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
Reviewers 2022
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

Translate this page into:

Case Report
PMID: 17642830

Parakeratosis pustulosa - a distinct but less familiar disease

Deepika Pandhi, S Chowdhry, C Grover, B SN Reddy
 Dept. of Dermatology and STD, MAM College and Lok Nayak Hospital, New Delhi, India

Correspondence Address:
Deepika Pandhi
E-6, Dronacarya Apartments, Mayur Vihar, Phase I Extn., Delhi - 110 091
How to cite this article:
Pandhi D, Chowdhry S, Grover C, Reddy B S. Parakeratosis pustulosa - a distinct but less familiar disease. Indian J Dermatol Venereol Leprol 2003;69:48-50
Copyright: (C)2003 Indian Journal of Dermatology, Venereology, and Leprology


Parakeratosis pustulosa (PP) is a distinct but less commonly known skin disease, which is frequently seen, in young girls. We describe the clinical and histological features of PP in a 7 month old female baby. Further, it is stressed that unless carefully looked for, this entity may be easily misdiagnosed as chronic paronychia, acrodermatitis of Hallopeau, pustular psoriasis, atopic dermatitis, tinea pedis or dry fissured eczematoid dermatitis and mistreated subsequently.
Keywords: Parakeratosis pustulosa


Parakeratosis pustulosa (PP) is predominantly seen in children as an eczematoid eruption adjacent to the free margin of nail, extending to the dorsal nail fold. Hyperkeratosis under free margin of nail results in lifting up of the nail plate and causes deformity resembling a gaping toecap separated from the sole at the seam. Finger nails are affected more commonly than the toe nails with pitting, cross ridging of the nail plate occasionally.[1] This entity was described initially by Sabouraud in 1931 as ′parakeratosa microbienna du about des doigts′.[2] Brocq reported similar subungual changes and described the entity as ′parakeratosis psoriasis formes.[3] While reporting a large series of these patients, Hjorth and Thompsen stressed that this entity is not adequately described in literature and is often overlooked with varying diagnoses such as psoriasis, eczema, acrodermatitis, atopic dermatitis etc.[4] As far as ascertained, this condition is not described in Indian literature and hence we felt it important to report this less familiar disease seen recently by us.

Case Report

A 7 - month -old female baby was brought to the Dermatology OPD with complaints of nail deformity and thickened scaly patches adjacent to the nail plates of left hand and right great toe. According to her mother, the problem started initially with scaling and gradual thickening of skin without any pustular eruption. It subsided after treatment with topical and systemic medication such as emollients, antibiotics, antimycotics etc, but only to recur after some time. No history of applying cosmetics such as nail polish at the affected sites could be obtained. The child had the habit of thumb sucking. The elder male sibling was normal and family history was non contributory.

Dermatological examination of the hands revealed eczematous scaly patches over the skin adjacent to the affected nails. Onychomadesis (proximal separation) with erythema and ragged cuticle over the left index finger nail and leuconychia and friability of the left middle finger and longitudinal ridge in the nail plate of left index finger was seen [Figure - 1]. The great toe nail plate of right foot showed thinning with lateral onycholysis and erythema of proximal nail fold [Figure - 2]. The nail bed and hyponychium of the affected nail were normal although the nail folds were erythematous and non-tender. The cuticles were ragged and absent at places. Subungual hyperkeratosis under the free margins of nails and ridging with fine pitting was seen at few sites. Potassium hydroxide examination of both the skin scrapings and nail clippings showed no evidence of fungal infection. Routine haematological and biochemical investigations were within normal limits and bacterial culture was sterile. Roentgenogram of hands and feet were normal.

Histopathology of the lesion revealed hyperkeratosis, parakeratosis, mild acanthosis, and papillomatosis with infiltrate around the dilated blood vessels.

The parents were counselled to stop thumb - sucking habit of the baby and advised to apply topical emollients only, which resulted in marked improvement of the condition within two weeks period.


The patient reported herein is diagnosed as a case of PP because of the characteristic eczematous scaly patches involving the skin adjacent to the nail plates. This is further supported by the fact that no infectious organism could be isolated from the site and the histology was consistent with the diagnosis of PP as described by Dulanto et al.[5]

The clinical features of PP were summarized by Hjorth and Thomsen in 91 cases and they stressed that this problem should be considered as a distinct clinical entity.[4] It presents commonly with scaly patches over the hands specially the thumb and index fingers, while on the feet the great toes are most commonly involved. Majority of the patients are young children with girls being affected more commonly than the boys.[4] Pustular eruption may be seen in some cases although such a history could not be obtained in our patient.

The course of PP is protracted and recurrences are the rule even after apparent and long peroids of cure. No specific therapy has been advocated for this condition. Stopping the thumb sucking habit and application of emollients improved the condition in our patient.

This entity needs to be differentiated from acrodermatitis of Hallopeau, pustular psoriasis, contact dermatitis, atopic dermatitis, tinea pedis, paronychia and dry fissured eczematoid dermatitis.b Pustules in parakeratosis pustulosa are rare and only seen in the initial stage, in contrast to pustular psoriasis or acrodermatitis of Hallopeau. The characteristic histopathology of psoriasis can urther confirm the diagnosis. Atopic dermatitis of the hands may cause nail deformity such as cross ridging due to the involvement of proximal nail fold. In addition, children with this disease usually have a flexural patch over the dorsum of histopathology reveals acute spongiotic dermatitis with eosinophils in dermal infiltrate. Dry fissured eczematoid lesions over the medial margin of the big toe and adjoining part of the feet may be seen in children with ichthyosis. This condition is usually bilateral and occurs in families. Tinea pedis shows maceration, scaling, occasional vesiculation, fissuring and the scrapings with KOH show fungal hyphae. Paronychia may be acute or chronic with signs of inflammation of the nail folds and etiological agents such as Staphylococcus aureus, Streptococcus pyogenes, Pseudomonas, Proteus species, anaerobes or Candida albicans may be isolated.

PP is rather a common but less known dermatological disorder in pediatric group with characteristic clinical features and must be considered as a separate entity. Atypical case can be recognized at a glance but anyone not acquainted with the clinical features may be tempted into a wrong diagnosis resulting in unnecessary medication. This is underscored by the absence of reported cases in Indian literature suggesting that this not so uncommon disease may have been wrongly typed in many instances.

Samman P D. In: The Nails in Disease, Edited by Heinemann W, London, 1986;88.
[Google Scholar]
Sabouraud R. Parakeratose microbienne du about des doigts'. Ann Derm. Syph Paris 1931;11 : 206
[Google Scholar]
Brocq L. In: Precis - Atlas de Dermatologic, Edited by Doyn G, Paris, 1921; 909.
[Google Scholar]
Hjorth N, Thomsen K. Parakeratosis pustulosa. Br J Dermatol 1967; 79:527-532.
[Google Scholar]
Dulanto F, Armijo - Moreno M, Comacho Matinez F. Histological findings in parakeratosis pustulosa. Acta Derm Venereal 1974; 54: 865-867.
[Google Scholar]
Camp RDR. In: Textbook of Dermatology, Edited by Champion RH, Burton JL, Burns DA, Breathnach SM, Blackwell Science, Oxford, 1998; 1- 11.
[Google Scholar]
Show Sections