Invisible palmar needles: thyroid disorder associated spiny keratoderma and the importance of proper light for visualization

Spiny keratoderma is a rare skin condition that presents on the palmar and plantar surfaces of the hands and/or feet. This condition is difficult to appreciate under ambient lighting but can be both physically and emotionally distressing to patients. Furthermore, because of the association with various neoplasms and systemic diseases, timely diagnosis and appropriate follow-up is of importance. We evaluate a case of spiny keratoderma in a patient with recently diagnosed hypothyroidism and emphasize the importance of proper lighting during a dermatology-focused physical examination. The patient's palmar lesions were only appreciable under LED light and with physical examination. A biopsy of the lesions confirmed the diagnosis of spiny keratoderma.

Coexistence of Lichen Planus Pemphigoides, Palmoplantar Keratoderma of Unna-Thost, and Atopic Dermatitis

Lichen planus pemphigoides (LPP) is a very rare autoimmune blistering disease associated with lichenoid skin changes. Unna-Thost palmoplantar keratoderma (PKK) is a type of diffuse palmoplantar keratoderma that mostly affects the palms of the hands and soles of the feet. It usually begins in early childhood. We present a unique case of coexistence of LPP, Unna-Thost PPK, and atopic dermatitis (AD). To our knowledge, there are three reported cases of both LPP and Unna-Thost PPK and a few reports of coexistence of Unna-Thost PKK and AD.

[Clinical Characteristics and Gene Mutations in 186 Cases of Kindler Syndrome]

Objective To investigate the clinical characteristics and genetic mutations in Kindler syndrome(KS)and provide a theoretical basis for the diagnosis and treatment of KS. Methods The clinical data of one case of KS from Peking Union Medical College Hospital and 185 cases reported in literature were collected. The gene mutation types,patient clinical data,and tumor characteristics were statistically analyzed. Results A total of 186 cases were enrolled,including 110 males and 76 females,with the mean age of(28±16)years. The data of gene mutation and specific clinical manifestations were available in 151 and 94 patients,respectively. The main clinical manifestations of KS included poikiloderma,occurrence of blister in childhood,and photosensitivity,and the secondary clinical manifestations included oral inflammation,palmoplantar keratoderma,webbing/pseudoainhum,dysphagia,urethral stricture and so on.Oral inflammation(r=0.234,P=0.023),palmoplantar keratoderma(r=0.325,P=0.001),webbing/pseudoainhum(r=0.247,P=0.016),dysphagia(r=0.333,P=0.001),urethral stricture(r=0.280,P=0.006)were significantly correlated with age,showing significantly higher incidence in the patients over 32 years old.Urethral stricture(χ²=11.292,P=0.001)and anal stenosis(χ²=4.014,P=0.045)were significantly correlated with sex,with higher incidence in males.Eighty different mutations were found in 151 patients,and the most common gene mutation was c.676C>T.Forty-one tumors occurred in 27 patients,among which squamous cell carcinoma accounted for 92.7%. The gene mutation site had no significant correlation with squamous cell carcinoma or patient country. Conclusions The c.676C>T in FERMT1 gene is the most common mutation in KS.The patients are prone to squamous cell carcinoma and mainly attacked at the exposure sites(hand and mouth).

Generalized epidermolytic ichthyosis with palmoplantar hyperkeratosis

Epidermolytic ichthyosis (EI, OMIM 113800) is a rare autosomal dominant keratinization disorder that is caused by keratin 1 or 10 gene mutation. It can be classified clinically based on the presence of palmoplantar hyperkeratosis involvement and extent of skin involvement. The diagnosis is made by clinical and histopathological examinations that can be confirmed by genetic testing. We present a 2-year-old girl who presented with erythematous and thick scaling skin. Her condition began at birth as multiple flaccid blisters that would easily break into erosions. There was no history of similar condition nor consanguinity within her family. Skin examination revealed diffuse erythematous skin covered with thick scales and erosion, predominantly on her face, extremities, palms, and soles. The skin histopathology examination showed diffuse parakeratosis with vacuolar and granular degeneration within granular and spinous layers along the epidermis. She was diagnosed with generalized EI with palmoplantar hyperkeratosis based on the clinical and histopathological examinations. Clinical improvement was observed after a one-month treatment with mupirocin cream, sodium bicarbonate bath, and moisturizer after bathing.

