Palmar and Plantar Keratoderma
Saturday, January 01, 2011
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
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.
- 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.
- 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
- If flexible colloidion is not helpful, tincture of benzoin
(20-25%) in zinc oxide paste may be helpful.
- Hydrated petrolatum with 20-40% urea applied nightly and as
needed during the day may be useful.
- 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
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.
- 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
- 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