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Home , Actinic keratosis, Callus, Hyperkeratosis, Keratoderma, Keratosis, Keratosis pilaris

Clinical REVIEW The effective management of

There are various conditions that fall under the umbrella term ‘hyperkeratosis’. and this article looks at the aetiology and subsequent modes of treatment in regards to these conditions.

yperkeratosis is an umbrella skin of the family, term for a number of skin affecting around 1 in 250,000 people. conditions. It involves a Hthickening of the It involves the clumping of (the outer layer of the skin), often filaments (Freedberg et al, 2003). This 8 Fungal associated with a keratin abnormality, is a hereditary disease, the symptoms 8 Hyperkeratosis and is also usually accompanied by an of which are hyperkeratosis, 8 Stratum corneum increase in the granular layer of the and . At birth, the skin of 8 Keratin skin. As the corneum layer normally the individual is entirely covered varies greatly in thickness across with thick, horny, armourlike plates different sites, some experience is that are soon shed, leaving a raw needed to assess minor degrees of surface on which scales then reform. hyperkeratosis (Kumar et al, 2004). Multiple minute digitate This thickening is often the skin’s hyperkeratoses (MMDH) normal protection against rubbing, MMDH is a rare familial or acquired pressure and other forms of irritation, cutaneous eruption of filiform , causing and corns on the typically found across the trunk and and feet or whitish areas inside the extremities. Histopathology, distribution mouth. Other forms of hyperkeratosis and history can distinguish it from occur as part of the skin’s defence other digitate keratoses. Goldstein against chronic , infection described the first case of MMDH in and the radiation of sunlight or irritating 1967, suggesting the term ‘multiple chemicals. Less often, hyperkeratosis minute digitate hyperkeratosis’ because develops on skin that has not been the projections were numerous, and irritated. These types may be part of an finger-like, comprising a horn of dense inherited condition, may begin soon orthokeratin (Goldstein, 1976). MMDH after birth and can affect skin on large presents with numerous digitate areas of the body (Freedberg et al, 2003). keratoses across the trunk and limbs, with sparing of the , palms, Types of hyperkeratosis and soles. The keratoses are skin- (hereditary) coloured, rod-shaped, non-follicular, Epidermolytic hyperkeratosis between 1–5mm in length, between This type of hyperkeratosis is 0.3–2mm in diameter, and arise from also known as ‘bullous congenital otherwise normal skin (Caccetta et ANN JAKEMAN is a Viability ichthyosiform erythroderma’, ‘bullous al, 2010). Nurse at the Royal Brompton and ichthyosiform erythroderma’, or Harefield Trust, London ‘bullous congenital ichthyosiform Focal acral hyperkeratosis erythroderma Brocq’ and is a rare Also known as ‘acrokeratoelastoidosis

