceptibility to developing carcinoma of the esophagus in the fifth decade of life. Two variants, one with a late onset of PPK and a higher risk of esophageal carcinoma and another with an early onset and a benign course, have been described. Oral leukokeratosis and follicular keratosis are often present.
  • Histologic findings include acanthosis, a prominent granular cell layer, and hyperkeratosis in the palms and soles. Patients have thickened sweat ducts of the dermis, with the lumen often occluded by a hyperplastic epithelium.
  • The tylosis esophageal cancer gene (TOC) is localized to a small region on band 17q25, a region frequently deleted in persons with sporadic squamous cell esophageal tumors.
• Oculocutaneous tyrosinemia (Richner-Hanhart disease)
• • Synonyms include tyrosinemia type II. Oculocutaneous tyrosinemia is inherited in an autosomal recessive fashion.
  • Clinical features include focal, painful PPK development in childhood or adolescence. Occasionally, hyperkeratotic lesions develop on the elbows, knees, and tongue. Patients have hyperhidrosis and bullous lesions. Photophobia and herpetiform corneal erosions often appear in infancy and can lead to corneal ulcerations, scarring, and glaucoma. Tyrosine crystal deposits can be seen during slit-lamp examination. Mental retardation develops, especially if patients are not treated.
  • Histologic findings include acanthosis with hyperkeratosis and hypergranulosis. Under electron microscopy, keratinocytes contain clumped tonofilament with adherent globoid keratohyalin granules and intracellular needle-shaped tyrosine crystalline inclusions can be found.
  • Molecular biology features include at least 15 mutations in the gene encoding tyrosine aminotransferase at band 16q22.1-q22.3. Deficiency of the enzyme tyrosine aminotransferase leads to increased levels of serum and urinary tyrosine and phenolic acid metabolites of tyrosine.
  • Treatment includes early institution of a low-phenylalanine and low-tyrosine diet.
• Pachyonychia congenita, types I and II⁷
• • This condition is inherited in an autosomal dominant manner; however, a rare autosomal recessive pattern is also observed.
  • Clinical features include localized areas of hyperkeratosis on the palms and the soles, typically found on pressure points and weightbearing areas of the palms and soles. Patients have discoloration and thickening of the nails, which may be striking. Follicular hyperkeratosis, angular cheilitis, oral leukokeratosis, hyperhidrosis, and hoarseness may develop.
  • Type 1 is the Jadassohn-Lewandowsky type and is the most prevalent type of pachyonychia congenita. It is characterized by severe focal PPK, possibly with blistering. Type 2 is the Jackson-Lawler type. The focal PPK is milder in type 2 than in type 1. Natal or neonatal teeth and multiple pilosebaceous cysts (steatocystoma multiplex) are also present and help distinguish this type from type 1.
  • Histologic features include hyperkeratosis with alternating orthokeratosis and parakeratosis. Large keratohyalin granules are present. Under electron microscopy, these granules appear as perinuclear keratin aggregates.
  • Molecular biology findings for the Jadassohn-Lewandowsky type include a keratin 16 gene mutation and keratin 6a gene mutations. The Jackson-Lawler type is associated with keratin 17 and keratin 6b gene mutations.
  • Treatment includes emollients and keratolytics in mild cases and oral retinoids in more severe disease. Surgical excision of severely deformed nails offers a temporary solution, but nail dystrophy recurs. Injection of botulinum toxin has shown relief for hyperhidrosis and pain.
  • Also see Pachyonychia Congenita. 
• Striate PPK with woolly hair and left-sided dilated cardiomyopathy (Carvajal-Huerta syndrome)
• • This condition is inherited in an autosomal recessive pattern. Both this disease and Naxos disease are autosomal recessive, whereas most of the hereditary dilated cardiomyopathies are autosomal dominant.
  • Clinical features include the appearance of striate PPK during early infancy. Left ventricular cardiomyopathy begins in adolescence and occasionally leads to early heart failure. Woolly hair is present at birth. Striated lichenoid keratoses of the flexures, follicular keratoses on the elbows and knees, and clubbing of the nails have been described. Skin fragility, characterized by transient vesicles and blisters on the trunk and extremities, is another clinical feature.
  • Histologic features include spongiform edema with large intercellular spaces, clustering of desmosomes at infrequent sites of keratinocyte adhesion, and perinuclear localization of keratin in suprabasal keratinocytes, which have all been demonstrated by immunohistochemistry studies, suggesting the presence of a collapsed intermediate filament network.
  • Molecular biology findings include homozygous mutations of the gene encoding desmoplakin, which maps to 6p24 and is the most abundant protein of the desmosome.

