Management of Acquired Perforating Disorder
Overview and Clinical Recognition
Acquired perforating disorder is a dermatologic condition—not a gastrointestinal emergency—characterized by hyperkeratotic papules with central keratotic plugs, primarily affecting the lower extremities in patients with diabetes mellitus and/or chronic renal failure. 1
The condition presents with:
- Asymptomatic to intensely pruritic hyperkeratotic papules and nodules with central adherent plugs 1, 2
- Predominant distribution on lower extremities, though face and upper extremities can be affected 1, 3
- Strong association with diabetes mellitus and uremia/chronic renal failure 1, 3
- Koebner's phenomenon may be present in some cases 3
Diagnostic Confirmation
Skin biopsy is essential to confirm the diagnosis, demonstrating transepidermal elimination of collagen bundles 2, 3. All patients presenting with suspected acquired perforating disorder should undergo dermatological examination and histopathologic confirmation 3.
Treatment Algorithm
First-Line Topical Therapy
Initiate treatment with topical tretinoin combined with intralesional glucocorticoids for localized disease 1. This combination addresses both the keratinization abnormality and inflammatory component.
Additional topical options include:
Second-Line Phototherapy
If topical therapy fails, ultraviolet B (UVB) phototherapy is the next appropriate step 1, 2. One case report demonstrated excellent results with photodynamic therapy (PDT) in a patient with diabetes-associated acquired perforating disorder, though this represents novel off-label use 2.
PUVA (psoralen plus ultraviolet A) is an alternative phototherapy option 2.
Systemic Therapy for Refractory Cases
For widespread or treatment-resistant disease:
- Systemic retinoids 1, 2
- Systemic glucocorticoids 1
- Allopurinol (particularly in patients with hyperuricemia) 2
Procedural Options
Cryosurgery can be considered for individual lesions 2.
Management of Underlying Conditions
Stabilization of the underlying renal disease or diabetes is critical, as lesions may spontaneously resolve with improvement in metabolic control 3. The acquired perforating disorder represents a cutaneous manifestation of systemic disease, and addressing the root cause is paramount for long-term management 3.
In patients with chronic renal failure:
- Lesions can disappear spontaneously with stabilization of renal damage 3
- Monitor renal function and optimize dialysis if applicable 3
Critical Clinical Pitfalls
Do not confuse acquired perforating disorder with gastrointestinal perforation—the terminology is similar but these are entirely different conditions. The evidence provided regarding esophageal, colonic, and peptic ulcer perforations is not relevant to this dermatologic disorder 4, 5, 6, 7, 8.
Do not expect uniform treatment response—conventional treatment options show mixed results, and an individualized approach based on disease severity, distribution, and patient comorbidities is necessary 2.
Screen all patients for diabetes mellitus and renal dysfunction if not already diagnosed, as these are the primary associated conditions 1, 3.