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Therapeutic Strategies

Keratosis Pilaris/Lichen Spinulosus

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011


Keratosis pilaris (KP) is an extremely common, often familial disorder that usually does not require treatment. Involvement of the face and upper arms, however, may cause a significant cosmetic problem, and frictional folliculitis not infrequently complicates KP on the buttocks and thighs. Keratosis pilaris is most frequently seen in association with atopic dermatitis.

First Steps

  1. Be sure that the patient understands that KP is not curable and that any therapeutic option only minimizes but does not erase the clinical lesions.
  2. A mild soap or a soapless cleanser should be used with a mild abrasive scrub pad. This treatment may gradually remove follicular plugs (over several weeks) and prevent new ones from emerging.
  3. Urea creams or lotions in concentrations of 10 to 20% may be effective, and can be tolerated by many patients with atopic dermatitis.
  4. Ammonium lactate 12% lotion applied once daily after bathing is also effective for KP. It may be combined with urea. Individuals with atopic disease tend to tolerate high concentrations of lactic acid (>5%) without some adjunctive therapy to control their atopic condition. Alternatively, lower concentrations of lactic acid or combinations of lactic acid and urea may be considered.
  5. Topical medium strength steroid ointments may be effective in KP associated with atopic dermatitis.

Alternative Steps

  1. A combination of salicylic acid 6% in propylene glycol 40% applied before bed or after bathing. This therapy is particularly effective when used in conjunction with a mild abrasive scrub pad (see above).
  2. Tazarotene 0.01% applied up to once daily can be effective in KP. It may trigger atopic dermatitis. 
  3. Retinoic acid 0.025% cream applied nightly, increasing to 0.05% and 0.1%, as tolerated, may be used alternatively.

Subsequent Steps

  1. After the keratinous plugs have been removed, an emollient cream containing 20% urea may prevent reappearance of lesions.
  2. Use of the abrasive scrub pad should be resumed at the first sign of reappearance of crops of new lesions.
  3. A "dry skin program" of bathing, mild soaps, and lubrication also should be employed, as KP is almost invariably associated with xerosis, and xerosis may, in fact, predispose to exacerbations of KP.


  1. Both salicylic and lactic acids may be irritating, especially when applied to inflamed skin. A medium-potency, topical corticosteroid cream can be applied with these agents to reduce inflammation.
  2. The side effects of topical retinoids are described in the chapter on acne vulgaris.

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