PUNCTATE HEREDITARY PPK

Section 5 of 10  

• Authors and Editors
• Introduction
• Diffuse Hereditary PPK
• Focal Hereditary PPK
• Punctate Hereditary PPK
• Acquired PPK
• Syndromes With PPK as an Associated Feature
• Treatment
• Acknowledgments
• References

Punctate PPK without associated features

• Punctate keratosis of the palms and soles (Buschke-Fischer disease)⁸
• • Synonyms include keratosis punctata palmaris et plantaris, Buschke-Fischer-Brauer disease, and keratosis papulosa. The prevalence is 1.17 cases per 100,000 population. This condition is inherited in an autosomal dominant manner, although sporadic cases have been reported. The age at onset is variable, between 10 and 70 years.
  • Clinically, asymptomatic, tiny, hyperkeratotic papules are present on the palmoplantar surface. Lesions are uncommon in childhood and usually manifest after age 20 years. This condition is not associated with hyperhidrosis. Patients commonly report pruritus. Most individuals lack associated features; however, spastic paralysis, ankylosing spondylitis, and facial sebaceous hyperplasia have been reported. An association with gastrointestinal and pulmonary malignancy is possible.
  • Histologic findings include substantial compact hyperkeratosis over a distinct area of epidermis, hypergranulosis, the presence of a cornoid lamella, and the absence of epidermal dyskeratosis or hydropic change, which help differentiate this condition from porokeratosis.
  • Molecular genetic studies have not yet identified specific genes involved, although linkage analyses have mapped the disease between bands 15q22.2 and 15q22.31.
  • Treatment includes keratolytics, topical salicylic acid, mechanical debridement, excision, and topical and systemic retinoids.
• Punctate keratosis of the palmar creases
• • Punctate keratosis of the palmar creases occurs most commonly in African American patients aged 15-40 years. An autosomal dominant inheritance pattern has been suggested.
  • Clinical features include small, round depressions filled with conical keratinous plugs, which typically occur on the creases of the palms, fingers, and, less commonly, on the soles. The lesions are aggravated by friction, and, occasionally, they may be painful.
  • Histologic features include hyperkeratosis and parakeratosis.
  • Treatment may include keratolytics and topical retinoids.
• Acrokeratoelastoidosis
• • Synonyms include acrokeratoelastoidosis of Costa. Acrokeratoelastoidosis is usually sporadic, although familial cases suggest an autosomal dominant pattern of inheritance. Onset usually occurs before the second or third decade of life.
  • Clinical features include round or oval, shiny, firm, yellowish papules that can appear umbilicated. These papules are distributed along the marginal border of the palms, soles, and/or digits and can also be seen in the space between the thumb and forefinger, on the anterior surface of the lower legs, and over the knuckles and nail folds. The papules are usually asymptomatic.
  • Histologic features include focal hyperkeratosis and elastorrhexis (fragmentation and a decreased number of elastic fibers in the reticular dermis).
  • No treatment is usually required for acrokeratoelastoidosis because lesions are asymptomatic. However, methods to remove the lesions for cosmetic purposes, including liquid nitrogen, salicylic acid, and topical tretinoin, have largely been unsuccessful.
• Focal acral hyperkeratosis
• • Focal acral hyperkeratosis is usually sporadic, but familial cases suggest an autosomal dominant pattern of inheritance. Onset peaks in the third decade. Some believe this entity is a variant of acrokeratoelastoidosis.
  • Clinically, the lesions are identical to those of acrokeratoelastoidosis. It has an insidious onset in childhood, reaching a maximum in early life. Initial reports suggested a predilection for those of African origin, but subsequent reports have refuted the importance of ethnicity. Associated findings may include hyperhidrosis, a gradual increase in the number and size of the lesions, and rapid progression during pregnancy.
  • Histologic features include focal hyperkeratosis, but no decrease or fragmentation of dermal elastic fibers is reported.
  • Topical treatments have been unsuccessful, although oral retinoids have been partially effective in long-term treatment.