Wounds Essentials 2012, Vol 1 65 Clinical REVIEW lichenoides’, this condition is a late-onset condition has been shown in several , inherited as an autosomal small-scale studies to respond well to These are small, non-cancerous skin dominant condition (single parental supplementation with and growths. They can be tan, brown or ), characterised by oval or polygonal rich in essential fatty acids. Some black and are found on the face, trunk, crateriform developing along research suggests this is due mainly arms or legs. These are very common the border of the hands, feet and wrist to vitamins E and B. A is and most people develop between one (Freedberg et al, 2003). also thought to be connected to the and 20 during their lifetime. Their cause pathology (Nadiger, 1980). is unknown (Freedberg et al, 2003). This is a rare that Site specific Corns appears at birth and continues Plantar hyperkeratosis A corn is a small area of skin which throughout a person’s life. It is This condition is a circumscribed has become thickened due to the passed down through families and keratotic area which may or may not pressure exerted on it. They are both parents must have at least be associated with a hammered great roughly round in shape and press into one abnormal gene to pass it on toe. Keratosis often resembles verruca the deeper layers of skin, becoming to their children. People with this plantaris, for which it is mistakenly painful. Hard corns commonly occur condition are born with a collodian treated, until the keratosis breaks down on the top of the smaller toes or on membrane — a shiny, waxy layer of and ulcerates or leaves a permanent the outer side of the little toe. These skin that sheds within the first two . Although keratosis under the are the areas where poorly fitted weeks of life. Red, scaly skin remains first metatarsal head is common, it is tend to rub the most. Soft corns underneath — this resembles the more usual to have disabling symptoms sometimes form in between the toes, surface of a fish (Morelli, 2007). underneath the middle three metatarsals most commonly between the fourth (Skinner and Fitzpatrick, 2008). and fifth toes. These are softer because X-linked ichthyosis (XLI) the sweat between the toes keeps XLI is also known as ‘steroid sulfatase Hyperkeratosis of the them moist. Soft corns can sometimes deficiency’, as well as ‘X-linked nipple and areola become infected (Freeman, 2002). recessive ichthyosis’ (from the Ancient This is an uncommon benign, Greek ‘ichthys’, meaning ‘fish’) and is a asymptomatic, acquired condition of Calluses skin condition caused by the hereditary unknown pathogenesis. A is larger, broader and has a deficiency of the steroid sulfatase (STS) less well-defined edge than a corn. enzyme, affecting between one in 2,000 These tend to form on the underside and one in 6,000 males. XLI manifests Lichen planus may appear as a lacy, of the (the sole). They commonly with dry, scaly skin and is due to white patch on the inside of the form over the bony area just deletions or mutations in the STS gene. mouth or as an itchy, violet, scaly underneath the toes. This area takes XLI can also occur in the context of patch elsewhere on the skin. In some much of your weight when you walk. larger deletions, causing contiguous cases, it affects the mouth, genitals, They are usually painless but can gene syndromes. Treatment is largely , nails, and rarely, other parts of become painful (Freeman, 2002). aimed at alleviating the skin symptoms the body. About one in 50 people (Gelmetti and Caputo, 2002). develop lichen planus and it occurs Other equally in men and women. More Hyperkeratosis lenticularis than two-thirds of cases occur in perstans (HLP) Also known as ‘follicular keratosis’, people aged 30–60 years, however, Also known as Flegel disease, HLP is keratosis pilaris is a common, it can occur at any age. It is not an a cutaneous condition characterised autosomal dominant, genetic follicular inherited disease, nor is it an infection, by rough, yellow-brown keratotic, condition that is manifested by the and the cannot be caught or flat-topped papules of irregular outline appearance of rough bumps on the passed on to others. Although the measuring 1–5mm in diameter and skin. It most often appears on the cause of this condition is unknown, up to 1mm in depth (Rapini et al, back and outer sides of the upper researchers suspect that it may be 2007). are located primarily on arms (although the lower arms can related to an abnormal reaction of the dorsal feet and lower legs, with a also be affected), and can occur on the . One theory decreasing likelihood of manifestation any body part except glabrous skin is that the immune system may be proximally. Most cases have been (naturally hairless, such as the palms triggered by a virus or other factor in reported in Europe. No instigating factor or soles of the feet). Less commonly, the environment to attack cells in the has been identified clearly, however, lesions appear on the face, which skin, which leads to the inflammation may be mistaken for . This (Lehman et al, 2009). Continued on p70

66 Wounds Essentials 2012, Vol 1 Table 1 – Treatment of Hyperkeratosis Type Treatment Side effects

Epidermolytic 8 Gene therapy is really the only true therapy 8 Oral therapy frequently causes revers- hyperkeratososiis for people with EHK. Until gene therapy solu- ible changes in liver function and serum tions finally become a reality, EHK sufferers 8 Up to 75% of retinoid-treated patients experi- must treat their fragile skin carefully. Most ence dose-related , which is reversible have learned that taking regular, extended upon discontinuation of therapy baths allows patients to care for their fragile 8 can cause major foetal abnormali- skin and keep it manageable. Baths that ties and is therefore contraindicated in preg- include sea salt seem to improve the process nant women of softening and removing the thickened skin 8 Topical are also contraindicated in (Brecher and Orlow, 2003) . Local reactions include: burning, 8 Oral retinoids — etretinate, acitretin, erythema, stinging, pruritus, dry/peeling skin (Brecher and Orlow, 2003). Con- (BMJ/RPS, 2012) traindicated in hyperlipidaemia, renal and hepatic impairment 8 Acitretin