Hereditary Hearing Impairment with Cutaneous Abnormalities

Syndromic hereditary hearing impairment (HHI) is a clinically and etiologically diverse condition that has a profound influence on affected individuals and their families. As cutaneous findings are more apparent than hearing-related symptoms to clinicians and, more importantly, to caregivers of affected infants and young individuals, establishing a correlation map of skin manifestations and their underlying genetic causes is key to early identification and diagnosis of syndromic HHI. In this article, we performed a comprehensive PubMed database search on syndromic HHI with cutaneous abnormalities, and reviewed a total of 260 relevant publications. Our in-depth analyses revealed that the cutaneous manifestations associated with HHI could be classified into three categories: pigment, hyperkeratosis/nail, and connective tissue disorders, with each category involving distinct molecular pathogenesis mechanisms. This outline could help clinicians and researchers build a clear atlas regarding the phenotypic features and pathogenetic mechanisms of syndromic HHI with cutaneous abnormalities, and facilitate clinical and molecular diagnoses of these conditions.

Acrokeratoelastoidosis: is there an association between asthma and sporadic cases in children?

Acrokeratoelastoidosis (AKE) is a rare, benign papular keratoderma that presents as keratotic papules on the lateral margins of the palms and soles. It is most commonly inherited in an autosomal dominant fashion, although sporadic cases are also described. We present a sporadic case of AKE in an 11-year-old girl with a past medical history significant for asthma. On literature review, we found three other cases presenting in children with a past medical history of asthma. We suggest a possible association between asthma and sporadic cases of AKE in children. Current understanding of the pathophysiology of AKE and its associated risk factors is limited and no effective treatment exists. Awareness of a possible association with asthma and atopy, careful history recording in young patients presenting with sporadic cases of AKE, and further research may help to delineate the likelihood of an association between AKE and asthma or atopy. Developing a better understanding of the associated factors that may contribute to the disease process may help guide more effective, targeted treatments in the future.

Spiny keratoderma

Spiny keratoderma is a rare entity characterized by filiform keratotic lesions on palms and soles. Although there are some inherited cases the majority are acquired. This last variant can be idiopathic or associated with neoplasms and chronic systemic diseases. We report a new case of spiny keratoderma associated with endometrial carcinoma.

Lhermitte-Duclos Disease in association with Cowden Syndrome

Cowden syndrome (CS) is a rare genetic disorder with autosomal dominant inheritance, linked to germline mutations in the PTEN tumor suppressor gene on chromosome 10. Cowden syndrome often co-exists with Lhermitte-Duclos disease (LDD), with LDD included as a major criterion in CD diagnosis. This case involves a woman presenting with many of the classic diagnostic criterions and associations of CD, as well as with several comorbidities and unique objective findings.

Punctate Palmoplantar Keratoderma with Pigmentary Lesions on the Dorsa of Feet and Ankles: Successful Treatment with a Combination of Low-Dose Oral Etretinate and Topical Calcipotriol

We describe a patient with typical keratotic lesions of punctate palmoplantar keratoderma on the hands and feet and unique pigmentary lesions on the dorsa of the feet and ankles. A combination of low-dose oral etretinate (10 mg/day) and calcipotriol ointment 0.005% resulted in a complete regression, whereas pigmentary lesions on the dorsa of the feet and ankles did not change during the treatment.

[Primary familial erythromelalgia. A case report]

Erythromelalgia is a rare disease whose etiology is poorly understood. It is characterized by paroxysmal attacks of erythema, pain, and warmth of the extremities and can be primary or secondary. We report a case of primary familial erythromelalgia and stress the difficulties in its therapeutic management. We provide a brief update on the pathophysiology and treatment of primary erythromelalgia.