Punctate PPK with associated features

• Rare single-pedigree syndromes
• • Cystic eyelids, punctate PPK, hypotrichosis, and hypodontia (Schöpf-Schulz-Passarge syndrome)
  • Punctate PPK with ankylosing spondylitis
  • Punctate PPK with facial sebaceous hyperplasia
  • Punctate PPK with spastic paralysis
  • PPK with lipomata

ACQUIRED PPK

Section 6 of 10  

• Authors and Editors
• Introduction
• Diffuse Hereditary PPK
• Focal Hereditary PPK
• Punctate Hereditary PPK
• Acquired PPK
• Syndromes With PPK as an Associated Feature
• Treatment
• Acknowledgments
• References

• Keratoderma climactericum
• • Synonyms include Haxthausen disease. Onset occurs in women of menopausal age.
  • Clinically, pressure areas on the soles are initially affected. Erythema and hyperkeratosis with fissuring make walking painful. Transgrediens is absent. Pruritus is minimal. Later in the course of the disease, palmar involvement is seen as discrete and centrally confined hyperkeratosis. Many patients are obese and hypertensive. A role for estrogen therapy has been proposed and is supported by the timing of onset and the response to topical and systemic estrogens. However, reports indicate that patients have normal hormone profiles. Some cases may represent a form of eczema or psoriasis.
  • Histologic features include compact orthokeratotic hyperkeratosis, hypergranulosis, irregular acanthosis with alternating thick and thin interpapillary ridges, and spongiosis with exocytosis of lymphocytes. In the dermis, a lymphocytic infiltrate is present around the upper dermal vessels.
  • Treatment includes topical estradiol 0.05% ointment or 25-40% urea.
• Keratoderma associated with internal malignancy
• • Keratoderma is associated with malignancy as a paraneoplastic phenomenon and as a manifestation of malignancy predisposition. Skin changes tend to precede discovery of the neoplasm by a few months, and metastasis is usually present at diagnosis. Keratodermas have been associated with carcinomas of the esophagus, lung, breast, stomach, pancreas, kidney, bladder, and colon.
  • Acrokeratosis paraneoplastica of Bazex is associated with squamous cell carcinoma of the upper gastrointestinal tract. The condition affects white men aged 40 years and older. Psoriasiform changes of the fingers and the toes with nail dystrophy extend to involve the palms, soles, limbs, and trunk. The paraneoplastic nature of the condition is supported by a tendency for both the time course and the skin involvement to parallel the extent of tumor. The skin may clear with the removal of the tumor, but relapses occur with tumor regrowth and cervical metastasis. Also see Acrokeratosis Neoplastica.
  • Tripe palms (acanthosis palmaris) is a distinct cutaneous paraneoplastic syndrome most often associated with malignancy of the stomach or lung. The palms are diffusely thickened, with a velvety texture and ridged appearance. Malignant tripe palms persists, with less than one third of patients responding to tumor therapy. Tripe palms is also associated with bullous pemphigoid, psoriasis, and exfoliative dermatitis.
• PPK due to inflammatory and reactive dermatoses
• • Chronic hand dermatitis is characterized by marked irritation, scaling, and fissuring. Causes may include atopic dermatitis, irritant contact dermatitis, or allergic contact dermatitis.
  • Psoriasis may manifest as diffuse hyperkeratosis or as scaly plaques with a scalloped margin.
  • Keratoderma blennorrhagica (Reiter syndrome) occurs in 30% of patients with Reiter syndrome. Lesions are compact, and the sole of the foot is the typical site of involvement.
  • Pityriasis rubra pilaris is associated with red-orange thick scale on the palms and soles with sharp borders. Usually, follicular papules with surrounding erythema are present, often on the dorsal proximal phalanges (see Pityriasis Rubra Pilaris).
