Successful treatment of aquagenic keratoderma with botulinum toxin injections

Aquagenic keratoderma is a rare skin disease with unknown etiology. Aquagenic keratoderma presents with translucent and white-colored papules on both palms. The lesions may be itchy and painful. The goal of treatment is to eliminate lesions and improve patient comfort [1].
A 22-year-old female patient presented with an 18-month history of painful and itchy white wrinkled appearance and hardness in the palms following exposure to water. The interval between contact with water and initiation of the symptoms was formerly 10 minutes. Recently, symptoms occurred after washing hands even for 2 minutes regardless of water temperature. The lesions regressed spontaneously 15 minutes after her hands dried. The patient was previously treated with urea 20% cream, topical aluminum chloride hexahydrate 20% and 53.5 mg hamamelis virginiana distillate and 180 mg zinc oxide cream without an adequate response. The past medical history and family history were both unremarkable. Regular use of any medication was denied. Dermatological examination of the hands was normal. However, after exposure of the hands to water for two minutes, mild edematous appearance and multiple flat-topped, 1–2 mm sized white papules were observed (fig. 1 A). Therefore, the diagnosis of aquagenic keratoderma was made and the patient was treated with botulinum toxin A. A total dose of 100 units of botulinum toxin A reconstituted in 2 ml of 0.9% sodium chloride was administered into palms as 1 cm apart subdermal injections of 1 unit of botulinum toxin using 1 ml syringe with 30 gauge. Tips of the thumbs and index fingers were spared to demonstrate the difference between treated and untreated areas. The patient noticed significant improvement of the symptoms one week after botulinum toxin injection and achieved a complete clinical response 3 weeks after treatment (figs. 1 B, C). The treatment was effective for 8 months.
Aquagenic keratoderma is a rare cutaneous disorder which usually affects young women and is characterized by translucent, white-colored papules, plaques and edema on the palms develop in minutes following exposure to water [1, 2]. The lesions may lead to itching, pain, tightness and burning sensation [3, 4]. The exact cause of aquagenic keratoderma remains unknown [4]. However, it has been associated with cystic fibrosis, palmar hyperhidrosis and medications such as acetylsalicylic acid, paracetamol, sulfasalazine and tobramycin [1–5]. The diagnosis of aquagenic...


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