Multiple minute 8 Topical combined with topical 8 Topical keratolytics – can cause , itching, digitate emollients burning, irritation, inflammation, dryness, hyperkeratosis 8 cream and oral swelling and tenderness at site of application. 8 Topical 5- cream – apply thinly This will heal once treatment is complete to the affected area once or twice per day 8 Tretinoin cream can cause stinging, burning, (max area 500cm2 for three to four weeks dry and peeling skin, sensitivity to UVB light. (BMJ/RPS, 2012). Eye irritation and oedema 8 Surgical care - the lesions can be trimmed or 8 Topical 5-fluorouracil cream can cause local clipped as needed irritation and photosensitivity (BMJ/RPS, 8 Diet – gluten-free diet plus frequent 2012) follow up

Focal acral 8 Treatment is not indicated in most patients n/a hyperkeratosis 8 Mild keratolytics occasionally help, but recurrences are common 8 Topical retinoids are not effective

Lamellar ichthyosis 8 Moisturisers containing , ammonium 8 Close monitoring of fluids, electrolytes, signs lactate, or other alpha-hydroxy acids of and placement in a high-humidity may help incubator for all newborns. 8 Retinoid medications, such as tazarotene, 8 Mild skin irritations, redness and flaking may be used on the skin (topically). Apply 8 Topical tazarotene can cause local irritation, once daily to the affected areas in the evening, pruritus, burning, erythema, non-specific rash, usually for 12 weeks. Not recommended for dry or painful skin. (BMJ/RPS, 2012) child under 18 years of age 8 Gene therapy to correct the genetic defect may be possible in the future (Morelli, 2007)

Keratosis pilaris 8 Daily exfoliating and moisturising. These (follicular actions may make the appearance less visible hyperkeratosis) 8 Suggest spending some time with the affected area in sunlight for a few minutes each day to minimise the appearance

Wounds Essentials 2012, Vol 1 67 Clinical REVIEW

Table 1 (continued) – Treatment of hyperkeratosis

Type Treatment Side effect X-linked ichthyosis 8 There is no cure for ichthyosis. The main goal 8 Oral isotretinion — dry skin, epidermal (XLI) of treatment is to moisturise and exfoliate. This fragility, dry /eyes/mouth, inflammatory helps prevent dryness, scaling, cracking and bowel disease, depression, hypersensitivity, build-up of skin hypertension, blurred vision. Contraindicated in 8 Oral retinoids, such as acitretin or isotretinoin, hypervitaminosis A, hyperlipidaemia, renal and can help to reduce scaling hepatic impairment and pregnancy 8 Topical isotretinoin – apply thinly once or 8 Topical isotretinion — contraindicated in preg- twice daily nancy. Women of childbearing years must use 8 Lanolin creams and products containing effective contraception. Local reactions include urea, lactic acid and other alpha hydroxyl burning, erythema, stinging, pruritus. Eye irrita- acids may help to exfoliate and moisturise skin tion and oedema, blistering or crusting of skin (BMJ/RPS, 2012) have been reported (BMJ/RPS, 2012)

Plantar 8 Topical cream formulation containing 10% urea 8 The water-binding, , exfoliative, hyperkeratosis and 8% glycerine and epidermal-thinning activities of urea 8 Palliative measures such as reduction of the and the skin softening and skin barrier repair horny accumulation and then padding of the area properties of glycerine, combine to deliver to distribute pressure give relief in most cases significant relief (Loden, 2003) 8 Intractable conditions over a non-weight bearing area respond to excision of the condylar promi- nence (Skinner and Fitzpatrick, 2008)