  • Callosities develop in response to repeated trauma over bony prominences.
  • Lichen planus may cause an erythematous, scaly PPK or a punctate, yellow, warty keratosis. PPK and nail dystrophy have been seen in lichen nitidus.
• Aquagenic keratoderma^{9, 10}
• • Synonyms include acquired aquagenic PPK, transient reactive papulotranslucent acrokeratoderma, and aquagenic syringeal acrokeratoderma. Onset occurs during the second decade of life.
  • Clinically, within minutes of immersion in water, translucent whitish papules and plaques appear on the palms and, less commonly, on the soles. A burning sensation and edema of the hands may also occur simultaneously. The lesion resolves minutes to hours after drying of the affected skin. Hyperhidrosis may be associated with the condition.
  • Histologically,  the epidermis and dermis may be normal or mild orthohyperkeratosis, hypergranulosis, acanthosis, or dilated eccrine ostia may develop.
  • Treatment includes 20% aluminum chloride hexahydrate, which has shown significant clinical improvement in signs and symptoms. Other options include 12% ammonium lactate cream, 20% acid salicylic in petroleum jelly, 10% urea cream, and botulinum toxin injections.
• PPK caused by infections
• • Dermatophytes manifest as hyperkeratosis affecting the soles, toe webs, and sides of the feet. Hyperhidrosis increases itching and malodor.
  • Human papillomavirus may form confluent exuberant masses on the palms and the soles, mimicking keratoderma.
  • Syphilis may manifest as a diffuse, symmetric keratoderma or papular PPK.
  • Leprosy can manifest as glove-and-stocking anesthesia, predisposing patients to infection, ulceration, and hyperkeratosis. Tuberculosis, especially miliary tuberculosis, may cause hyperkeratosis of the palms and soles.
  • Encrusted scabies may progress into strikingly hyperkeratotic and/or crusted lesions on palmar surfaces.
• Drug-related PPK
• • Chronic arsenic exposure can lead to multiple, irregular, warty keratotic lesions on the palms and soles. Onset of the keratoses may occur 10-30 years after ingestion
  • Drug hypersensitivity may result from agents such as glucan, verapamil, quinacrine, etodolac, mepacrine, proguanil, mexiletine, methyldopa, lithium, venlafaxine, gold, tegafur, fluorouracil, bleomycin, hydroxyurea, practolol, and doxorubicin.
• Systemic disease–associated PPK
• • Myxedema is associated with distinctive features that include its response to treatment and the severity and verrucosity of the hyperkeratosis, with diffuse involvement of the plantar surface and more limited involvement of the palms. The mechanism is unclear; however, it has been postulated that inhibition of carotene conversion to vitamin A by thyroxine deficiency may cause hyperkeratosis. Mild relief is achieved with thyroid hormone replacement.
  • Diabetes mellitus features include discrete plantar keratosis under the metatarsal arch and the great toe.
  • Chronic lymphedema and other circulatory disorders such as acrocyanosis and livedo reticularis have been associated with keratoderma.
  • Cutaneous T-cell lymphoma features diffuse hyperkeratosis accompanied by subungual hyperkeratosis and nail dystrophy, which is typical of Sézary syndrome.
  • Diets lacking protein energy and vitamin deficiency have been implicated in PPK with associated fissuring.

SYNDROMES WITH PPK AS AN ASSOCIATED FEATURE

Section 7 of 10  

• Authors and Editors
• Introduction
• Diffuse Hereditary PPK
• Focal Hereditary PPK
• Punctate Hereditary PPK
• Acquired PPK
• Syndromes With PPK as an Associated Feature
• Treatment
• Acknowledgments
• References

