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Punctate palmoplantar keratoderma in Adult
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Punctate palmoplantar keratoderma in Adult

Contributors: Vivian Wong MD, PhD, Susan Burgin MD, DiAnne Davis MD
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Punctate palmoplantar keratoderma (punctate PPK), or keratosis punctata, is a heterogeneous group of conditions characterized by small hyperkeratotic growths on the palms and soles. Many cases are inherited in an autosomal dominant fashion, although sporadic cases have also been reported. There is no sex predilection.

Numerous subtypes have been identified, and varied classification systems exist:

Punctate PPK type 1, also known as the diffuse type, Buschke-Fischer-Brauer disease, keratosis punctata palmaris et plantaris, and keratosis papulosa – Patients present with small hyperkeratotic papules on the palms or soles that appear in late childhood to adolescence. These lesions increase in size and number with time. Mutations in the alpha and gamma adaptin binding protein (AAGAB) on chromosome 15 have been identified. Only a few reported kindreds have associated malignancy (squamous cell carcinoma, Hodgkin disease, and renal, breast, lung, prostatic, pancreatic, and colonic adenocarcinomas). Other rare associations include spastic paralysis, ankylosing spondylitis, anodontia, deuteranopia, deuteranomaly, freckle-like hyperpigmentation, or HIV disease.

Punctate PPK type 2, also known as spiny keratoderma and music box spine keratoderma – In the inherited form, patients present with tiny keratotic spines on the palms and soles that appear in childhood. Sporadic cases present later in life and may be associated with renal, pulmonary, and gastrointestinal carcinomas, as well as lymphoproliferative malignancies and melanoma. Other reported underlying disease associations have included polycystic kidney disease, chronic renal failure, type 4 hyperlipoproteinemia, and pulmonary tuberculosis.

Punctate PPK type 3, also known as acrokeratoelastoidosis (AKE), marginal keratoderma, acrokeratoelastoidosis lichenoides, focal acral hyperkeratosis (FAH), and acrokeratoelastoidosis of Costa – Patients present with flat or umbilicated keratotic shiny papules on the marginal border of the palms, soles, and digits that erupt during adolescence or young adulthood. Hyperhidrosis may occur in some patients.

FAH appears during young adulthood and is clinically identical to AKE. The major difference between these 2 disorders is the histopathologic finding of elastorrhexis (fragmentation and degeneration of elastic fibers) in the dermis, a feature that is present in AKE but absent in FAH. In addition, hyperhidrosis is rarely associated with AKE but is not associated with FAH. It is still controversial whether FAH is a distinct entity or a variant of AKE.

Punctate PPK of the palmar creases (keratosis punctata of the palmar creases) is a distinct variant that has been identified in patients of African descent.

In Cole disease, punctate PPK is seen in association with guttate hypopigmentation, with or without calcifications within tendons, skin, and breast tissue.

Related topic: palmoplantar keratoderma


L85.2 – Keratosis punctata (palmaris et plantaris)

402773000 – Punctate palmoplantar keratoderma

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Last Reviewed:05/05/2021
Last Updated:01/23/2022
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Patient Information for Punctate palmoplantar keratoderma in Adult
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Contributors: Brenda Umenita Imo, DiAnne Davis MD


Punctate palmoplantar keratoderma (PPPK), also known as keratoderma punctata, is characterized by areas of tiny pits or bumps and thickened skin of the palms and soles.

There are numerous subtypes of PPPK that are all usually inherited.

PPPK is a life-long condition in which skin lesions develop with age. The thickened skin lesions may interfere with engaging in certain activities. Although in most cases one's general health is not affected, cancers of the colon, lung, kidney, breast, and the lymphatic system can rarely occur.

Who’s At Risk

PPPK is rare. Because the disease can be inherited, family history is a strong indicator for diagnosis. For those with PPPK in the family, it is particularly important to know about any family history of internal cancers.

PPPK of the palmar creases is a distinct subtype that has been identified in Black patients.

Signs & Symptoms

PPPK is characterized by areas of tiny pits or bumps and thickened skin of the palms and soles. Some present with pits and others with raised lesions or spines. Palms of the hands and soles of the feet are affected. In some subtypes, the instep of the sole and the side of the hand are also affected.

Self-Care Guidelines

  • Moisturizing creams
  • Treatments for improving thickened skin (keratolytic agents) such as salicylic acid, propylene glycol, lactic acid, urea

When to Seek Medical Care

When the lesions on the palms and soles enlarge and come together to form calluses on pressure points, it may cause pain and discomfort, which would be a reason to see a doctor for treatment.

The following red flag symptoms are an indication to seek medical treatment:
  • Impaired hand or finger movements
  • Difficulty walking
See a doctor to discuss risk for internal cancers and to guide further monitoring if indicated.


Treatments your physician may prescribe:
  • Topical retinoids
  • Topical corticosteroids
  • Oral retinoids (eg, acitretin)
  • Topical vitamin D ointment (calcipotriene)
  • Topical 5-flurouracil cream
  • Photochemotherapy (eg, psoralen plus UVA [PUVA])
  • Pairing down of thickened areas of skin (eg, cryosurgery, mechanical debridement, excision)
Because the disease can be inherited, family history is a strong indicator for diagnosis. The doctor may perform a skin biopsy to confirm the diagnosis.
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Punctate palmoplantar keratoderma in Adult
A medical illustration showing key findings of Punctate palmoplantar keratoderma : Palms and soles, Pits
Copyright © 2023 VisualDx®. All rights reserved.