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  Table of Contents     
Year : 2021  |  Volume : 67  |  Issue : 3  |  Page : 184-185

Isolated aquagenic acrokeratoderma of dorsal hands

Department of Dermatology, Venereology and Leprosy, Government Medical College and Hospital, Chandigarh, India

Date of Submission03-Jul-2020
Date of Decision10-Sep-2020
Date of Acceptance25-Nov-2020
Date of Web Publication06-Mar-2021

Correspondence Address:
P Pande
Department of Dermatology, Venereology and Leprosy, Government Medical College and Hospital, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpgm.JPGM_779_20

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How to cite this article:
Pande P, Poonia K, Kaur J. Isolated aquagenic acrokeratoderma of dorsal hands. J Postgrad Med 2021;67:184-5

How to cite this URL:
Pande P, Poonia K, Kaur J. Isolated aquagenic acrokeratoderma of dorsal hands. J Postgrad Med [serial online] 2021 [cited 2023 May 28];67:184-5. Available from:

Aquagenic acrokeratoderma is an infrequently reported, transient skin condition characterized by development of wrinkling of skin over the acral body parts within minutes of exposure to water. It is mostly seen over the palms, predominantly in the female population. We report a case in a male with isolated involvement of dorsal surface of hands.

A 31-year old male, software-engineer, presented with a 2-month history of asymptomatic wrinkling and roughness of hands within minutes of washing hands/immersion in water. Patient was otherwise healthy and there was no history of respiratory, gastrointestinal complaints or any other co- morbidities. There was no history of atopy, hyperhidrosis, activities which might lead to barrier damage or any prior drug intake including NSAIDs and aminoglycosides. He was married for 1 year and didn't have any children till then. There was no history of similar complaints or cystic fibrosis in the family. Pre- exposure, the cutaneous examination was normal. He was asked to immerse his hands and feet in a water-filled container. Within 1-2 minutes of this, he developed multiple well-defined skin-colored to whitish tiny papules over dorsum of both hands. Skin of the palms and feet was normal [Figure 1] and [Figure 2]. Rest of the cutaneous examination was normal as well. The papules subsided within 15–20 minutes of drying the hands. Histopathology of skin biopsy sample, taken from the papules post- immersion in water showed an epidermis with hyperkeratosis, orthokeratosis, and focal acanthosis; focal eccrine ducts showed dilatation and dermis showed minimal lymphomononuclear cell infiltrate [Figure 1]. The patient was also screened for cystic fibrosis through investigations such as serum electrolytes, stool examination for fat globules and chest X-ray; all of which were normal. The patient refused any further testing. A diagnosis of aquagenic acrokeratoderma was made. The patient was advised frequent use of emollients and was counselled about recurrent, transient, and benign course of the condition. He showed partial improvement in 4 weeks with emollients and further, the patient was lost to follow-up.
Figure 1: Multiple skin colored to whitish tiny papules over dorsum of (a) Left Hand & (b) Right Hand; (c) Histopathological examination (hematoxylin & eosin, 100×) showing hyperkeratosis, orthokeratosis and dilated focal eccrine ducts

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Figure 2: (a) Closer view showing the papules; (b) Normal skin of the palms post-immersion in water

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Aquagenic acrokeratoderma is also known as aquagenic wrinkling of the palm, acquired aquagenic papulotranslucent acrokeratoderma and aquagenic syringeal acrokeratoderma.[1] It is an uncommon condition characterized by development of multiple, tiny skin-colored to whitish pebbly papules over the palms and rarely over the soles; within minutes of exposure to water. The condition can be asymptomatic or present with pain, burning sensation, pruritus, and paresthesia.[2] The etiopathogenesis is poorly understood. Many hypotheses have been laid such as genetic susceptibility, impaired epidermal barrier function which causes enhanced water absorption, transient structural, or functional modifications in stratum corneum leading to alteration in eccrine sweat ducts. It has also been postulated that transient skin barrier damage could occur in susceptible individuals on prolonged exposure to water or external agents like detergents. It has been reported in association with cystic fibrosis- both patients and carriers, and with the use of cyclooxygenase- 2 inhibitors, thus supporting the role of impaired barrier function and increased sweat salt concentration leading to sodium retention in epidermis that causes increased water absorption and development of lesions on exposure to water. Palmoplantar hyperhidrosis and atopic diathesis are also associated.[3],[4] In a minority, it can be a presenting feature of atypical cystic fibrosis manifesting in adulthood. Therefore, relevant history and investigations including genetic testing is advisable to rule out milder phenotypes and carriers of cystic fibrosis.[2] Some cases can remit spontaneously over time, possibly due to recovery of the damaged skin barrier.[5] The histopathological examination of lesional skin reveals orthohyperkeratosis/normal epidermis with dilatation of eccrine ducts. Treatment includes topicals like aluminum chloride hexahydrate, urea, salicylic acid, ammonium lactate, and botulinum injections. Mostly, the response to treatment is unsatisfactory.[4]

As aquagenic wrinkling of palms is a transient and mostly asymptomatic condition, it is probably underreported. Majority of the previously reported cases have been in females and with palmar involvement. After extensive literature search, only 6 cases with dorsal hand involvement were found; 5 having both palmar and dorsal involvement and 1 with only dorsal involvement.[1],[2],[3],[4],[5],[6] The present case shows isolated dorsal hand involvement in a male patient, which is a rare occurrence. Aquagenic acrokeratoderma is possibly not as uncommon as is thought to be and the present case adds to the scant literature available. More research into the pathogenesis and treatment options is prompted.

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 :: References Top

Yoon TY, Kim KR, Lee JY, Kim MK. Aquagenic syringeal acrokeratoderma: Unusual prominence on the dorsal aspect of fingers? Br J Dermatol 2008;159:486-8.  Back to cited text no. 1
Angra D, Angra A, Rodney IJ. Aquagenic palmoplantar keratoderma with dorsal hand involvement in an adolescent female. JAAD Case Rep 2016;2:239-40.  Back to cited text no. 2
Kutlubay Z, Engin B, Baglam S, Khatib R, Demirkesen C, Aydemir EH. Treatment failure in a case of aquagenic syringeal acrokeratoderma. J Cosmet Laser Ther 2015;17:224-6.  Back to cited text no. 3
Dhawan AK, Bisherwal K, Gandhi V, Kawthekar P, Diwaker P. Aquagenic syringeal acrokeratoderma. Indian Dermatol Online J 2016;7:327-9.  Back to cited text no. 4
[PUBMED]  [Full text]  
Luo DQ. Aquagenic acrokeratoderma: A case with family history and unusual involvements of the palms and soles, and the dorsum of fingers and toes. J Dermatol 2011;38:612-5.  Back to cited text no. 5
Xia Q. Aquagenic acrokeratoderma: Case report with no involvement of the palms. Int J Dermatol 2012;51:1391-3.  Back to cited text no. 6


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2004 - Journal of Postgraduate Medicine
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