• Basal cell nevus syndrome
• Bullous congential ichthyosiform erythroderma
• Cantu syndrome - Hyperkeratosis-hyperpigmentation syndrome
• Cerebral dysgenesis, neuropathy, ichthyosis, and keratoderma (CEDNIK) syndrome
• Cole disease - Guttate hypopigmentation and punctate PPK
• Congenital nonbullous ichthyosiform erythroderma
• Darier disease
• Ectodermal dysplasia with skin fragility
• Epidermodysplasia verruciformis
• Epidermolysis bullosa herpetiformis (Dowling-Meara type)
• Erythrokeratoderma variabilis
• Familial pityriasis rubra pilaris
• Hystrixlike ichthyosis-deafness (HID) syndrome
• Ichthyosis hystrix of Curth-Macklin
• Ichthyosis vulgaris
• Incontinentia pigmenti
• Keratitis, ichthyosis, and deafness (KID) syndrome
• Lamellar ichthyosis
• Progressive symmetric erythrokeratoderma
• Schöpf-Schulz-Passarge syndrome - PPK with hidrocystomas, hypodontia and hypotrichosis
• Sjögren-Larsson syndrome

TREATMENT

Section 8 of 10  

• Authors and Editors
• Introduction
• Diffuse Hereditary PPK
• Focal Hereditary PPK
• Punctate Hereditary PPK
• Acquired PPK
• Syndromes With PPK as an Associated Feature
• Treatment
• Acknowledgments
• References

Treatment of all types of hereditary and nonhereditary keratodermas is difficult. The most common therapeutic options only result in short-term improvement and are frequently compounded by unacceptable adverse effects. Treatment tends to be symptomatic and may vary from simple measures (eg, saltwater soaks, paring) to topical keratolytics, systemic retinoids, or reconstructive surgery with total excision of the hyperkeratotic skin followed by grafting. The mainstays of treatment include the following:

• Topical keratolytics (eg, salicylic acid 5%, lactic acid 10%, urea 10-40%) are useful in patients with limited keratoderma.
• Topical retinoids (eg, tretinoin) are effective, but treatment is often limited by skin irritation.
• Consider potent topical steroids with or without keratolytics in dermatoses with an inflammatory component.
• Oral retinoids are effective, especially in some hereditary PPKs such as mal de Meleda, Papillon-Lefèvre syndrome, and erythrokeratoderma variabilis. Most hereditary PPKs require long-term treatment. Results indicate that acitretin is comparable to etretinate. Intermittent therapy should be attempted whenever possible. To limit unacceptable long-term adverse effects, the optimal dosage of acitretin in adults is 30-35 mg/d (0.5-1 mg/kg/d for adults and 0.5 mg/kg/d for children). Treatment of women of childbearing age results in long-term potential teratogenic effects. The maintenance dose can be reduced to 25 mg/d. Caution is advised if the patient has an epidermolytic form because large erosions may occur with retinoid therapy. Some patients with KID syndrome have had worsening keratitis with retinoids. Patients should be started on a low dose, and the dose should be carefully increased to avoid flaring the disease and/or causing erosions.
• Specific therapies dependent on the PPK type may be used. Psoralens and ultraviolet A (PUVA) or re-PUVA (a combination of oral retinoids and PUVA) may be indicated in persons with PPK secondary to psoriasis or eczema. Patients with oculocutaneous tyrosinemia may benefit from dietary restriction of phenylalanine and tyrosine. Improvement has been seen in persons with nonhereditary PPK after oral 1-alpha, 25-dihydroxyvitamin D-3.
• Careful selection of footwear and treatment of fungal infections are important.
• Dermabrasion may permit increased penetration of topical agents, and carbon dioxide laser treatment may be beneficial in persons with limited keratodermas.
• For severe and refractory keratoderma, consider surgery. Total excision of hyperkeratotic skin followed by grafting has been successful in a number of cases.
• Paraneoplastic keratodermas are generally refractory to local treatment and may only respond to removal of the underlying neoplasm.