Hyperkeratosis 8 The disease has a benign course and may n/a of the nipple and only be a cosmetic problem. Treatment with areola topical retinoic acid can induce an acceptable response (Perez-Izquierdo et al, 1990) Lichen planus 8 No treatment is an option if symptoms are mild 8 Steroid tablets taken for longer than a few 8 A steroid cream or ointment can reduce inflam- weeks are not usually advised due to possible mation. Steroid pastes or mouthwashes may help side effects. Therefore, the rash may reappear to ease painful mouth after the tablets are stopped 8 A course of steroid tablets may be advised 8 Oral — abnormal renal function, 8 Ciclosporin and azathioprine are recommended uncontrolled hypertension, not if lichen planus is severe. These reduce inflamma- under control, malignancy, UVB sensitiv- tion. Potential serious side effects mean that they ity. Contra-indicated in hepatic and renal are not used routinely impairment/pregnancy 8 PUVA (psoralen and UVA) is a special light 8 Oral azathioprine — malaise, dizziness, therapy that may be advised by a skin specialist if vomiting, diarrhoea, , rigors, myalgia, hy- you have extensive and severe lichen planus potension and interstitial nephritis. Also 8 Psoralen increases the skin’s sensitivity to UV light marrow suppression, liver impairment, and can be administered topically or orally 1.5–2 jaundice and hair loss hours before exposure to light (BMJ/ RPS, 2012) 8 Antihistamine may help to ease the 8 Emollients are often also given to provide moisture to your skin. These can also help to reduce the itching

68 Wounds Essentials 2012, Vol 1 Table 1 (continued) – Treatment of hyperkeratosis

Type Treatment Side effect Seborrheic keratosis 8 A variety of techniques may be used to treat 8 Ammonium lactate — do not ap- seborrheic keratosis. They include with ply to the face unless advised by a carbon dioxide (dry ice) or liquid nitrogen, electro-des- doctor. Do not apply on sunburned, iccation and curettage, curettage alone, shave wind-burned, dry, cracked, irritated, or excision, or laser or . However, or broken skin some of these techniques destroy the without 8 Avoid exposure to sunlight or artifi- providing a specimen for histopathologic diagnosis cial UV rays 8 Ammonium lactate and alpha hydroxy acids have 8 Contraindicated in pregnancy been reported to reduce the height of seborrheic kerato- 8 Alpha hydroxy acids — (as above) sis. Superficial lesions can be treated under expert su- pervision by applying these treatments and repeating if the full thickness is not removed on the first treatment. There is some evidence that superficial peeling will hasten the transition of closed lesions to the surface of the resulting in a quicker clearance (Kem- piak and Uebelhoer, 2008) 8 Topical treatment with tazarotene applied once daily to the affected areas in the evening usually for 12 weeks 8 Not recommended for children under 18 years of age

Corns and calluses 8 Paring and trimming. The thickened skin of a corn n/a or callus can be pared down (trimmed) by a podia- trist by using a scalpel blade 8 Correcting poor footwear will reduce any rubbing or friction on your skin. In many cases, a corn or callus will go away if rubbing or pressure is pre- vented through improved footwear 8 Depending on the site of a corn or callus, a cush- ioning pad or insole may be of benefit 8 Surgery is recommended for foot or toe abnormal- ity causing recurring problems (Hogan et al, 2008)

Hyperkeratosis 8 Topical 5% fluorouracil and a synthetic vita- n/a lenticularis perstans min D-3 derivative over several months have been used together with effective results 8 Local excision may be successful, especially if the number of lesions is small 8 Dermabrasion is a possible surgical modality. However, a large number of lesions, as well as lesion location, make this an impractical approach 8 Cryotherapy is an additional possibility how- ever this causes pain, swelling and blistering 8 Oral retinoids have been successful only with continuous therapy. Patients tend to relapse when therapy has ended (Metze et al, 2000)