Richner-Hanhart syndrome (tyrosinemia type II): a case report of delayed diagnosis with pseudodendritic corneal lesion

Richner-Hanhart syndrome (tyrosinemia type II) is a rare autosomal recessive disease associated with high serum tyrosine levels caused by the deficiency of tyrosine aminotransferase enzyme. We report a 15-year-old female patient with complaints of bilateral photophobia and tearing, which started during the infancy period. Biomicroscopic examination revealed bilateral circular corneal opacities on the inferior quadrant and small dendritic lesions at the center of the circular opacities. Blood tests showed a tyrosine level of 508 micromol/L (normal range: 30-150). On her dermatologic examination, plantar hyperkeratosis and seborrheic dermatitis were noted, and mild mental retardation was detected. One and a half months after the tyrosine- and phenylalanine-restricted diet, her tyrosine level dropped to 395 micromol/L level, her corneal lesions subsided, and a symptomatic relief was achieved. Tyrosinemia type II should be suspected in patients demonstrating dermatologic signs, especially palmoplantar keratosis, associated with bilateral pseudodendritic corneal lesions unresponsive to antiviral therapy.

Hereditary palmoplantar keratoderma and deafness resulting from genetic mutation of Connexin 26

Gap junctions, which mediate rapid intercellular communication, consist of connexins, small transmembrane proteins that belong to a large family of proteins found throughout the species. Mutations in the GJB2 gene, encoding Connexin 26, can cause nonsyndromic autosomal recessive or dominant hearing loss with or without skin manifestations. A 3-yr-old Korean female and her mother presented to our clinic with diffuse hyperkeratosis of the palms and soles (May 3, 2007). Skin biopsies from the soles of both patients demonstrated histopathological evidence of palmoplantar keratoderma. The patient and a number of her maternal family members also had congenital hearing loss. The combination of congenital hearing loss and palmoplantar keratoderma, inherited as an autosomal dominant trait, led us to test for a mutation in the GJB2 gene in both patients. The results showed the R75W mutation of the GJB2 gene in both. In conclusion, the simultaneous occurrence of a GJB2 mutation in a mother and daughter suggests that R75W mutation cause autosomal dominant hearing loss presenting with palmoplantar keratoderma. To the best of our knowledge, this is the first report of a GJB2 mutation associated with syndromic autosomal dominant hearing loss and palmoplantar keratoderma in a Korean family.

Syphilitic palmoplantar keratoderma and ocular disease: a rare combination in an HIV-positive patient

Approximately 349 million individuals worldwide are actively infected with syphilis. The incidence of syphilis in North America and Europe is low but has been rising in recent years. The rate of concomitant infection with human immunodeficiency virus (HIV) and syphilis also has been increasing. Concomitant infection with HIV can cause syphilis to have atypical characteristics. These atypical findings can involve the skin as well as organs that rarely are affected in HIV-negative individuals such as the eyes. We present a case of syphilis causing palmoplantar keratoderma and ocular disease in a patient with HIV infection, and discuss the differences in diagnosis and treatment of patients with both diseases.

Hereditary palmoplantar keratoderma associated with primary (congenital) lymphedema

The palmoplantar keratodermas are a heterogenous group of hereditary disorders of keratinization. They are characterized by epidermal thickening and a yellow waxy appearance of the palms and soles. Genetic studies have linked various forms of palmoplantar keratoderma to markers on chromosomes one, twelve, and seventeen, and several genes have been identified. Primary lymphedema is occasionally present at birth (congenital lymphedema or Milroy's disease), but more commonly develops at puberty (lymphedema praecox). Genetic studies have linked various autosomal dominant forms of primary lymphedema (Milroy's disease and lymphedema distichiasis), to genes on chromosomes five and sixteen respectively. We report a case of palmoplantar keratoderma in a child with congenital lymphedema. To our knowledge, this has not been previously described and may represent a new phenotype for future genetic study.

