Sir,

A 21-year-old woman, with no relevant personal or family medical-surgical history, not taking any medication and in very good general health, presented with lesions on both hands lasting for the past six months, which appeared within minutes of contact with water.

On physical examination, a dermatosis was noted on the palms, more prominent on the right hand, consisting of whitish patches (Figs. 1a and 1b). Upon immersing her hands in water, the patient observed that the lesions became more pronounced, especially on the right palm (Fig. 2). The rest of the physical examination was within normal limits.

	Figure 1: a and b Witish patches on the palms.
	Figure 2: Upon immersing her hands in water, the lesions became more pronounced.

Based on these findings, a diagnosis of aquagenic keratoderma was made, and treatment with 2% aluminum chloride was prescribed. Unfortunately, we received no further follow-up from the patient.

Aquagenic keratoderma is described as a benign dermatosis characterized by whitish, translucent papules with a macerated appearance. This is a rare condition that primarily affects the palms, while its presence on the soles or dorsal aspects of the fingers is less common. The lesions appear within minutes of water contact and usually resolve spontaneously once the skin dries. It is important to note that this condition tends to occur in young women, and symptoms may include pain, burning, or itching [1].

On the other hand, the etiological cause remains unclear; however, it is believed that there is an alteration involving aquaporins, overactivity of eccrine gland function, neuronal dysfunction, and increased water absorption due to an abnormal osmotic gradient. It is associated with [1,2]:

Regarding clinical manifestations, papules may coalesce into plaques with an edematous and macerated appearance. These lesions typically appear around three minutes after immersion in water and resolve with drying after 30–60 minutes. Pruritus and intense palmar pain may also occur. The condition is usually bilateral but may occasionally present unilaterally. Although frequently associated with adolescents, it may also affect children and young adults [1,3].

Diagnosis is clinical and includes a test known as the “hand-in-the-bucket” test, in which the affected extremity is immersed in room-temperature water for five minutes to provoke lesion development. Histopathological evaluation may reveal [1]:

In terms of therapeutic management, the severity of the clinical presentation should be considered. In mild cases, topical 20% aluminum chloride is used to reduce sweating, or 20% salicylate in petrolatum may be applied, often leading to symptomatic remission. In moderate or severe presentations, oral oxybutynin (5 mg/day) is used due to its effectiveness and tolerability, as it acts on sweat glands to reduce perspiration and improve symptoms [1,2]. When symptoms such as pain, burning, or scaling are present, treatment options include [2]:

In conclusion, aquagenic keratoderma is considered a benign condition with a clinical diagnosis based on water-induced lesions. This dermatosis may affect the patient’s quality of life and, therefore, requires individualized management depending on the severity of symptoms, guiding appropriate topical or systemic treatment. Early identification and regular follow-up are key to achieving effective symptom control, therapeutic response, and clinical evolution [1,3].

REFERENCES

1.López-Carrera YI, Arias-Lima A. Aquagenic keratoderma successfully treated with oral oxybutynin and topical tacrolimus. Dermatol Rev Mex. 2024;68:806-11.

2.Carbonell Pradas M, Grimalt Santacana R. Aquagenic keratoderma:Treatment update. Actas Dermosifiliogr. 2022;113:254-60.

3.Lindsay J, Incristi A, Liu A, Chong C. Connecting the past and present:An updated literature review of aquagenic syringeal acrokeratoderma. Cureus. 2024;16:76002