Wounds Essentials 2012, Vol 1 69 Clinical REVIEW

Table 1 (continued) – Treatment of hyperkeratosis

Type Treatment Side effect Actinic 8 An emollient may be sufficient for mild lesions 8 sodium 3% gel — may cause keratosis 8 Diclofenac sodium 3% gel is suitable for the treatment gastrointestinal disturbances including nausea, of superficial lesions in mild disease Apply thinly to diarrhoea and occasional and ulcera- affected areas for 60 to 90 days (BMJ/RPS, 2012) tion. Contraindicated in hepatic, liver, respira- 8 5-fluorouracil cream is effective against most types of tory, renal and cardiac impairment non-hypertrophic . Apply thinly to the 8 5-fluorouracil — local irritation (use a topical affected area once or twice daily for 3–4 weeks (BMJ/ for severe discomfort associated RPS, 2012) with inflammatory reactions). Photosensitiv- 8 (immune response modifier) is used topoi- ity. Max area of skin to be treated at one time is cally for lesions of the face and when cryotherapy 500cm2 or other topical treatments cannot be used. Apply to 8 Imiquimod — avoid normal or broken skin and lesions three times a week for four weeks, assess and open wounds. Itching, burning sensation, ery- repeat four-week course if lesions persist — maximum thema, erosion, oedema, excoriation and scab- two-week course (BMJ/RPS, 2012) bing, headache and influenza type symptoms. 8 with liquid nitrogen, by freezing off the Less commonly local ulceration and alopecia actinic keratosis (BMJ/RPS, 2012) 8 is a new therapy involves in- jecting a chemical into the bloodstream, which makes actinic keratosis more sensitive to any form of light 8 Laser therapy, notably CO2 and Er:YAG lasers. A Laser resurfacing technique is often used with diffuse actinic keratosis 8 Electrocautery — this involves burning off actinic keratosis with electricity 8 Different forms of surgery (Quaedvlieg et al, 2006)

Warts 8 No treatment may be required. may regress 8 is not suitable for diabetic patients on their own and treatment may only be required if at risk of naturopathic ulcers. Avoid broken skin. they are painful, unsightly, persistent or cause dis- Not suitable for application to face, anogential re- tress. Treatment usually relies on tissue destruction gion, or large areas and may cause skin irritation 8 Salicylic acid is suitable for treating warts of the hands and feet but not suitable for anogential warts. Apply carefully to ensuring to protect the surrounding skin with soft paraffin or appropriate . Rub wart gently with file or pumice stone once weekly. Treat- ment may need to continue for up to three months 8 Cryotherapy causes pain, swelling and blistering and may be no more effective than topical salicylic acid some investigators have implicated been described in association with the lesions. At present, all of these are ultraviolet light (Miljkovic, 2004). endocrine abnormalities, including considered unsatisfactory due to high and hyperthyroidism, while rates of recurrence (Metze et al, 2000). HLP, described by Flegel in 1958, a possible relationship with digestive is considered to be an autosomal and cutaneous tumours is more open Actinic keratoses dominant inherited keratinisation to debate. Many treatment options This is a premalignant condition of disorder, although most cases are have been discussed, including topical thick, scaly, or crusty patches of skin. sporadic, affecting patients aged 40– and systemic retinoids, 5-fluorouricil, It is more common in fair-skinned 50 years with no noted predominance derivatives, psoralen, UV-A people. It is associated with those who in either sex. The condition has therapy, excision and dermabrasion of are frequently exposed to the , as it is

