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Aquagenic wrinkling of the palms

Author: Dr Mathew Ludgate, Dermatology Registrar, Greenlane Hospital, Auckland, New Zealand, 2005. Updated by Dr Ebtisam Elghblawi, Tripoli, Libya. March 2017.


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Introduction

Aquagenic wrinkling of the palms is a rare condition that often occurs in patients with cystic fibrosis. It may also occur in carriers of the cystic fibrosis gene. A similar disorder may arise in the setting of marasmas and nephrotic syndrome.

Aquagenic wrinkling of the palms has previously been called transient reactive papulotranslucent acrokeratoderma, aquagenic palmoplantar keratoderma, aquagenic acrokeratoderma, aquagenic syringeal acrokeratoderma, and "the hand in the bucket" sign. It is an exaggeration of the normal finger wrinkling that occurs when fingers are soaked in water for a prolonged period.

Aquagenic wrinkling of the palms

What is the cause of aquagenic wrinkling of the palms?

The cause of aquagenic wrinkling of the palms is unknown but relates to sweating. It may be caused by a salt imbalance in the skin cells, which results in increased water retention within these cells and increased transepidermal water loss.

Some cases have been related to medications, such as aspirin, non-steroidal anti-inflammatories and some antibiotics, and is possibly due to drug-induced dysregulation of skin aquaporin, a protein that is responsible for water transport across the cell membrane.

What are the clinical features of aquagenic wrinkling of the palms?

Aquagenic wrinkling of the palms resembles the exaggerated transient wrinkling of the palms that is caused by spending a prolonged period in a bath or pool.

It is characterised by the appearance or worsening of a palmar eruption following brief exposure to water (about 3 minutes). It takes longer to appear in mutation carriers (about 7 minutes) than in patients with cystic fibrosis (2–3 minutes). Wrinkling typically disappears within 10–60 minutes after drying, however, the eruption can persist for longer periods.

The palmar eruption is comprised of small, white or translucent papules that coalesce into plaques. The feet are unaffected. Patients may report an uncomfortable tight, burning or itchy sensation during an eruption.  

How is the diagnosis of aquagenic wrinkling of the palms made?

The diagnosis of aquagenic wrinkling of the palms is usually made on the basis of the clinical history and physical findings. The palmar eruption can usually be readily demonstrated by exposing the hands to water.

A biopsy may be taken to confirm the diagnosis.

What is the treatment for aquagenic wrinkling of the palms?

Some patients with aquagenic wrinkling of the palms have had relief with an antiperspirant such as 20% aluminium chloride hexahydrate applied to the palms at night. Other treatments include:

 

References

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  • Tolland JP, Boyle J, Hall V, McKenna KE, Elborn JS. Aquagenic wrinkling of the palms in an adult cystic fibrosis population. Dermatology. 2010; 221(4): 326–30. doi: 10.1159/000319754. Epub 2010 Sep 25. PubMed PMID: 20881360.
  • Gild R, Clay CD, Morey S. Aquagenic wrinkling of the palms in cystic fibrosis and the cystic fibrosis carrier state: a case–control study. Br J Dermatol. 2010 Nov; 163 (5): 1082–4. doi: 10.1111/j.1365-2133.2010.09914.x. PubMed PMID: 20560957.
  • Garçon-Michel N, Roguedas-Contios AM, Rault G, Le Bihan J, Ramel S, Revert K, Dirou A, Misery L. Frequency of aquagenic palmoplantar keratoderma in cystic fibrosis: a new sign of cystic fibrosis? Br J Dermatol. 2010 Jul; 163(1): 162–6. doi: 10.1111/j.1365-2133.2010.09764.x. Epub 2010 Mar 10. PubMed PMID: 20302572.
  • Berk DR, Ciliberto HM, Sweet SC, Ferkol TW, Bayliss SJ. Aquagenic wrinkling of the palms in cystic fibrosis: comparison with controls and genotype-phenotype correlations. Arch Dermatol. 2009 Nov; 145(11): 1296–9. doi: 10.1001/archdermatol.2009.260. PubMed PMID: 19917960.
  • Kabashima K, Shimauchi T, Kobayashi M, Fukamachi S, Kawakami C, Ogata M, Kabashima R, Mori T, Ota T, Fukushima S, Hara-Chikuma M, Tokura Y. Aberrant aquaporin 5 expression in the sweat gland in aquagenic wrinkling of the palms. J Am Acad Dermatol. 2008 Aug; 59(2 Suppl 1): S28–32. doi: 10.1016/j.jaad.2008.04.023. PubMed PMID: 18625374.
  • Glatz M, Muellegger RR. Drug-associated aquagenic wrinkling of the palms in an atopic male patient. BMJ Case Rep. 2014 Jun 5; 2014. pii: bcr2014203929. doi: 10.1136/bcr-2014-203929. Journal PMC4054404
  • Grasemann H, Ratjen F, Solomon M. Aquagenic wrinkling of the palms in a patient with cystic fibrosis. N Engl J Med. 2013 Dec 12; 369(24): 2362–3. doi: 10.1056/NEJMc1308349. Journal
  • Kim DW, Woo SH, Kim JI, Oh YJ, Yun SK, Kim HU, Park J. Idiopathic aquagenic wrinkling of the palms in Korean patients. Ann Dermatol. 2015 Dec; 27(6): 776–7. doi: 10.5021/ad.2015.27.6.776. Epub 2015 Dec 7. PubMed
  • Gündüz Ö, Özsaraç KÇ, Ercin ME. Aquagenic palmar wrinkling induced by combined use of salazopyrin and indomethacin. Case reports in dermatology. 2013; 5(1): 21–26. doi: 10.1159/000346744. PMCID: PMC3573775 PubMed
  • Marinello E, Dan G, Linder DM, Fortina AB, Peserico A, Piaserico S. Symmetrical, hypopigmented papules and plaques on the palms induced by contact with water: a quiz — aquagenic wrinkling of the palms. Acta Derm Venereol. 2016 May; 96(4): 575–6. PMID: 26576727. doi: 10.2340/00015555-2293 Journal
  • Katz M, Ramot Y. Aquagenic wrinkling of the palms. CMAJ : Canadian Medical Association Journal. 2015; 187(18): E515. doi:10.1503/cmaj.150074. PMID: 26283724 Journal
  • Uyar B. Aquagenic syringeal acrokeratoderma. Indian Journal of Dermatology. 2014; 59(6): 632. doi: 10.4103/0019-5154.143578. PubMed
  • Weibel L, Spinas R. Images in clinical medicine. Aquagenic wrinkling of palms in cystic fibrosis. N Engl J Med. 2012 May 24; 366(21): e32. doi: 10.1056/NEJMicm1103833. PubMed

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