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Therapeutic Strategies

Palmar and Plantar Keratoderma

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Overview

Palmoplantar keratodermas (PPK) can occur as a primary, inherited disorder of the volar surfaces, or as part of a generalized disorder, such as psoriasis, cutaneous T-cell lymphoma, or ichthyosis. Discussion of treatment here is limited to inherited forms only.

First Steps

There is no uniformly effective therapy for PPK, but try all topical therapies, alone or in combination, before administering systemic therapy. Reserve systemic therapy, particularly with oral retinoids, for incapacitated individuals.

  1. Cracks and fissures: Application of flexible collodion 5% in ethyl acetate once or twice daily. This preparation burns upon application, but provides a protective film that may protect for several hours. Painful fissuring may be due to superinfection with bacteria, usually S. aureus. Appropriate antibiotic treatment may be required.
  2. A combination of salicylic acid 6% in propylene glycol 40% applied after bathing and once more daily; or salicylic acid 3% and benzoic acid 6% in 40% urea in petrolatum (half-strength Whitfield's ointment) applied daily after bathing. Occlusion at night with plastic or vinyl gloves may enhance the efficacy of keratolytics.

Alternative Steps

  1. If flexible colloidion is not helpful, tincture of benzoin (20-25%) in zinc oxide paste may be helpful.
  2. Hydrated petrolatum with 20-40% urea applied nightly and as needed during the day may be useful.
  3. If no improvement occurs, and the keratoderma interferes with either work or ambulation, the patient may be a candidate for oral retinoids. Currently, acitretin appears to be more effective than isotretinoin, but relatively high doses are usually required (e.g., 1 mg/kg or greater.). After 6 weeks, therapy should be adjusted upward or downward according to the initial response

Subsequent Steps

If some degree of relief is obtained with any of the above regimens, therapy should be continued on an indefinite basis, as these diseases are generally nonremitting.

Pitfalls

  1. Patients on long-term systemic retinoid therapy require monitoring of serum lipids, liver function tests, and complete blood count with platelets, as well as sequential radiographic studies (to look for calcification of the ligaments and premature epiphysial closure).
  2. Some patients with PPK, treated with retinoids, develop severe skin fragility, which can make the patient more uncomfortable than prior to treatment, even in the face of substantial improvement of the PPK.

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