Transient Reactive Papulotranslucent Acrokeratoderma in a 50-Year-Old Woman

A 50-year-old woman who presented with intermittent symmetric edema and wrinkling of the palms after soaking in water was found to have transient reactive papulotranslucent acrokeratoderma (TRPA). This is the oldest patient ever reported to have this condition. The patient was advised to avoid water exposure as much as possible and to wear gloves. Topical treatment with 5% salicylic acid in Vaseline? also provided some relief.

TRPA presents with translucent, white, confluent papules that become evident on the palms after 3–5 minutes’ exposure to water (the so-called ‘hand-in-the-bucket’ sign) and resolve within a short time after drying. It is a rare disorder with fewer than 40 cases having been reported in the world literature. The disease is seen mostly in female patients, with ages ranging from 6 to 44 years prior to our case in a 50-year-old woman. The most common histologic findings are hyperkeratosis and dilated eccrine ostia. The etiopathogenesis of the disease remains unknown but a transitory structural or functional alteration of components of the stratum corneum or aberration of the sweat duct have been considered. TRPA has been reported in patients with cystic fibrosis and more recently, in patients taking selective cyclo-oxygenase-2 inhibitors. Therefore, the pathogenesis of the condition appears to be related to increased water absorption as a result of an increased epidermal sodium level. Treatment with barrier creams such as hydrophilic petrolatum, glycerin emollients, 5–20% salicylic acid in Vaseline®, 10% urea cream, and 12% ammonium lactate cream have been reported. Cases with associated hyperhidrosis respond well to aluminum chloride-containing products.