ARTICLE
ejd.2012.1660
Auteur(s) : Heiko Poppe, Hermann Kneitz, Eva-B. Bröcker,
Henning Hamm hamm_h@klinik.uni-wuerzburg.de
Department of Dermatology,
Venereology and Allergology
University Hospital Würzburg,
Josef-Schneider-Str. 2,
D - 97080 Würzburg
Germany
In 1967 Goldstein described a 32-year-old patient with multiple
minute digitate hyperkeratoses on his chest, arms and legs [1].
Since then this rare feature has been reported under a variety of
terms like hyperkeratotic spicules, minute aggregate keratosis,
punctate porokeratotic keratoderma or music box spine keratotic
plugs [2-4]. Spiny hyperkeratoses can affect only the palms and/or
the soles or they can occur in disseminated arrangements on the
trunk and extremities without palmoplantar involvement. Both
manifestations may be associated with malignancies [3, 4].
Here we report a case of spiny hyperkeratoses on the palms
associated with an in situ melanoma on the back.
An 85-year-old man presented with an irregularly shaped,
inhomogeneously pigmented patch on his back of unknown duration.
Apart from this lesion, which was excised and histologically
diagnosed as an in situ melanoma, he presented multiple
spiny hyperkeratoses of 1-2 mm size on his palms (figure
1A) and the volar sides of some fingers. They had
been present for more than 10 years without causing discomfort.
Other parts of the body, particularly the soles, were not affected.
Referring to a recently proposed new classification for digitate
hyperkeratosis, the manifestation pattern in our patient, with
hyperkeratoses confined to the palms, would be in line with “spiny
keratoderma” [2].
The medical history of our patient included renal failure due to
kidney cysts, arterial hypertension, arteriosclerosis, coronary
heart disease, hypercholesterolemia, hyperuricemia, benign
prostatic hyperplasia and rheumatism. There were no known
malignancies, and a colonoscopy performed 3 years ago was
inconspicuous. The patient's long-term medication consisted of
celiprolol, amlodipine, simvastatin, furosemide, allopurinol,
acetylsalicylic acid and prednisolone.
Histological examination of a keratotic lesion showed a sharply
bound, columnar hyperorthokeratosis with hypogranulosis (figure
1B). Diagnostic procedures, including ultrasound of
abdomen and lymph nodes, chest radiographs, laboratory tumour
markers and an ear, nose and throat examination did not reveal any
secondary malignancy. As our patient did not feel hampered by the
hyperkeratosis, he refused treatment. In the year following
excision of the in situ melanoma, the spiny hyperkeratoses
remained unchanged.
Spiny hyperkeratoses mostly occur in elderly patients. They may
be associated with malignancies or internal diseases but can also
occur as an idiopathic or, rarely, as a familial condition
[3, 4]. Histology typically shows a column of hyperortho- or
hyperparakeratosis without signs of dysplasia or inflammation.
Below the column, well-demarcated hypogranulosis is often noted and
corresponds to a loss of keratohyaline granules on ultrastructural
examination. Palmoplantar porokeratosis is an important
differential diagnosis, histologically characterised by a
distinctly narrower cornoid lamella. Other differential diagnoses
include arsenic keratoses, viral warts, acanthosis nigricans and
hyperkeratosis lenticularis perstans [2-4].
Spiny hyperkeratoses can easily be removed by shaving with a
razor blade. Topical treatment with keratolytic agents or
corticosteroids and oral treatment with tretinoin do not show
satisfying effects [5]. A significant improvement was achieved in
one case under topical application of 5% 5-fluorouracil cream twice
daily [6].
Spiny hyperkeratoses have often been reported to occur in
patients with malignancies. In the approximately 60 cases published
so far the most frequently associated neoplasms were breast, lung
and sigmorectal cancer. In one patient, a nodular melanoma
developed 2 years after palmar spiny hyperkeratoses had first been
recognised [3]. Another patient diagnosed with a subungual melanoma
in situ presented hundreds of palmoplantar spiny
hyperkeratoses that had been increasing in number over the last 20
years [5].
Whether the conjoint occurrence of spiny hyperkeratoses and
malignancies represents a real paraneoplastic phenomenon or is
merely coincidental is currently unclear. Until this question is
definitively answered it is advisable to perform a thorough
screening for malignant, especially solid, tumours in every patient
with spiny hyperkeratoses.
Disclosure
There are no funding sources that supported the work and no
conflicts of interest.
References
1. Goldstein N. Multiple minute digitate hyperkeratoses.
Arch Dermatol 1967; 96: 692-693.
2. Caccetta TP, Dessauvagie B, McCallum D, Kumarasinghe
SP. Multiple minute digitate hyperkeratosis: A proposed
algorithm for the digitate keratoses. J Am Acad Dermatol
2010 Nov 1 [in press corrected proof].
3. Kaddu S, Soyer HP, Kerl H. Palmar filiform
hyperkeratosis – a new paraneoplastic syndrome? J Am Acad
Dermatol 1995; 33: 337-340.
4. Mevorah B, Gat A, Golan H, Brenner S. Unilateral spiny
hyperkeratosis: case report and a review of the literature.
Dermatology 2008; 217: 181-186.
5. Friedl TK, Sardy M, Herzinger T, Ruzicka T,
Braun-Falco M. Spiny acral hyperkeratosis in coincidence with
malignant melanoma. Clin Exp Dermatol 2011; 36: 307-309.
6. Osman Y, Daly TJ, Don PC. Spiny keratoderma of the
palms and soles. J Am Acad Dermatol 1992; 26: 879-881.
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