A novel missense mutation in GJB2 disturbs gap junction protein transport and causes focal palmoplantar keratoderma with deafness

Gap junctions are intercellular channels that mediate rapid intercellular communication. They consist of connexins, small transmembrane proteins that belong to a large family found throughout the animal kingdom. In the skin, several connexins are expressed and are involved in the regulation of epidermal growth and differentiation. One of the skin expressed gap junction genes is GJB2, which codes for connexin 26 and is associated with a wide variety of keratinisation disorders. Here, we report on a family with a novel GJB2 mutation (p.His73Arg) causing a syndrome of focal palmoplantar keratoderma with severe progressive sensorineural hearing impairment, a phenotype reminiscent of Vohwinkel syndrome. Using fluorescent connexin fusion proteins, we show that the mutation induces a transport defect similar to that found for the Vohwinkel syndrome mutation p.Asp66His. Co-transfection into cells expressing wild type connexin26 shows that the mutant has a dominant negative effect on connexin trafficking. We suggest that there may be a weak genotype-phenotype correlation for mutations in GJB2.

Rothmund-Thomson syndrome. The first case with plantar keratoderma and the second with coeliac disease

We report two unusual patients with Rothmund-Thomson syndrome (RTS), a rare genodermatosis. The first patient is a 5-year-old girl with congenital poikiloderma, photosensitivity, plantar punctate keratoderma, stunted growth and severe mental retardation. Plantar keratoderma associated with RTS has been reported only once. The second patient is a 21-year-old female presenting with rounded "moon" face, trunk obesity, coeliac disease, short stature and mild mental retardation. This is the first case of RTS associated with coeliac disease.

The IGF system in a case of Costello syndrome

Costello syndrome is characterized by facial dysmorphia, hyperpigmented skin, palmar and plantar hyperkeratosis, curly hair, perioral and nasal papillomata (more rarely localized anally and on vocal cords), short stature, mental retardation and sociable personality. Although growth retardation is typical of Costello syndrome, its cause is not defined. We report on a 10-yr-old Caucasian girl affected by Costello syndrome with fasting hypoglycemia and short stature, associated low circulating levels of acid-labile subunit (ALS), relatively low levels of IGF-I and IGFBP-3, and normal IGF-II, mostly circulating in a binary complex with IGFBP-2 and -6 instead of in a 150 kDa ternary complex. The reduced ALS concentration and the consequent impaired formation of the circulating 150 kDa ternary complex can induce an accelerated clearance rate of IGF peptides and of IGFBP-3, contributing to the decreased IGF-I growth promoting activity in our patient. Moreover, the presence of IGF-II in the binary complex, which has been postulated to increase the insulin-like effects of these peptides, can explain, at least in part, the patient's asymptomatic fasting hypoglycemia.

[Focal acral hyperkeratosis associated with pitted keratolysis]

Focal acral hyperkeratosis is characterized by the same clinical appearance as acrokeratoelastoidosis, but without abnormalities in the elastic fibers. We present the case of a woman with a 10-year case of dermatosis localized on the palms, soles and dorsum of the metacarpophalangeal joints, consisting of multiple polygonal papules and associated hyperhydrosis, clinically compatible with acrokeratoelastoidosis. Her father had a history of the disease. In addition, the patient presented with palmoplantar pitted keratolysis. The histopathological study ruled out elastorrhexis, and the pitted keratolysis was corroborated by the clinical appearance and the presence of coccoid elements in the stratum corneum, evident with a PAS stain. In our opinion, the focal acral hyperkeratosis is not a separate entity from the acrokeratoelastoidosis.

Malignant acanthosis nigricans, tripe palms and the sign of Leser-Tre'lat, a hint to the diagnosis of early stage ovarian cancer: a case report and review of the literature

BACKGROUND

Malignant acanthosis nigricans is a mucocutaneous eruption associated with internal malignancies. Tripe palms refers to a characteristic velvety thickening of the palms, with exaggeration of normal skin markings. The sign of Leser-Tre'lat is the presence of multiple seborrheic keratoses and scattered skin tags caused by a malignancy. We are reporting the first case of ovarian cancer in association with three coexisting cutaneous paraneoplastic dermatosis.

CASE

A 52-year-old female presented with skin manifestation consistent with MAN, TP and the sign of Leser-Tre'lat. Patient underwent extensive work up and was discovered to have stage I, high grade adenocarcinoma of the ovary. Skin manifestations gradually recovered after initiation of chemotherapy.

