Aquagenic palmar wrinkling as a presenting feature of cystic fibrosis gene dysfunction

ECFS standards of care on CFTR-related disorders: Identification and care of the disorders

This is the third paper in the series providing updated information and recommendations for people with cystic fibrosis transmembrane conductance regulator (CFTR)-related disorder (CFTR-RD). This paper covers the individual disorders, including the established conditions - congenital absence of the vas deferens (CAVD), diffuse bronchiectasis and chronic or acute recurrent pancreatitis - and also other conditions which might be considered a CFTR-RD, including allergic bronchopulmonary aspergillosis, chronic rhinosinusitis, primary sclerosing cholangitis and aquagenic wrinkling. The CFTR functional and genetic evidence in support of the condition being a CFTR-RD are discussed and guidance for reaching the diagnosis, including alternative conditions to consider and management recommendations, is provided. Gaps in our knowledge, particularly of the emerging conditions, and future areas of research, including the role of CFTR modulators, are highlighted.

Normative data for aquagenic wrinkling of palms in children 1-15 years of age: A cross-sectional study

BACKGROUND

Aquagenic wrinkling of palms (AWP) is emerging as a screening test for cystic fibrosis (CF). There is lack of normative data for the same in our population.

OBJECTIVES

To generate normative data for AWP in children 1-15 years of age and to describe the factors associated with it.

METHODS

Children aged 1-15 years were enrolled after obtaining informed consent and assent of the parent and child based on age. Information regarding age, gender, anthropometry, indications for visiting hospital and drug intake were noted down. Wrinkling test was done using distilled water maintained in room temperature. Sweat chloride analysis was done using Nano duct sweat analysis system for children having AWP within 3 min. The mean/median time to wrinkle was noted and presented as centile curves after smoothing.

RESULTS

The mean (SD) and median (interquartile range [IQR]) aquagenic wrinkling time in children 1-15 years of age was 4.88 (1.066) and 5 (4-5.75) minutes respectively. The mean (SD) and median (IQR) time for AWP was 4.78 (1.076) and 5 (4-5) minutes respectively for boys and 4.98 (1.048) and 5 (4-6) minutes, respectively for girls. The time taken to wrinkle was observed to increase with age. Males have earlier AWP than females. There was no association between AWP and anthropometry or sweat chloride levels.

CONCLUSION

We have estimated the normative data for AWP in children 1-15 years of age which can be used for CF screening in children with typical clinical features from resource limited settings.

Aquagenic Keratoma: Treatment Update

{0>La Queratodermia Acuagénica (QA) es una afectación dermatológica adquirida poco frecuente que se caracteriza por la aparición de edema y pápulas blanquecinas-translúcidas desencadenado por la inmersión o contacto con agua.<}100{>Aquagenic keratoderma is an uncommon acquired dermatosis characterized by edema and whitish-translucent papules triggered by immersion or contact with water.<0} {0>Se han descrito casos asociados a fármacos, hiperhidrosis y a fibrosis quística.<}100{>Cases have been described in association with certain medications, hyperhidrosis, and cystic fibrosis.<0} {0>Los objetivos del estudio son evaluar la efectividad de los distintos tratamientos existentes para la QA.<}0{>The aim of this review is to evaluate the effectiveness of different treatments for aquagenic keratoderma.<0} {0>Realizamos una revisión de la literatura existente al respecto hasta el momento, incluyendo series de casos y reportes de caso.<}94{>We reviewed the literature and analyzed treatments for aquagenic keratoderma described in case series and reports.<0} {0>El tratamiento de la QA es efectivo en las formas asociadas a hiperhidrosis.<}100{>Aquagenic keratoderma associated with hyperhidrosis can be treated effectively.<0} {0>La iontoforesis de agua del grifo, la simpatectomía torácica endoscópica, las inyecciones de toxina botulínica y la oxibutinina son efectivas en las formas refractarias.<}100{>Tap water iontophoresis, endoscopic thoracic sympathectomy, botulinum toxin injections, and oxybutynin are effective against refractory forms.<0} {0>La aplicación tópica de ácido salicílico o sales de aluminio es efectiva pero resulta poco eficaz como tratamiento de mantenimiento.<}0{>Topical salicylic acid and aluminum salts are effective, but of little value as maintenance therapy.<0} {0>Probablemente la mejor alternativa para el tratamiento de la QA sea la Oxibutinina 5mg/día v.o.<}100{>Oral oxybutynin 5 mg/d is probably the best option for treating aquagenic keratoderma.<0} {0>Se ha observado que los efectos fisiopatológicos de los antiinflamatorios no esteroideos en la QA podrían justificar el uso de las prostaglandinas como un tratamiento dirigido de la enfermedad.<}100{>The reported pathophysiological effects of nonsteroidal anti-inflammatory drugs in this setting suggest that the use of prostaglandins might be justified.<0} {0>Se necesitan estudios adicionales para fortalecer estas deducciones y abordar las incertidumbres restantes.<}100{>Additional studies are needed to investigate these hypotheses and resolve other questions.<0}.

Aquagenic (pseudo) keratoderma (aquagenic palmoplantar keratoderma, aquagenic wrinkling of palms)

Aquagenic palmoplantar keratoderma (APK) is an uncommon hereditary or sporadic condition that is characterized by edematous flat-topped papules appearing on palmar skin with wrinkling after brief water exposure. APK has been associated with cystic fibrosis (CF), presenting with the same mutations found in CF (usually ΔF508 of the CFTR gene), either homozygous or heterozygous. APK may be idiopathic or drug-induced. The diagnosis is easily made if one is aware of this entity. Topical aluminum hydroxide and botulinum toxin injections are the most commonly used treatments. The sporadic form may have a shorter course compared with the hereditary one, resolving spontaneously after a few years. The condition should no longer be considered a true keratoderma but rather a pseudo keratoderma, and in spite of the many different names found in the literature, the term "aquagenic (pseudo) keratoderma" seems to be the most appropriate one.

Aquagenic palmar wrinkling induced by combined use of salazopyrin and indomethacin

Aquagenic palmar wrinkling (APW) is an uncommon dermatological condition, which manifests as asymptomatic or tender palmar papules and may cause discomfort and manual functional limitations during its flares. Despite some studies implying a relationship between cystic fibrosis (CF) and APW, there are also reports of APW cases without an accompanying CF. In this report we describe a 19-year-old ankylosing spondylitis patient, who developed APW lesions after the start of combined salazopyrin and indomethacin treatment. His palmar lesions were resistant to topical corticosteroid and aluminium hydroxide therapy and disappeared only after stopping the anti-inflammatory drugs. With this report, we aim to highlight and address this underrecognized dermatological condition and possible role of aquaporins in its pathogenesis.

Aquagenic wrinkling of the palms and the potential role for genetic testing

Aquagenic wrinkling of the palms (AWP) is a condition characterized by excessive wrinkling, palmar edema, and whitish papules accompanied by pain, pruritus, or discomfort after brief immersion of the hands in water. It is well documented to be associated with cystic fibrosis (CF), with several theories regarding the pathogenesis having been proposed. We report a case of two sisters with AWP in whom CF has not been diagnosed and review the literature on AWP and its association with CF and CF carrier status. Because diagnosis of mild forms CF or knowledge of an underlying CF genetic mutation is frequently unknown, identification of AWP may represent the only sign of such mutations. The dermatologist plays an integral role in early detection of AWP, and the importance of genetic testing in such patients cannot be overlooked. We recommend various measures to apply in clinical practice to ensure diagnosis and decrease morbidity and mortality in patients.