70 Wounds Essentials 2012, Vol 1 usually accompanied by solar damage. of denuded skin can lead to infection, childbirth, as the STS expressed in the Since some of these pre- progress sepsis and electrolyte imbalance and placenta plays a role in normal labour. to squamous cell , they should intravenous fluids or will be For this reason, carriers should ensure always be treated. When skin is exposed necessary. Other complications include their obstetrician is aware of the to the sun constantly, thick, scaly, or a variety of benign and malignant skin condition (Morelli, 2007). crusty bumps appear. The scaly or crusty lesions, including melanocytic lesions part of the bump is dry and rough. The (Hutcheson et al, 2004). Untreated lesions in actinic keratosis growths start out as flat scaly areas, and have upto 20% risk of progression to later grow into a tough, wart-like area. Although some authors have and should proposed a relationship between be treated immediately. Preventive An actinic keratosis site commonly MMDH and malignancy and/ measures recommended are similar ranges between 2–6mm in size, and or inflammatory disorders, this to those for skin (Quaedvlieg can be dark or light, tan, pink, red, a contention was based on a broad et al, 2006). combination of all of these, or have definition of MMDH that included the same pigment as the surrounding disorders that are now recognised With plantar hyperkeratosis, calluses skin. It may appear on any sun-exposed as distinct from MMDH. However, are basically caused by shoes with area, such as the face, ears, neck, scalp, adopting the more stringent criteria pointed toes, short toes, or both. If chest, backs of hands, forearms or lips proposed by Caccetta et al (2010), untreated these can force the toes to (Quaedvlieg et al, 2006). their findings did not find evidence for buckle and thus produce a ‘hammer associating MMDH with malignancy toe’ deformity at the (Skinner Warts or systemic disease. That stated, and Fitzpatrick, 2008). These are small rough lumps on the malignancy screening could still be skin. They are caused by a virus (human considered (Caccetta et al, 2010). After the rash has cleared up, a change papillomavirus HPV) that causes a in skin colour may occur (a brown or reaction in the skin. Warts can occur Babies with lamellar ichthyosis are at grey mark), which can sometimes last anywhere on the body, but are found risk of infection when the collodian for months. This is known as post- most commonly on hands and feet. membrane is shed. Later in life, eye inflammatory , and problems may occur because the eyes tends to be more noticeable in people Verrucas cannot close completely. Pre-natal with darker skin. Additionally, there is Verrucas are warts that occur on the morbidity due to sepsis is a concern, some evidence that lichen planus may soles of the feet. They are the same as therefore, an intensive care environment increase the risk of certain cancers, warts on any other part of the body. should be considered for affected such as squamous cell carcinoma, and However, they may look flatter, as they children. Widespread areas of denuded oral, penile and vulvovaginal cancer. tend to get trodden in (note: anal and skin may also lead to fluid and electrolyte genital warts are different). imbalances, especially in (Di Lesions affecting the and Giovanna and Robinson-Bostom, 2003). vagina often do not respond well to General Complications treatment and are difficult to manage. The most common complication In the case of XLI, aside from the skin Therefore, the condition can result in encountered in all types of hyperkeratosis scaling, it is not typically associated significant sores or permanent changes is a foul smelling odour, produced by with other major medical problems. to vulvovaginal tissues that at times bacteria, when the macerated scales Corneal opacities may be present but may scar. Because severe itching, pain become infected. Without intervention, do not affect vision. Cryptorchidism and burning sensations are common, heavy bacterial colonisation may result in is reported in some individuals the condition can result in subsequent sepsis at any age. (DiGiovanna and Robinson-Bostom, sexual dysfunction (Lehman et al, 2009). 2003). Mental retardation can also Epidermolytic hyperkeratosis is be seen in some affected individuals, Complications of seborrheic keratosis generalised redness, with thick, generally and is thought to be due to deletions include, skin , , dark, scales that tend to form parallel encompassing neighboring in and scarring. Malignant rows of spines or ridges, especially addition to STS (Van Esch et al, 2005). associated with seborrheic keratosis has near large joints. The skin is fragile and rarely been reported in the literature, blisters easily following trauma, however, Larger deletions that include the with disagreement regarding whether the extent of blistering and amount of SHOX gene can result in short stature. it is coincidental or whether malignant scale is variable. Neonatal patients may Female carriers generally do not transformation occurs. Because need to be transferred to the neonatal experience any of these problems, but seborrheic keratoses are common and ICU for monitoring. Widespread areas can sometimes have difficulty during association with malignant melanoma

