Are You Confident of the Diagnosis?
What you should be alert for in the history
The diagnosis of keratolysis exfoliativa is made based on history and clinical examination. Patients typically complain of asymptomatic peeling on the palms (and occasionally the soles) that recurs every few weeks. It most commonly occurs in young adults and is typically worse in the summer months or with warm weather.
Some patients may find that this condition is exacerbated by chemical or physical irritants such as water, soap, and detergents. Others may associate it with hyperhidrosis. Most patients deny any itching, but may rarely complain of slight tenderness. This is likely a common condition that rarely presents to physicians because it is largely asymptomatic.
Characteristic findings on physical examination
On physical examination there are symmetrical, irregular circumscribed annular or circinate patches of superficial scaling on the palms and, less often, the soles (Figure 1). The scaling gradually extends peripherally, leaving an adherent collarette. Keratolysis exfoliativa is also characterized by a lack of inflammation.
Expected results of diagnostic studies
There is usually no need for further diagnostic testing, as this is typically a clinical diagnosis; however, in more difficult cases, a potassium hydroxide (KOH) scraping or fungal culture to rule out tinea should be negative and patch testing to rule out allergic contact dermatitis should also be negative.
The differential diagnosis of keratolysis exfoliativa includes the following entities:
1. Pompholyx or dyshidrotic eczema (differentiated by its chronic nature, associated pruritus, fissures, and lichenification seen on examination)
2. Palmoplantar pustulosis or palmoplantar psoriasis (distinguished by occasional involvement of typical psoriasis on other locations of the body, observation of pustules on exam, and the chronic nature of this disease)
3. Allergic contact dermatitis (differentiated by its pruritic nature, response to topical steroids, inflammatory appearance with erythema on exam, and a possible exposure history)
4. Tinea (typically seen with associated changes in the fingernails or toenails, occasionally pruritic, does not wax and wane, positive fungal scraping or culture, and responds to treatment with antifungal agents)
Who is at Risk for Developing this Disease?
Keratolysis exfoliativa is thought to be a very common condition with limited epidemological data available since it rarely presents itself to physicians because of its asymptomatic nature. Some believe that it is more frequently associated with underlying atopic dermatitis, while others report an association with primary hyperhidrosis.
What is the Cause of the Disease?
The etiology of keratolysis exfoliativa is unknown, but the condition appears to be worsened by heat or sweating. There is also some suggestion that it is incited by low-grade physical or chemical damage to the stratum corneum of the volar skin, leading to a superficial separation of the stratum corneum.
Systemic Implications and Complications
There are no associated systemic implications or complications seen in patients with keratolysis exfoliativa. There may be an association with underlying atopic dermatitis, thus one may also see a combination of asthma and allergies more frequently.
Treatment options are summarized in Table I.
|Medical Treatment||Surgical Procedures||Physical Modalities|
|Protection from irritants, wear gloves, good moisturization. Treat hyperhidrosis if present.||None recommended||Photochemotherapy (hand/foot PUVA)|
|Keratolytic creams containing urea, lactic acid, ammonium lactate or salicyclic acid.|
|Topical corticosteroids-usually not of much benefit|
PUVA: psoralen and ultraviolet A light
Optimal Therapeutic Approach for this Disease
Any exacerbating factors should be controlled. This should include protecting the hands from any physical or chemical irritants and encouraging the patient to wear gloves when possible. Educating the patient on the benign nature of this condition is imperative, as often the patient merely wants a diagnosis and does not desire any further treatment. Inquire about any history of atopic dermatitis.
If there is a component of primary hyperhidrosis, attempt to treat it with topical medication. Drysol, applied to dry skin at bedtime, or oral glycopyrrolate, starting at a dosage of 1mg by mouth 2-3 times daily, may be helpful.
Aggressive moisturization is one of the most important treatments and is often the safest and most effective treatment modality.
Keratolytic creams containing urea, lactic acid, ammonium lactate, or salicylic acid have been the most beneficial treatment for the majority of patients. Examples of these include urea 20% or 40% cream, ammonium lactate 12% cream, salicyclic acid 6% cream, and lactic acid 12% cream. Any one of these can be applied up to twice daily.
A trial of potent (betamethasone dipropionate 0.05% or equivalent) or ultrapotent (clobetasol 0.05% or equivalent) topical corticosteroid applied twice daily for no more than 2 weeks could be attempted; however, these are typically not found to be very beneficial as this disease is characterized by a lack of inflammation.
There are some texts that mention the use of photochemotherapy with hand/foot psoralen and ultraviolet A light (PUVA) for severe cases. This should be reserved for severe or symptomatic patients, as otherwise the risks outweigh the benefits. Patients should be aware that this treatment is purely anecdotal and data to support its benefit is lacking.
It is important to explain the natural history of keratolysis exfoliativa to the patient before initiating any treatment. The patient should be aware of the condition’s benign nature and understand that typically, it will improve over time without any treatment.
Treatments are mainly anecdotal and may or may not lead to improvement. If the patient’s condition worsens or becomes symptomatic, then the diagnosis should be questioned and it may be important to review the differential diagnosis and re-evaluate the patient to rule out other etiologies. The majority of patients, with only mild disease, can be treated with topical moisturizers or keratolytics and followed up as needed.
Unusual Clinical Scenarios to Consider in Patient Management
Keratolysis exfoliativa is a straightforward diagnosis; for any unusual clinical presentations, the correct diagnosis should be questioned.
What is the Evidence?
Lee, YC, Rycroft, RJ, White, IR, McFadden, JP. ” Recurrent focal palmar peeling”. Australas J Dermatol. vol. 37. 1996. pp. 143-4. (A report of three cases of recurrent focal palmar peeling, of which two were misdiagnosed as chronic dermatitis. Provides a good description of the clinical features of recurrent focal palmar peeling and how to differentiate it from other conditions.)
Abdel-Hafez, K, Safer, AM, Selim, MM, Rehak, A. ” Familial continual skin peeling”. Dermatologica. vol. 166. 1983. pp. 23-31. (Provides a description of the microscopic pattern of splitting seen in keratolysis exfoliativa and contrasts these finding with that of familial continual peeling of the skin)
Lee, HJ, Ha, SJ, Ahn, WK, Kim, D, Park, YM, Byun, DG. ” Clinical evaluation of atopic hand-foot dermatitis”. Pediatr Dermatol. vol. 18. 2001. pp. 102-6. (A study that characterizes the clinical characteristics of 108 atopic dermatitis patients with hand-foot dermatitis. Reports the frequency of keratolysis exfoliativa in patients with atopic dermatitis.)
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