A 19-year-old Hispanic male presents complaining that the skin on his palms has been peeling for several months. He denies any new activities or exposures. The skin is not itchy or painful and, there were no preceding blisters.
The patient denies fever or other illness prior to the onset of the condition. He is otherwise healthy, and does not have a history of eczema or other skin disease. His family history is non-contributory.
On exam, the patient is fit and appears healthy. A complete skin exam reveals only focal areas of superficial desquamation of the palms. A potassium hydroxide preparation is negative for fungal elements. What’s your diagnosis?
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Keratolysis exfoliativa is a common skin condition consisting of superficial desquamation of the palms and occasionally soles.
Lesions are asymptomatic and non-inflammatory. Initially, small white spots appear, which subsequently rupture and develop into a collarette of desquamating skin. The leading edge of the collarette can be easily peeled off. Blisters do not precede the condition, and patients with keratolysis exfoliativa have negative results on fungal studies.
Some patients have a history of atopic dermatitis, dyshidrotic eczema or palmar/plantar hyperhidrosis. Some authors consider keratolysis exfoliativa itself a mild, subclinical form of eczema. Others believe that it occurs secondary to physical or chemical damage and affects the most superficial layers of the skin.1,2
Diagnosis is generally based on the clinical finding of asymptomatic, superficial desquamation of the palms and/or soles, without any preceding inflammatory lesions. A potassium hydroxide preparation is recommended to distinguish keratolysis exfoliativa from tinea manuum/pedis. 1,2
Trychophyton rubrum is the most common cause of tinea manuum and tinea pedis. This infection produces dry and scaly erythema. When there is both palmar and plantar involvement, most commonly both feet, but only one hand are involved. The potassium hydroxide preparation will show fungal elements.3
Kytococcus sendentarius causes pitted keratolysis, a superficial bacterial infection in which the weight-bearing aspects of the sole are covered with small round pits. Humid weather, sweaty feet and male sex are risk factors for the condition. The infection is usually malodorous but otherwise asymptomatic. Treatment is with topical clindamycin or erythromycin.4
Peeling skin syndrome is a very rare autosomal-recessive disorder, which is present at birth or early childhood. In this condition, the palms and soles are thickened with generalized desquamation.5
Keratolysis exfoliativa is asymptomatic, and no treatment is necessary. Some patients report spontaneous improvement.
Topical corticosteroids are generally ineffective. When treatment is desired, keratolytic agents such as urea, lactic acid, ammonium lactate and salicylic acid may produce improvement. 1,2
Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine in Houston.
- Bolognia J , Jorizzo JL, Rapini RP. “Chapter 40: Diseases of the Eccrine and Apocrine Sweat Glands.” Dermatology. 2008; St. Louis, Mo.: Mosby/Elsevier.
- James WD, Berger TG, Elston DM et al. “Chapter 11: Pityriasis Rosea, Pityriasis Rubra Pilaris, and Other Papulosquamous and Hyperkeratotic Diseases.” Andrews’ Diseases of the Skin: Clinical Dermatology. 2006; Philadelphia: Saunders Elsevier.
- James WD, Berger TG, Elston DM et al. “Chapter 15: Diseases resulting from fungi and yeasts.” Andrews’ Diseases of the Skin: Clinical Dermatology. 2006; Philadelphia: Saunders Elsevier.
- JamesWD, Berger TG, Elston DM et al. “Chapter 14: Bacterial Infections.” Andrews’ Diseases of the Skin: Clinical Dermatology. 2006; Philadelphia: Saunders Elsevier.
- Bolognia J , Jorizzo JL, Rapini RP. “Chapter 56: Ichthyoses, Erythrokeratodermas and Related Disorders. Dermatology. 2008; St. Louis, Mo.: Mosby/Elsevier.