Exfoliative Keratolysis

What is Exfoliative Keratolysis?

Exfoliative keratolysis is a condition of hands and feet, belonging to a group of skin disorders called Dermatitis. The main characteristics of this disease is patchy peeling of the skin from palms, soles or both ^[1]. It is also known as “Focal palmar peeling” and “Dyshidrosis lamellosa sicca” ^[2].

Skin anatomy

The main two parts of the skin are dermis and epidermis. Epidermis does not contain any blood vessels and gets its nutrition via the dermoepidermal junction. This layer consists mainly from keratinocytes in multiple stages of differentiation. The upper layer of cells is called the stratum corneum, and it consists of completely differentiated cells that devoid of nuclei and later shed in the process of epidermal turnover. This layer also contains melanocytes- pigment cells, Langerhans cells that serve as immune cells for the skin and Merkel cells that specialize in perception of light touch.

Dermis is the skin layer that supports and sustains the epidermis. This structure is complex and consists of connective tissue, blood vessels, nerve endings, lymph vessels and immune cells. It also contains fat layer which cushions the skin ^[3].

Anatomy of the skin. Epidermis is a thin layer, but it has many important functions.
image source: webmd.com

Causes

The exact cause of this syndrome is unknown. It is believed that the corneocytes in the skin separate from each other prematurely. Why this happens is also not known and no genetic abnormalities also have not been found. There has not been found a link between microorganisms and exfoliative keratolysis, like in Staphylococcal scalded skin syndrome.

Risk factors and factors that can aggravate the condition include exposure to irritants such as water, soap, detergents and solvents ^[2]. Also, sweating and heat can worsen the symptoms.

Other risk factors are:

• Presence of allergic condition.
  • Exposure to certain allergen can cause exfoliative keratolysis as a symptom
• Genetic predisposition to skin disorders
• Often seen amongst fisherman
  • Sun, salt water and bacteria can contribute to skin peeling
• Stress
  • Can trigger the onset of an episode, or worsen an ongoing episode ^[4]

Symptoms

The main symptom of this condition is peeling of the skin, mainly on the palms and soles. First sign is usually small, superficial, air-filled blister on fingers or palms. When the blister bursts, it leaves an expanding area or tender and peeled areas. These areas are not protected against the environmental factors. The lack of barrier function leads to the skin becoming red, tender, dry and cracked (also see Skeeter syndrome). Usually there is no pain or itchiness. In some cases the fingertips become split, and the cracks can go deeper, leading to numbness of the skin and also pain and infection.

This condition is more often seen in summer months. It mostly affects young adults, although the precise epidemiology is not known, since the patients rarely seek medical help. It is more common seen in people with sweaty palms.

Although this condition doesn’t have severe symptoms, it can cause general discomfort for the patient. The unpleasant appearance often results in embarrassment, lowered self-esteem and depression ^[2,5].

Typical presentation of exfoliative keratolysis.
Image source: nailsmag.com

Diagnosis

The diagnosis is usually made by clinical examination of the patient. History of the symptoms has to be obtained, focusing on the onset of symptoms and possible risk factors. Usually the diagnosis is supported by performing a patch test (skin allergy test), which is negative ^[7].

Differential diagnosis

Exfoliative keratolysis is often confused with:

• Eczema
• Pompholyx (an itchy form of eczema, which is characterized by the formation of small, fluid-filled blisters)
• Psoriasis, which is characterized by scaly patches
• Epidermolysis bullosa- localized blistering of skin
• Tinea- a fungal infection
• Contact dermatitis ^[7]

Some experts believe that this condition is associated with atopic dermatitis or primary hyperhidrosis.

Treatment

This condition mainly resolves without any treatment in 1 to 3 weeks.

In case the symptoms are severe and interfere with the daily life of the patient, topical steroids are given. In severe cases intravenous steroids might be prescribed, but their use has to be weighed against the possible side effects.

Other remedies can be helpful, including:

• Protecting the affected area from irritants, like water, soap and other chemicals
• Avoiding the possible allergens
• Using hand creams that contain silicone, lactic acid or urea. Keratolytic creams are the most beneficial treatment option.
  • 20% or 40% Urea cream
  • Ammonium lactate 12% cream
  • Salicylic acid 6% cream
  • Lactic acid 12% cream ^[5]
• Photochemotherapy- technique for boosting immune system ^[6]

Photochemotherapy can boost skin immune system.
Image source: cedarmed.com

Some home remedies can also be used to heal the skin:

• Prevention by using healthy diet
• Use of walnuts, almonds and cashew nuts
• Use of gloves
• Use of Aloe vera juice or cream
• Soaking hands in an oatmeal bath ^[4]

References

1. What is exfoliative keratolysis: http://www.msdmanuals.com/professional/dermatologic-disorders/dermatitis/hand-and-foot-dermatitis
2. General information: http://www.dermnetnz.org/topics/exfoliative-keratolysis/
3. Skin anatomy: http://emedicine.medscape.com/article/1294744-overview
4. Risk factors and treatment: http://healthylifemed.com/exfoliative-keratolysis/
5. Symptoms: http://www.mdedge.com/edermatologynews/dsm/312/dermatology/keratolysis-exfoliativa-lamellar-dyshidrosis-recurrent-focal#cont2
6. Treatment: http://www.dermatalk.com/blogs/skin-disorders/exfoliative-keratolysis/
7. Diagnosis: https://www.ncbi.nlm.nih.gov/pubmed/8771868