CONCLUSION

The presence of acanthosis nigricans in conjunction with tripe palms and the sign of Leser-Tre'lat are highly suggestive of an internal malignancy and necessitate an extensive investigation in order to discover the underlying malignancy.

Pityriasis rubra pilaris, type IV

A 4-year-old girl presented with a 3-year history of demarcated, salmon-pink, hyperkeratotic plaques, which were symmetrically distributed on the elbows, knees, ankles, and dorsal aspects of the hands and feet. A diffuse, orange-pink palmoplantar keratoderma was also evident. Clinical and histologic findings were consistent with a diagnosis of pityriasis rubra pilaris (PRP), type IV (circumscribed juvenile). Type IV PRP develops in prepubertal children, is typically localized to the distal aspects of the extremities, and has an unpredictable course. Although ultraviolet (UV) radiation can potentially exacerbate PRP, our patient has improved with broad-band UVB phototherapy.

Hereditary papulotranslucent acrokeratoderma: a case report and literature review

Hereditary papulotranslucent acrokeratoderma is a rare autosomal-dominant syndrome of the hands and feet characterized by persistent, asymptomatic, yellowish to white papules and plaques associated with fine-textured scalp hair and an atopic diathesis. Histopathologically, focal hyperkeratosis, hypergranulosis, and acanthosis of the epidermis are seen. We present a case of hereditary papulotranslucent acrokeratoderma in a young adult woman. The literature of this unusual condition is reviewed, and its relationship to acquired papulotranslucent acrokeratoderma is discussed.

Effect of painful keratoses debridement on foot pain, balance and function in older adults

BACKGROUND

Painful feet in older people can detrimentally affect balance and are a risk factor for falls. Pain is often associated with plantar hyperkeratoses, which are easily treated by podiatrists. Currently, there is no data defining the effect this treatment has on balance or functional ability.

OBJECTIVE

To determine the effects of scalpel debridement of painful plantar hyperkeratoses on pain, balance and functional ability in older people aged 65 years and over.

SUBJECTS

Nineteen men and women aged 65-84 years (mean age 72, standard deviation 5.6).

METHODS

Pain resulting from plantar hyperkeratoses was measured using a visual analogue scale. Static balance and functional ability were measured using tests of postural sway, co-ordinated stability and timed walking and stepping tests. Painful plantar hyperkeratoses were debrided with a scalpel then all tests were repeated, immediately and 7 days later.

RESULTS

Following scalpel debridement, pain levels (sensory and afferent) were significantly reduced (P<0.0001) and functional ability was significantly increased (P<0.0001). There was no change in static balance ability. One week after debridement the improved performance in functional ability tests was maintained.

CONCLUSIONS

Debridement of painful plantar hyperkeratoses reduces pain and improves functional ability in older people. Its effect on static balance was inconclusive.

Palmoplantar keratoderma is associated with esophagus squamous cell cancer in Van region of Turkey: a case control study

BACKGROUND

Esophagus squamous cell cancer (ESCC) is the most common cancer in women with 20.2% and second in men with 10.7% relative frequency among all cancer cases diagnosed in Van Region in the east of Turkey. Ninety percent of all esophageal cancer cases are ESCC and 20-30% of them have family history of esophageal cancer. The most clear defined hereditary predisposition associated with ESCC is palmoplantar keratoderma (PPK). To examine the relationship between ESCC and PPK, we have carried out this case control study.

METHODS

The case group consisted of 48 subjects who had new diagnosis of ESCC and did not receive any chemo or radiotherapy. The control group consisted of 96 healthy individuals who were visitors of their relatives in the hospital. Two control persons who matched for age, gender, living place (urban/rural) and region were selected for each case. All subjects were evaluated for PPK by dermatologist. Evaluation was graded as none, mild, evident and severe. None and mild subjects were classified as negative for PPK; and others as positive. Relationship between ESCC and PPK was evaluated with odds ratios and confidence intervals for cases with or without family history of ESCC.

