How should a 60-year-old patient with a two-month history of diffuse palmoplantar keratoderma and painful fissures be investigated and managed, what is the appropriate treatment duration, and is the condition curable?

Management of Diffuse Palmoplantar Keratoderma with Fissures in a 60-Year-Old Patient

For a 60-year-old patient with 2 months of diffuse palmoplantar keratoderma and fissures, initiate clobetasol propionate 0.05% cream twice daily combined with urea 10-40% cream for keratolysis, and if no response after 4 weeks, escalate to oral acitretin 25 mg daily, which demonstrates significant improvement within 2 months. 1

Initial Investigations Required

Before initiating treatment, obtain the following workup to distinguish acquired from hereditary causes and identify any underlying systemic disease:

• Complete blood count, liver function tests, and lipid panel to establish baseline before potential systemic therapy 2
• Medication history review to exclude drug-induced palmoplantar keratoderma, particularly BRAF inhibitors (73.7% of drug-induced cases), MEK inhibitors, tyrosine kinase inhibitors, or chemotherapy agents 3
• Family history assessment to differentiate hereditary forms (which may require genetic testing) from acquired forms 4
• Exclude systemic associations including thyroid disease, malignancy, and inflammatory conditions that can cause acquired palmoplantar keratoderma 4

The 2-month duration suggests this is likely an acquired rather than hereditary form, as hereditary palmoplantar keratoderma typically presents earlier in life 5, 4

Treatment Algorithm by Severity

Mild to Moderate Disease (First 4 Weeks)

Start with topical therapy:

• Clobetasol propionate 0.05% cream or ointment twice daily to affected areas for the inflammatory component 1
• Urea cream ≥10% once or twice daily for keratolysis, increasing concentration up to 40% for severe localized thickening 1
• "Soak and smear" technique: soak hands and feet in plain water for 20 minutes, then apply moisturizer to damp skin to enhance penetration 1
• Physical debridement with emery board or nail file after soaking in warm water for mild hyperkeratosis 1

Urea demonstrates superior safety compared to salicylic acid and lactic acid, with no reported toxicity cases 1. The British Association of Dermatologists recommends this as first-line keratolytic therapy 1.

Moderate Disease Not Responding After 4 Weeks

Escalate topical therapy and add phototherapy:

• Continue high-potency topical corticosteroids and increase urea to 40% 1
• Add tazarotene 0.05-0.1% as first-line topical retinoid to reduce scaling and skin thickening 1
• Refer for topical PUVA therapy 2-3 sessions weekly, which achieves clearance in 50-67% of hyperkeratotic conditions 1
• Professional podiatric debridement when lesions are too painful or thick for self-management 1

Severe Disease or Failure of Topical Therapy

Initiate systemic therapy:

• Oral acitretin 25 mg daily is the most effective treatment for severe palmoplantar keratoderma with marked hyperkeratosis and fissures 1
• Expect substantial improvement within 2 months in both scaling, thickness, and fissuring 2, 1
• Monitor lipids and liver function due to potential elevations in triglycerides and cholesterol 2
• Dose reduction to 25 mg on alternate days may be possible after achieving control 2

The British Association of Dermatologists recommends acitretin as the most supported systemic option based on clinical evidence, though data comes from small case series 1. The American Academy of Dermatology guidelines demonstrate significant improvement in palmoplantar psoriasis with similar presentation within 2 months of acitretin therapy 2.

Treatment Duration

• Topical therapy requires several months for adequate clearing and maintenance of control 2
• Systemic acitretin shows substantial improvement within 2 months, but long-term maintenance therapy is typically required 2, 1
• Complete resolution with drug discontinuation in drug-induced cases occurs within a mean of 2.4 months (range: 2 weeks to 6 months) after stopping the causative agent 3

Is This Condition Curable?

This condition is generally NOT curable but is manageable:

• Hereditary forms are not curable and require lifelong symptomatic management 5, 6
• Acquired forms may resolve if an underlying cause (medication, systemic disease) is identified and corrected 3, 4
• Treatment options are restricted to symptomatic therapy; no cure exists for most forms 6
• Recurrence is common when treatments are discontinued, particularly with topical therapies alone 7, 6

The persistent use of medications frequently exhausts patients because the problem returns as soon as local applications are discontinued 7. Surgical excision has limited success, significant morbidity, and recurrence is common 6.

Critical Pitfalls to Avoid

• Never dismiss the quality of life impact from palmoplantar involvement—it is disproportionate to the small body surface area affected and justifies systemic therapy when topical treatments fail 2, 1
• Avoid overdebridement of hyperkeratotic lesions, as this makes underlying skin susceptible to increased blistering and tenderness 1
• Do not use salicylic acid or lactic acid if considering this for any reason, as they have higher toxicity risk compared to urea 1
• Screen for drug-induced causes before assuming this is idiopathic, as discontinuation of the causative medication leads to complete resolution in 50% of drug-induced cases 3
• Recognize that long-term PUVA increases skin cancer risk, so minimize the number of treatments when possible 2