Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Study Letters
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
Therapy Letters
View Point
What’s new in Dermatology
View/Download PDF

Translate this page into:

Letter To Editor
doi: 10.4103/0378-6323.35749
PMID: 17921628

Acquired crateriform hyperkeratotic papules of the feet: An unusual variant of focal acral hyperkeratosis

Sathish Pai Ballambat1 , Kanthilatha Pai2
1 Department of Dermatology, Belhoul Specialty Hospital, Albaraha, Dubai, United Arab Emirates
2 Department of Pathology, Belhoul Specialty Hospital, Albaraha, Dubai, United Arab Emirates

Correspondence Address:
Sathish Pai Ballambat
Department of Dermatology, Sikkim Manipal Institute of Medical Sciences, 5th mile, Tadong, Gangtok, Sikkim - 737 102
United Arab Emirates
How to cite this article:
Ballambat SP, Pai K. Acquired crateriform hyperkeratotic papules of the feet: An unusual variant of focal acral hyperkeratosis. Indian J Dermatol Venereol Leprol 2007;73:359-361
Copyright: (C)2007 Indian Journal of Dermatology, Venereology, and Leprology
Figure 1: Hyperpigmented, hyperkeratotic, crateriform papules
Figure 1: Hyperpigmented, hyperkeratotic, crateriform papules


Focal acral hyperkeratosis is a rare clinical entity that presents with hyperkeratotic lesions on the margins of the hands and feet. Focal acral hyperkeratosis and acrokeratoelastoidosis (AK) of Costa share similar clinical features and identical histologic epidermal alterations. [1] These disorders are distinguished solely on the basis of the absence of elastorrhexis in the former. Multiple therapies have been attempted for focal acral hyperkeratosis, but they have been found to be unsuccessful. We report a case of crateriform hyperkeratotic papules of the feet, which is an unusual variant of focal acral hyperkeratosis, responding to calcipotriol.

A 25-year-old African black female presented with hyperpigmented lesions over both her feet since four years. She had received treatment earlier, without any improvement. The patient denied any symptoms of hyperhidrosis, itching, excessive sun-exposure or trauma. The lesions were asymptomatic, but were cosmetically unappealing to the patient. The family history was noncontributory. On physical examination, multiple 1-4 mm firm, hyperpigmented, hyperkeratotic and crateriform papules coalescing into plaques [Figure - 1] were located on the dorsal and lateral aspects of both the feet. The palmar and plantar surfaces were spared. Morphologically, the individual papules closely resembled those described in acrokeratoelastoidosis (AK) of Costa and in focal acral hyperkeratosis of Dowd (FAH).

A biopsy taken from a papule showed epidermal hyperkeratosis and hypergranulosis with a normal dermis that is consistent with the diagnosis of focal acral hyperkeratosis. The elastic stain revealed no loss of elastic fibers in the dermis. She was treated with topical calcipotriol twice daily for 8 weeks and showed dramatic improvement. No recurrence of lesion was noted 8 months following the treatment.

Focal acral hyperkeratosis was first described in 1983 by Dowd et al. and is considered to be a variant of AK of Costa. [2] It is more frequent among the black people with the onset of symptoms before 20 years of age in over 80% of the instances. . It is clinically identical to AK of Costa from which it can only be distinguished by histopathological or ultrastructural features. Focal acral hyperkeratosis unlike AK has histopathological alterations that are limited to the epidermis (hyperkeratosis and acanthosis) and shows no elastic fibre alteration (elastorrhexis) in the reticular dermis and normal collagen fibers. Several conditions share keratotic papules, usually crateriform along the borders of hands and feet as a common clinical finding. The differential diagnosis includes AK of Costa, AK of Mathews and Harman, mosaic acral hyperkeratosis, hereditary papulotranslucent acrokeratoderma, acrokeratoderma hereditarian punctatum, degenerative collagenous plaques of the hands, verruca plana, acrokeratosis verruciformis of Hopf, xanthoma, colloid milium, keratoelastoidosis marginalis and digital papular calcinosis. [3]

The subtypes of focal acral hyperkeratosis include hereditary type, acquired type and FAH with sensorineural deafness. Clinically, it presents as small, firm, yellow, waxy and translucent papules that appear on the margins of the hands and feet during childhood. [4] The papules often coalesce to form plaques and may be present on the dorsal surfaces as well as the knees. The most characteristic site of these papules is the boundary between the dorsal and palmar or plantar skin and in the space between the thumb and forefinger. These lesions are usually asymptomatic; however, they may be associated with hyperhidrosis. Although the condition is benign, it may cause embarrassment.

In acquired crateriform hyperkeratotic papules of lower limbs, which is an unusual variant of AK of Costa, the hands and feet are spared. [5] In our case, the dorsal and lateral aspects of feet were involved, but the palms and soles were spared.

Multiple therapies have been used for focal acral hyperkeratosis, such as liquid nitrogen cryotherapy, salicylic acid, tretinoin, prednisone and etretinate with unsuccessful results. Our patient improved with calcipotriol.

Calcipotriol is a synthetic vitamin D3 analogue used in the treatment of psoriasis since 1991. It is found to be effective in the treatment of acrodermatitis of Hallopeau, acanthosis nigricans, confluent and reticulated papillomatoses, disseminated superficial actinic porokeratosis, Darier′s disease, lichen amyloidosis, prurigo nodularis, pityriasis rubra pilaris and vitiligo. [6] The exact mechanism of action is not known; however, it has been speculated to improve disorders that have histological elements such as hyperkeratosis, acanthosis, parakeratosis and epidermal hyperproliferation by modifying the epidermal growth pattern through the stimulation of terminal differentiation and the simultaneous inhibition of proliferation. [6] The clearance of the lesions following the use of calcipotriol in our case could be possibly due to the abovementioned mechanism.

Erkek E, Kocak M, Bozdogan O, Atasoy P, Birol A. Focal acral hyperkeratosis: A rare cutaneous disorder within the spectrum of Costa acrokeratoelastoidosis. Pediatr Dermatol 2004;21:128-30.
[Google Scholar]
Dowd PM, Harman RR, Black MM. Focal acral hyperkeratosis. Br J Dermatol 1983;109:97-103.
[Google Scholar]
Rongioletti F, Betti R, Crosti C, Rebora A. Marginal papular acrokeratodermas: A unified nosography for focal acral hyperkeratosis, acrokeratoelastoidosis and related disorders. Dermatology 1994;188:28-31.
[Google Scholar]
Blum SL, Cruz PD Jr, Siegel DM, Tigelaar RE. Hyperkeratotic papules on the hands and feet: Focal acral hyperkeratosis (FAH). Arch Dermatol 1987;123:1225,8.
[Google Scholar]
Helbling I, Tucker SC, Chalmers RJ. Acquired crateriform hyperkeratotic papules of the lower limbs: An unusual variant of acrokeratoelastoidosis of Costa. Clin Exp Dermatol 2001;26:263-5.
[Google Scholar]
Holm EA, Jemec GB. The therapeutic potential of calcipotriol in diseases other than psoriasis. Int J Dermatol 2002;41:38-43.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections