Photo Quiz

Palmar Rash in a Young Child


Am Fam Physician. 2020 Nov 1;102(9):565-566.

A healthy 10-year-old patient presented with a pruritic rash that developed when the palms were exposed to water and resolved when the hands were dried. The symptoms began about two years earlier. The patient had no significant personal or family history or allergies. The patient was born outside of the United States and had not received conventional newborn screening.

Physical examination initially showed no abnormalities. After the hands were exposed to tap water for 30 seconds, multiple flat, white lesions developed on both palms (Figure 1). There was no erythema.




Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

  • A. Aquagenic palmoplantar keratoderma.

  • B. Bothnian palmoplantar keratoderma.

  • C. Aquagenic urticaria.

  • D. Pityriasis versicolor.

  • E. Primary hyperhidrosis.


The answer is A: aquagenic palmoplantar keratoderma, also known as aquagenic wrinkling of the palms. It can be acquired or genetic and causes thickened skin and white or translucent lesions on the palms after water exposure. These changes can be accompanied by pruritus or a burning sensation. The condition is most common on the palms but rarely involves plantar surfaces. Other areas are spared. Symptoms resolve soon after drying.1,2

The pathogenesis of aquagenic palmoplantar keratoderma is unclear; increased epidermal salt concentrations may play a role because of an association with cystic fibrosis, infantile marasmus, and nonsteroidal anti-inflammatory drug (NSAID) use.2 Aquagenic palmoplantar keratoderma occurs in up to 84%

Address correspondence to Eugene Kim, MD, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Yan AC, Aasi SZ, Alms WJ, et al. Aquagenic palmoplantar keratoderma. J Am Acad Dermatol. 2001;44(4):696–699....

2. Katz KA, Yan AC, Turner ML. Aquagenic wrinkling of the palms in patient with cystic fibrosis homozygous for the delta F508 CFTR mutation. Arch Dermatol. 2005;141(5):621–624.

3. Thomas JM, Durack A, Sterling A, et al. Aquagenic wrinkling of the palm. Lancet. 2017;389(10071):846.

4. Bolognia JL, et al., eds. Dermatology. 4th ed. Elsevier; 2018.

5. McConaghy J, Fosselman D. Hyperhidrosis: management options. Am Fam Physician. 2018;97(11):729–734. Accessed September 23, 2020.

6. Houle MC, Dhaybi RA, Benohanian A. Unilateral aquagenic keratoderma treated with botulinum toxin A. J Dermatol Case Rep. 2010;4(1):1–5.

7. Cao X, Yin J, Wang H, et al. Mutation in AQP5, encoding aquaporin 5, causes palmoplantar keratoderma Bothnia type. J Invest Dermatol. 2014;134(1):284–287.

8. Ely JW, Rosenfeld S, Seabury Stone M. Diagnosis and management of tinea infections. Am Fam Physician. 2014;90(10):702–710. Accessed September 23, 2020.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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