Wounds Essentials 2012, Vol 1 71 Clinical REVIEW is very rare, many experts conclude that and management of these patients. A Di Giovanna JJ, Robinson-Bostom L the association is coincidental. However, clinician usually reaches the diagnosis (2003) Ichthyosis: etiology, diagnosis, because of the association of other of hyperkeratosis using a detailed and management. Am J Clin Dermatol malignancies, a biopsy of any suspect or history and embarking on a thorough 4(2): 81–95 changing seborrheic keratosis is essential skin inspection. (Zabel et al, 2000). Flegel H (1958) Hyperkeratosis lenticu- Laboratory investigations are often laris perstans. Hautarzt 9: 362–64 Corns and callus that are not treated needed in order to arrive at a correct will become painful. They will not heal diagnosis, as many of these conditions Freedberg IM, Eisen AZ, Wolff K, independently unless the associated share clinical similarities. Austen KF et al (2003) Fitzpatrick’s pressure is removed. If it is not, then specimens from involved areas may in General . (6th the skin will continue to thicken and be required for histopathological ed). McGraw-Hill, Columbus, USA become more painful. After a while, purposes. The exact mode of the body will start treating it as a treatment depends on the type of Freeman DB (2002) Corns and calluses and an () hyperkeratosis. resulting from mechanical hyperk- can develop. This can get infected and eratosis. Am Fam Physician 1: 65(11): the infection can spread. Instances The prognosis is good for most types of 2277–80 of infections of corns on the toe are hyperkeratosis, however, actinic keratosis more common than calluses. This can and, very rarely, seborrheic keratosis, can Goldstein N (1976). Multiple Minute be a serious complication for those develop into skin cancers. As researchers Digitate Hyperkeratoses. Arch Derma- with poor circulation, peripheral learn more about the condition and what tol 96(6): 692–3 neuropathy and those requiring causes it, they continue to move closer care (Freeman, 2002). to effective treatments, and perhaps, Hogan DJ, Basile AL. Corns. eMedicine. ultimately, a cure. WE January 2008 Conclusion Although the symptoms of all types Hutcheson AC, Nietert PJ, Maize JC of hyperkeratosis can be difficult and References (2004) Incidental epidermolytic hyperk- uncomfortable, the disease can be eratosis and focal acantholytic dyskera- successfully managed. Hyperkeratotic Brecher AR, Orlow SJ (2003) Oral retin- tosis in common acquired melanocytic skin disorders are characterised by oid therapy for dermatologic conditions nevi and atypical melanocytic lesions. J red, dry cracked and scaling skin in children and adolescents. J Am Acad Am Acad Dermatol 50(3): 388–90 affecting 10–20% of the Western Dermatol 49(2): 171–82 population. While the rate of Kempiak S, Uebelhoer N (2008) Su- incidence of hyperkeratotic condition BMJ/RPS (2012) British National perficial chemical peels and microder- increases with age, different types Formulary 63. March, BMJ Group mabrasion for acne vulgaris. Seminars affect persons of all ages, gender and Macmillan, London in Cutaneous Medicine and Surgery. racial/ethnic groups. 27(3): 212–20 Caccetta T, Dessauvagie B, McCallum A variety of treatment options D, Kumarasinghe S (2010) Multiple Kumar V, Fausto N, Abbas A (2004) exists for hyperkeratosis, including minute digitate hyperkeratosis: A Robbins & Cotran Pathologic Basis of keratolytics, moisturisers and proposed algorithm for the digitate Disease (7th ed). Saunders, US: 1230 that promote keratoses. J Am Acad Dermatol Nov: 1 skin hydration and promote an [Epub ahead of print] Lehman JS, Tollefson MM, Gibson LE increased lipid content in the (2009) Lichen planus. Int J Dermatol stratum corneum. Emollients and Gelmetti C, Caputo R (2002) Pediatric 48(7): 682–94 moisturisers are frequently used to Dermatology and : disrupt the cycle of skin dryness and A Concise Atlas. Informa Healthcare, Loden M (2003) Role of topical emol- other skin barrier disorders. London lients and in the treatment of dry skin barrier disorders. Am J Clin Due to the visual similarities in some Connetics Corporation (2004). Dermatol 4(11): 771–88 these conditions, it is vital to ensure Soriatane (acitretin) capsules. that the correct diagnosis is confirmed Complete product information. McClure SL, Valentine J, Gordon KB prior to initiating treatment. A Available at: http://www.connetics. (2002) Comparative tolerability of multidisciplinary approach is key com, http://www.prnewswire.com systemic treatments for plaque-type to early detection, correct diagnosis (accessed 20 June, 2012) . Drug Saf 25(13): 913-27

