ACRAL DERMATITIS 
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I have a 9 year old girl who I have been seeing since the age of 4, at which
time she had the gradual onset of a progressively severe eruption  limited to
the palms and , more intermittently, the soles.  It consists of marked
erythema and "peeling scale" without  vesiculation, itching or burning, but
with some hyperhidrosis.  There is no personal history of atopic symptoms,
but the father does have seasonal sinusitis.   The eruption does fluctuate in
severity, but can flare at any time of year.  The  interesting part about
this is that it initially cleared whenever the child was given antibiotics by
the pediatrician, and it initially cleared when I gave her a trial of
Erythromycin, but that is no longer successful.  Topical steroids (both
fluorinated and not, from several groups) are of no benefit.  The child is in
otherwise good health.
    This resembles the sort of acral dermatitis I've seen in children with a
person of strong family history of atopy, but is more severe and oddly
resistant to treatment.  Does anyone have a similar case, and how would you
proceed?

John Uhlemann, M.D.
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Drysol will stop the sweating, if that is a major factor (hs,under occlusion
for 2 nights and then once weekly) 

Steven D. Emmet, M.D.
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This is a corynebacterila infection seen in patients with hyperhidrosis.
The old name used to be "keratosis exfoliativa" However, it often appears
as "scalds" which lok red and glazed rather than exfolliative. Part of
the response is immunologic the other is mechanical to the keratolysins
produced. Therefore treat with not only antibacterial rx but also topical
steroid. This is one of the few conditions where lotrisone may be
indicated. Benzoyl peroxide plus hydrocortisone also works. 

Haines Ely  MD
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Do you mean KERATOLYSIS EXFOLIATIVA? If so, it's a different entitiy, 
etiology unknown.

Jerry Litt
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Try this: a woods lamp exam of the affected skin may show a faint orange 
fluorescence. Why? Because corynebacteria produce porphyrins sometime. The 
stratum corneum will often show gram positive cocci in chains or filaments 
using Brown-Brenn stain/culture is difficult but can be done. 

Haines Ely
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This and smelly feet are great indications for Benzac Wash or
comparable benzoyl peroxide washes. But I also prescribe a p.o.
anti-corynebacterium for several weeks (thick skin).  

Diane Thaler
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I have been following your exchange with interest because I recently saw a
case of an 18 yo wf with a 6 -year history of recurrent, nearly continous
desquamation of the palms, accompanied by mild palmar erythema.  She is not
hyperhidrotic, and her feet do not peel.  She never develops bullae, and the
peeling occurs without pain or pruritus.  On examination it looks like 1-3 cm
sheets of stratum corneum are peeling off, and the whole palm has a
geographic pinkness.  She has had  recurrent superficial folliculitis and
nasal staph aureus.  After treatment of this with combined dicloxacillin and
rifampin the staph was eliminated; however, her hands were unchanged.  She is
otherwise in perfect health.  Can you give me any suggestions?  

Gene Sienkiewicz, M. D.
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