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Viral hand warts versus palmar keratoderma

Both viral warts and keratoderma are benign but can cause problems on the hands.  Failing to differentiate them can lead to inappropriate treatment - as occurred with the patient pictured here with palmar keratoderma.

Viral hand warts

  • Hyperkeratotic papules with a rough irregular surface
  • Size 1mm to 1cm.
  •  Can occur on any part of the body but most commonly seen on hands and feet
  • Usually round but may be elongated if at side of nail
  •  Usually asymptomatic but may be very tender and can cause cosmetic problems
  •  Spread by direct or indirect contact.  Autoinoculation may occur. (Patient illustrated is an insulin dependent diabetic who has developed these warts at sites of capillary blood sampling)
  • Caused by infection with human papilloma virus.  Viral particles are found in the basal layer of the epidermis
  •  Warts are very common – prevalence is about 10%
  • Treatment may be with keratolytics such as salicylic acid or lactic acid, or alternatively with cryotherapy.

Palmar keratoderma

  •  Hyperkeratotic papules
  •  Linear hyperkeratosis extending up volar aspect of the fingers
  •  The epidermal thickening may be exacerbated by local trauma (therefore more likely to be worse in manual labourer)
  •  May be asymptomatic or uncomfortable and often causes cosmetic problems
  •  Keratodermas are a mixed group of hereditary disorders of keratinization giving rise to epidermal thickening of palms and soles
  • Striate keratoderma (illustrated) is autosomal dominant with variable phenotype expression
  •  Onset usually in early adult life
  • Keratolytics are mainstay of therapy but topical and oral retinoids have been used. 
  • The patient illustrated refused treatment when a correct diagnosis of palmar keratoderma was made- after having a number of ineffective treatments with liquid nitrogen cryotherapy.

Dr Andy Jordan is a GP and hospital practitioner in dermatology in Chesham, Buckinghamshire.

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