RESULTS

The PPK frequencies were 92.3% in ESCC cases with family history, 62.5% in ESCC cases without family history, 70.8% in all ESCC cases, and 28.1% in the control group. Odds ratios for cases with or without family history of esophageal cancer, and for the whole case group were found as 30.7 (95%CI = 3.8-247.4), 4.3 (95%CI = 1.9-9.8) and 6.2 (95%CI = 2.9-13.3) respectively.

CONCLUSION

Presence of PPK lesions represents genetic susceptibility for ESCC. This susceptibility for ESCC is the highest among those who have PPK lesions and a positive family history of esophageal cancer. Furthermore, a PPK sufferer has an increased risk of developing ESCC even if there is no family history of esophageal cancer.

Woolly hair and palmoplantar hyperkeratosis may present with hypertrophic cardiomyopathy

Woolly hair and palmoplantar hyperkeratosis is an infrequent autosomal recessive ectodermal disorder that may be associated with arrhythmogenic right ventricular dysplasia (Naxos disease) or dilated cardiomyopathy. We report the sporadic occurrence of the aforementioned skin-hair anomalies in a patient with physical findings compatible with Noonan's syndrome and hypertrophic cardiomyopathy-an association heretofore not described.

Acral Malignant Melanoma and Striated Palmoplantar Keratoderma (Brunauer-Fohs-Siemens Syndrome): A Fortuitous Association?

BACKGROUND

Striated palmoplantar keratoderma or Brunauer-Fohs-Siemens syndrome is a very rare, focal, nonepidermolytic palmoplantar keratoderma with autosomal inheritance. Unlike other palmoplantar keratodermas, no association with visceral or skin cancer has ever been reported.

OBJECTIVE

We report a case of malignant melanoma arising in the hyperkeratotic lesions on the right heel of a patient with striated palmoplantar keratoderma. The lesion was completely excised; our patient also underwent sentinel lymph node biopsy and then was treated with high-dose interferon adjuvant therapy.

METHODS

Sentinel lymph node biopsy incision was made in elliptical fashion, long enough to harvest a full-thickness skin graft to cover the wide local excision defect. The skin graft was defatted by sharp dissection. Several perforations were made in graft and it was secured in place with sutures and bolster dressing.

RESULTS

At follow-up, the grafted skin showed hyperkeratotic changes but no local or systemic signs of the disease was observed.

CONCLUSION

The association between striated palmoplantar keratoderma and acral melanoma is discussed.

Arrhythmogenic right ventricular cardiomyopathy (Naxos disease): report of a Turkish boy

Naxos disease is a recessively inherited arrhythmogenic right ventricular cardiomyopathy in which the cardiac phenotype is associated with palmoplantar keratoderma and woolly hair. This disease is a heart muscle disorder causing life-threatening ventricular arrhythmias, heart failure, and sudden cardiac death. The pathological hallmark of the disease is the progressive replacement of myocardial cells by fat and fibrous tissue. It appears in families descending from the Hellenic island of Naxos. We presented a 13-year-old Turkish boy with Naxos disease associated with ventricular tachycardia because of its rarity, and reviewed the literature.

Malignant melanoma developing in an area of hereditary palmoplantar keratoderma (Mal de Meleda)

Palmoplantar keratoderma (PPK) refers to a genetically heterogeneous group of skin diseases, which may be inherited in autosomal dominant or recessive fashion. We observed a case of a 74-year-old man with Mal de Meleda, who developed malignant melanoma inside the hyperkeratotic palmar skin of the right hand. Many authors have reported a higher incidence of cancer in cases affected by palmoplantar hyperkeratosis both for hereditary association and particularly for mechanical damage of the affected areas. The association with melanoma has already been described, but not in a true Mal de Meleda type syndrome as in the case reported in this paper.

X-linked dominant inheritance in palmoplantar keratoderma with leukokeratosis: a study of the pedigree of two cases

Keratoderma of the palms and soles is not of rare occurrence. Its association with leukokeratosis of the mouth is well recognized. We describe two siblings having callosities like keratoderma over the weight bearing areas of soles, pressure areas of palms and palmar creases with leukokeratosis of cheeks. On study of the pedigree of these probands we could trace the trait transmission by a rare X-linked dominant mechanism.