HYPERKERATOTIC ECZEMA

By Gary M. White, MD

hyperkeratotic Eczema


Hyperkeratotic eczema (HE) is a relatively common type of eczema of the hands in adults. It often affects older men and is a significant cause of time off work.

Clinical

Diffuse, thickened, fissured hyperkeratosis of the palms occurring in a middle-aged man is characteristic. Patch testing and KOH should be done to exclude allergic contact dermatitis and tinea. Psoriasis may present similarly and indeed some cases of HE evolve into classic psoriasis.

Hyperkeratotic Eczema vs Hand Eczema

Characteristic Hyperkeratotic Eczema Hyperkeratotic Eczema, Palmar Psoriasis
Morphology Thin, eczematous lesions, itching, vesicles Sharply demarcated areas of thick scaling or hyperkeratosis
Location Fingers and palms. Proximal or middle aspects of the palms
Associations Atopic dermatitis, numular eczema, allergies, hay fever, asthma, exposure to allergens, wet work. Psoriasis elsewhere
Histology Presence of granular layer, eczematous Loss of granular layer, psoriasiform hyperplasia

Hyperkeratotic hand eczema may be considered a variant of palmar psoriasis [JAAD 2017;77;130].

Treatment

A patient handout is available. Potent topical steroids, lubrication, and keratolytics may be tried. A steroid-impregnated tape (e.g., Cordran) has been helpful for some. Any scratching or rubbing should be reduced. The use of gloves may be helpful to reduce both friction and contact with irritants. If painful fissures develop, super glue (e.g., Krazy glue) may be recommended.

Treatment for Recalcitrant HE

UV therapy can be of great benefit for cases that are eczema, psoriasis, or idiopathic. UVB or soak PUVA may be done 1-3 times weekly. Alitretinoin 30 mg/day resulted in clear or almost clear hand eczema in 48% of the patients Arch Derm 2004;140;1453]. Those with vesicular hand eczema (more akin to pompholyx and not hyperkeratotic eczema discussed here) did less well. Acitretin may be tried and the effectiveness of CSA has been reported. Methotrexate as given for psoriasis or azathioprine as given for eczema can be very beneficial here as well. The biologics may also be considered.

For related treatment ideas, see hand dermatitis.

Additional Pictures

hyperkeratotic Eczema

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