Keratolysis exfoliativa also known as focal palmar peeling is a common disorder that is rarely reported and often overlooked as hand eczema. Hand dermatitis can be a very difficult condition to diagnosis due to the numerous conditions that mimic one another when presenting on the hands. This is where a thorough intake can give the practitioner clues leading them to a proper diagnosis and ultimately an effective treatment. Conditions such as psoriasis, tinea, pompholyx eczema, contact dermatitis, keratolysis exfoliativa, and hand eczema can sometimes make pin pointing a diagnosis difficult due to the sometime subtle appearance of these conditions. When lesions are present elsewhere in addition to the hands, some of these conditions can be ruled out. Unfortunately, this isn't always the case and makes attention to all the subjective and objective details an essential so that the patient can receive an appropriate treatment.
Keratolysis exfoliativa is a condition that often presents during the summer due to the hot weather that will bring on palmar sweating (hyperhydrosis). It is thought that excessive palmar sweating may be a contributing factor to the presentation of this condition. It is also thought that this condition may be a precursor to pompholyx eczema. The presenting symptoms often begin with small, superficial air-filled vesicles that appear on the fingers and/or palms. There is typically not much itching however, some individuals will have an initial bout of itching that will then subside which is atypical for hand eczema or pompholyx eczema where itching is very prominent. These small blisters will break and lead to collarete peeling and can expand leading to loss of large layers of the stratum corneum. As this layer of tissue is lost, erythema and dryness can present in the areas lacking the stratum corneum. Keratolysis exfoliativa is also known as recurrent focal palmar peeling since the condition cycles through an active phase and then transitions into a brief period of resolution followed by another cycle. This cycle can continue to repeat itself for an indeterminate period and often times requires treatment if it is interfering with an individual's daily activities. For some, the active flares are nothing more than a few air-filled vesicles that break open and clear without causing much change to the skin of the palms. However, others can have very active flares leading to the loss of large portions of the stratum corneum on the fingers and palms leading to tender hands which can interfere with their daily activities.
Triggers for this condition can often come in the form of contact irritants of the hands. In these cases, it is imperative that these known irritants be avoided so that the skin may settle and heal. Sometimes these irritants may seem very benign such as the hand soap that is being used or even water. In these cases, trying very bland and simple soaps until one is found that shows no signs of irritating the skin. In cases where water may act as an irritant, it is best to try and reduce the amount of hand washing that is done throughout the day. Also, using lukewarm water is always best as cold or hot water will stress the skin and this is what we want to avoid. Any stress to active skin will set off an inflammatory response leading to a relapse of the condition.
In the case of keratolysis exfoliativa, topical steroids are ineffective in treating this condition unlike hand eczema or psoriasis. I've found in my practice that internal Chinese herbs and topical Chinese herbal ointments can be very effective in controlling the active condition and preventing a recurrence. If this is a condition that has been affecting your life, this is a good treatment option to consider to address the root cause of the inflammatory cycle.