ACKNOWLEDGMENTS

Section 9 of 10  

• Authors and Editors
• Introduction
• Diffuse Hereditary PPK
• Focal Hereditary PPK
• Punctate Hereditary PPK
• Acquired PPK
• Syndromes With PPK as an Associated Feature
• Treatment
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthors Ravi Ratnavel, MD, and Pascale C Gruber, MBBS, MRCP, to the development and writing of this article.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Diffuse Hereditary PPK
• Focal Hereditary PPK
• Punctate Hereditary PPK
• Acquired PPK
• Syndromes With PPK as an Associated Feature
• Treatment
• Acknowledgments
• References

1. Yang JM, Lee S, Kang HJ, Lee JH, Yeo UC, Son IY, et al. Mutations in the 1A rod domain segment of the keratin 9 gene in epidermolytic palmoplantar keratoderma. Acta Derm Venereol. Nov 1998;78(6):412-6. [Medline].
2. Rajashekhar N, Moideen R. Palmoplantar keratoderma--Mal de Meleda syndrome. Int J Dermatol. Nov 1997;36(11):854-6. [Medline].
3. Kabashima K, Sakabe J, Yamada Y, Tokura Y. "Nagashima-type" keratosis as a novel entity in the palmoplantar keratoderma category. Arch Dermatol. Mar 2008;144(3):375-9. [Medline].
4. Gach JE, Munro CS, Lane EB, Wilson NJ, Moss C. Two families with Greither's syndrome caused by a keratin 1 mutation. J Am Acad Dermatol. Nov 2005;53(5 Suppl 1):S225-30. [Medline].
5. Nakajima K, Nakano H, Takiyoshi N, Rokunohe A, Ikenaga S, Aizu T, et al. Papillon-Lefèvre syndrome and malignant melanoma. A high incidence of melanoma development in Japanese palmoplantar keratoderma patients. Dermatology. 2008;217(1):58-62. [Medline].
6. Hart TC, Bowden DW, Ghaffar KA, Wang W, Cutler CW, Cebeci I, et al. Sublocalization of the Papillon-Lefevre syndrome locus on 11q14-q21. Am J Med Genet. Sep 1 1998;79(2):134-9. [Medline].
7. Lucker GP, Steijlen PM. Pachyonychia congenita tarda. Clin Exp Dermatol. May 1995;20(3):226-9. [Medline].
8. Oztas P, Alli N, Polat M, Dagdelen S, Ustün H, Artüz F, et al. Punctate palmoplantar keratoderma (Brauer-Buschke-Fischer syndrome). Am J Clin Dermatol. 2007;8(2):113-6. [Medline].
9. Bardazzi F, Savoia F, Dika E, Tabanelli M, Giacomini F. Acquired aquagenic keratoderma. Pediatr Dermatol. Mar-Apr 2007;24(2):197-8. [Medline].
10. Yan AC, Aasi SZ, Alms WJ, James WD, Heymann WR, Paller AS, et al. Aquagenic palmoplantar keratoderma. J Am Acad Dermatol. Apr 2001;44(4):696-9. [Medline].
11. Griffiths WAD, Judge MR, Leigh IM. Disorders of keratinization. In: Textbook of Dermatology. Vol 2. 6^th ed. Oxford, England: Blackwell Science; 1998:1557-88.
12. Itin PH, Fistarol SK. Palmoplantar keratodermas. Clin Dermatol. Jan-Feb 2005;23(1):15-22. [Medline].
13. Kimyai-Asadi A, Kotcher LB, Jih MH. The molecular basis of hereditary palmoplantar keratodermas. J Am Acad Dermatol. Sep 2002;47(3):327-43; quiz 344-6. [Medline].
14. Krol AL. Keratoderma. In: Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology. Vol 1. 2^nd ed. Spain: Elsevier Limited; 2008:777-89.
15. Lucker GP, Van de Kerkhof PC, Steijlen PM. The hereditary palmoplantar keratoses: an updated review and classification. Br J Dermatol. Jul 1994;131(1):1-14. [Medline].
16. Patel S, Zirwas M, English JC 3rd. Acquired palmoplantar keratoderma. Am J Clin Dermatol. 2007;8(1):1-11. [Medline].
17. Ratnavel RC, Griffiths WA. The inherited palmoplantar keratodermas. Br J Dermatol. Oct 1997;137(4):485-90. [Medline].
18. Saywell C, Griffiths WAD. Acquired keratodermas. Retinoids Today Tomorrow. 1994;34:15-19.

Article Last Updated: Jul 28, 2008