A localized form of aquagenic syringeal acrokeratoderma

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 palmoplantar keratoderma during treatment of Langerhans cell histiocytosis]

BACKGROUND

Aquagenic palmoplantar keratoderma (APPK) is characterised by whitish oedematous papules, sometimes itchy or painful of rapid onset following immersion of the palms and/or soles in water. We report a case that was atypical in terms of the secondary appearance of persistent fine desquamation.

PATIENTS AND METHODS

A 6-year-old girl presented with typical APPK, present for three months and characterised by swelling, skin wrinkling, hyperhidrosis and secondary desquamation of the palms and soles, and which occurred after bathing. The patient had been treated with vinblastine, mercaptopurine and oral corticosteroids for Langerhans cell histiocytosis ongoing for six months. Physical examination revealed persistent fine desquamation of the palms and soles, occurring some time after immersion in water. There was no mutation of the CFTR gene. No similar cases could be found in the pharmacovigilance database. Topical therapy with an emollient provided some relief. Symptoms had partially resolved two months after discontinuation of chemotherapy and oral corticosteroids.

DISCUSSION

Cases of unilateral palmar damage involving unusual sites have been reported. Neither secondary desquamation nor association with Langerhans cell histiocytosis have been described. Hyperhidrosis and association with 1 or 2 CFTR mutations appear to constitute predisposing factors. There are cases of APPK related to anti-inflammatory intake. In view of the clinical course, an iatrogenic origin cannot be excluded in this case.

CONCLUSION

Persistent fine palmoplantar desquamation may be a manifestation of APPK.

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.

Unilateral aquagenic keratoderma treated with botulinum toxin A

BACKGROUND

Aquagenic keratoderma is a rare transient disease that occurs after water immersion and disappears shortly after drying. Most cases involve the palms and fingers bilaterally but it can also affect the soles. Few cases have been associated with drugs but its pathogenesis remains unclear.

MAIN OBSERVATION

We report a 60-year-old man with a 30-year-history of aquagenic keratoderma of the right palm without associated hyperhidrosis or history of drug intake. After unsuccessful treatment with 15% aluminium chloride hexahydrate gel, botulinum toxin A injections led to significant improvement within 2 weeks.

CONCLUSIONS

To our knowledge, this case is the first report of idiopathic unilateral aquagenic keratoderma in the medical literature. It is the third report of successful treatment with botulinum toxin A which is in favor of a role of sweat glands in the pathogenesis of aquagenic keratoderma.