26726 A case of transient reactive papulotranslucent acrokeratoderma: Exploring the role of epidermal barrier dysfunction during the COVID-19 pandemic

Abstract

Transient reactive papulotranslucent acrokeratoderma (TRPA) is characterized by an acquired transient induction of edematous translucent papules or ‘wrinkling’ on the palmar and/or plantar surfaces that occurs after a few minutes of water immersion and disappears with hand-drying. While this condition is likely more common than initially thought, the etiopathogenesis and the optimal treatment have yet to be elucidated. We present a case of TRPA appearing in a 21-year-old atopic female during a period of increased hand-washing amidst the COVID-19 pandemic. Diagnosis was made on a clinical basis, including review of patient photos and a water immersion test, which revealed characteristic edematous papules on the bilateral palmar surfaces that disappeared with hand-drying. The patient was initially treated with 20% ammonium lactate with significant, but not complete improvement after two weeks of treatment. A punch biopsy of the palmar surface obtained at this time was inconclusive. Topical calcipotriene was added to the patient’s treatment regimen with complete resolution of the dermatosis after 2 weeks of use. The authors feel TRPA could become a more frequent dermatologic office complaint given its proposed relationship with epidermal barrier dysfunction. We postulate that increases in hand washing and sanitizing during the pandemic may contribute to disease incidence in susceptible individuals. We also propose atopic dermatitis, a dermatosis in which epidermal barrier dysfunction plays a prominent role, could represent a factor for increased risk. In addition, atopic patients who develop TRPA may respond better to treatment with agents that target the epidermal barrier.