Exfoliative Keratolysis

Overview

Exfoliative Keratolysis (skin peeling disease) is a common condition of the skin usually misdiagnosed as dermatitis (eczema) and characterized by local flaking, eruptions and dryness mainly of palms of hand and/or soles of feet. It can also affect the fingers of both extremities,  typically involving the tips. Before rupturing, lesions of Exfoliative Keratolysis are seen as air-filled blisters which are usually recognized as the early stage of this condition. Exfoliative Keratolysis can rarely present as painful where it leaves behind red inflamed underlying layers of skin. Most often this condition recurs in a matter few weeks and seldom reported due to its largely asymptomatic nature.

Causes

No immediate cause has been associated with Exfoliative Keratolysis to this date. However, latest research suggests a link to premature separation and disruption of corneocytes (cells of the layer “corneum stratum”). In some cases, a genetic connection has been loosely established but no direct confirmation is available.

Exfoliative Keratolysis seen on palms of both hands

Predisposing & Aggravating Factors

Several factors have been identified that can predispose an individual with a history of this condition.

  • Weak immune response
  • Allergy
  • Temperature: More common in summers
  • Irritants: Soaps, detergents, solvents, and over-exposure to water,
  • Age: Young population is affected mostly
  • More common in sweaty hands

Complications

Extreme cases can present with bleeding and itching, and in rare cases, result in lifelong damage of the affected areas of skin.

Signs and Symptoms

In the early stage, Exfoliative Keratolysis presents as small air-filled blisters and eruptions. Later on, these lesions burst, rarely associated with pain, revealing a red underlying layers of skin in a circular pattern. Tip of fingers of both extremities and palmar side of hands are the most affected parts of the body. Lesions of Exfoliative Keratolysis have air instead of fluid as seen in other similar conditions.
Pain is an infrequent complaint in Exfoliative Keratolysis. Rarely, tenderness can occur after the blisters burst, producing a red inflamed underlying zone of skin.
Skin can become rough and hard in chronic cases of this condition due to continuous peeling of skin over an extended period of time.
Exfoliation is soon replaced with normal skin, however, the lesions return after a few weeks often in the same areas affected before.

Differential Diagnosis

Following conditions must be ruled out before establishing diagnosis of Exfoliative Keratolysis:-

  • Palmoplantar Psoriasis
  • Contact Dermatitis
  • Tinia (fungal) infections

    Exfoliative Keratolysis on fingers (Courtesy: www.dermnetnz.org)

Treatment and Prevention

Exfoliative Keratolysis is also different from other conditions in terms of treatment. It does not respond to conventional drugs such as topical steroids, or other anti-inflammatory drugs. Hence, no effective management with drugs has been established yet. Only one case has been reported so far to have responded to oral Soriatane (Acitretin), showing improvement with continual increase in dosage.
With drug therapy being ruled out, the best approach is then to apply the preventive approach along with use of a few other methods. Following options are suggested:-

  • Limiting exposure to known irritants and allergens.
  • Use of particular creams and lotions having lactic acid, salicylic acid and urea which are helpful in preventing infection.
  • Photochemotherapy can help prevent recurrence of this condition comprising of Psoralen and ultraviolet A light (PUVA) in extreme cases.
  • Extra attention is recommended in summers, especially sweating being a concern in such a situation. Use of topical Drysol or oral glycopyrrolate can reduce excessive sweating.

Sources

https://www.dermnetnz.org/topics/exfoliative-keratolysis/

https://www.ncbi.nlm.nih.gov/pubmed/26990340

https://www.ncbi.nlm.nih.gov/pubmed/23039091

http://www.mdedge.com/edermatologynews/dsm/312/dermatology/keratolysis-exfoliativa-lamellar-dyshidrosis-recurrent-focal#cont2