72 Wounds Essentials 2012, Vol 1 3MTM CavilonTM Skin Care Products Metze D, Lübke D, Luger T (2000). [Hyperkeratosis lenticularis perstans (Flegel’s disease) — a complex disorder of epidermal differentiation with good response to a synthetic vitamin D3 derivate]. Hautarzt 51(1): 31–5

Miljkovic J (2004) An unusual general- ized form of hyperkeratosis lenticularis perstans (Flegel’s disease). Wien Klin Wochenschr 116 Suppl 2: 78–80 The Morelli JG (2007). Disorders of kerati- nization. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Protective Nelson Textbook of Pediatrics (18th ed). Phila- Instinct delphia, Pa: Saunders Elsevier; chapter In wound care 657

Perez-Izquierdo JM, Vilata JJ, Sanchez When skin is vulnerable, it needs protection. JL, et al (1990) Retinoic acid treatment of nipple hyperkeratosis. Arch Derma- 3M™ Cavilon™ No Sting Barrier Film tol 126: 687–88 provides a barrier to protect peri-wound areas from maceration and further Nadiger, HA (1980) Role of in breakdown from exposure to wound the aetiology of phrynoderma (follicular exudate. It will also protect skin from hyperkeratosis) and its interrelation- adhesive damage when removing wound ship with B-complex vitamins. Br J Nut 44(3): 211–14 dressings and tapes.

Quaedvlieg PJ, Tirsi E, Thissen MR, 3M™ Cavilon™ Durable Barrier Cream Krekels GA (2006) Actinic keratosis: provides an effective moisturising barrier how to differentiate the good from the bad ones? Eur J Dermatol 16(4): for intact skin at risk from breakdown. It 335–39 is associated with a significant decrease in grade 1 pressure ulcers when used Rapini RP, Bolognia JL, Jorizzo JL (2007) as part of a sacral care protocol.1 Dermatology: 2-Volume Set. Mosby, St Louis 3M™ Cavilon™ Durable Barrier Skinner H, Fitzpatrick M (2008) Cur- Cream + Honey provides a barrier and rent Essentials: Orthopedics. Mc- moisturiser suitable for lymphoedema, Graw–Hill Medical, USA dermatology, leg ulcer or other patient groups with potential sensitivities. Van Esch H, Hollanders K, Badisco L, Honey acts as a natural Melotte C, et al (2005) Deletion of VCX- A due to NAHR plays a major role in replacing and perfumes. the occurrence of mental retardation in patients with X-linked ichthyosis. Hum If you would like more information about Cavilon skin care products, Mol Genet 14 (13) to receive product samples or to arrange a representative visit, call 0800 616066 (answer phone) or visit www.cavilon.co.uk. Zabel RJ, Vinson RP, McCollough ML (2000) Malignant melanoma arising 1. Bale, S. The benefits of implementing a new skin care protocol in nursing homes. in a seborrheic keratosis. J Am Acad Journal of Tissue Viability, Vol 14, No. 2. April 2004. Dermatol 42(5): 831–33

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