Translucent whitish papules on the palms after exposure to the water – aquagenic syringeal acrokeratoderma

Aquagenic syringeal acrokeratoderma (ASA) was described for the first time in two sisters by English and McCollough in 1996. The authors called this rare entity transient reactive papulotranslucent acrokeratoderma to emphasize the transient nature of translucent papules occurring on the palms after short-time exposure to water and differentiate it from hereditary papulotranslucent acrokeratoderma (HPA), which is characterized by persistent white papules on the palms and soles, hair abnormalities and atopic diathesis [1]. Several synonymous names have been used in the literature to describe this condition, including aquagenic palmoplantar keratoderma [2] and transient aquagenic palmar hyperwrinkling [3].
A 13-year-old boy presented with a 4-month history of burning sensation within both palms evoked by short water contact, which was more pronounced when the water was warm. The sensation was accompanied by the presence of whitish discoloration and translucent papules of the palms. The papules and the burning sensation resolved spontaneously after drying within 15 min. Otherwise, the boy was healthy, did not take any medications and had no atopic background. No other family member had similar symptoms.
Physical examination revealed discrete symmetrical erythema and mild exfoliation on both palms (Figure 1 A), while the skin on the soles, hair and nails remained normal. Considering the intriguing medical history, a water immersion test was performed. After 5-minute contact with water of 20°C, the boy started to feel burning of the palms, which was accompanied by thickening of the palmar skin and presence of translucent whitish papules and plaques with prominent eccrine pores (Figure 1 B). The burning sensation and translucent papules disappeared after drying within 15 min. A 4-mm punch biopsy was taken from erythematous skin before water exposure and revealed orthokeratotic hyperkeratosis with dilated eccrine ostia and normal dermis (Figure 2). Based on the clinical presentation, positive water exposure test and histopathological findings, the diagnosis of aquagenic syringeal acrokeratoderma was made. The patient was treated with antiperspirant cream containing aluminum chlorohydrate, zinc oxide and urotropine, with a satisfying improvement and no relapse during the follow-up period of 6 months.
Aquagenic syringeal acrokeratoderma is a rare acquired condition characterized by translucent whitish papules and plaques which develop 2–10 min...


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