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Current Concepts In Diagnosing And Treating Keratoderma Climactericum

Haxthausen disease, also known as keratoderma climactericum, was first described in 1934 by the Danish dermatologist Holger Haxthausen, MD. He noted the condition was characterized by the development of hyperkeratotic patches occurring primarily in pressure areas of menopausal women.1 In addition to the palmoplantar hyperkeratoses, Haxthausen drew connections with hypertension, obesity and arthritis of the joints. The later three have been coined the “post-climacteric triad,” which is now frequently associated with the disease.1

Keratoderma climactericum is a type of acquired palmoplantar keratoderma.2 Lesions of keratoderma climactericum begin as round or oval-shaped hyperkeratotic patches that initially develop on the palms and soles, especially around the heels.2 The hyperkeratotic lesions on the palms first begin centrally before slowly growing to involve the entire palm.3 As keratoderma climactericum progresses, the lesions fissure, becoming erythematous and painful. In severe cases, patients seek treatment because the painful fissured hyperkeratoses cause difficulty walking.2 Fortunately for most women, these hyperkeratoses are non-painful and patients instead seek treatment due to the unsightly appearance of the palms and soles.3

Upon physical examination, it is especially important to note the extension of hyperkeratosis beyond the palmar or plantar skin. Keratoderma climactericum will not demonstrate contiguous extension beyond the palmar or plantar skin. Appreciation of this characteristic should cue the practitioner to rule out other causes of palmoplantar keratodermas, such as contact dermatitis, psoriasis or tinea pedis.2

Although it has been associated with menopause and hormonal dysregulation, the exact pathophysiology of keratoderma climactericum remains largely unknown.2 Several studies have demonstrated decreased collagen content in the skin in relation to the menopausal and chronological age in women.4,5 This decrease in collagen content in theory contributes to keratoderma climactericum.2

The diagnosis of keratoderma climactericum is typically based on clinical findings, including the age and gender of the patient, the presence of obesity and hypertension, the initial involvement of the feet, and the presence of erythema and fissuring.2 A skin biopsy may confirm the diagnosis or rule out other causes. Histopathologic features of keratoderma climactericum include compact orthokeratotic hyperkeratosis and hypergranulosis of the epidermis although these findings are non-specific.2,6

Treatment of keratoderma climactericum should begin with addressing any fissures or hyperkeratoses. Using a dremel with an appropriate skin sanding disc, one can perform gentle debridement of diffuse hyperkeratoses. Painful and/or deep fissures may have reapproximation using Dermabond (Ethicon) or other skin adhesives. One can apply topical keratolytics, such as 40% urea cream or 5% salicylic acid cream, combined with topical steroids, such as triamcinolone 0.5% cream, twice a day for two weeks.7 These help with reducing the hyperkeratoses and decreasing inflammation. If no improvement is visible, one may attempt a short one-to two-week week trial of topical estradiol 0.05% cream in combination with keratolytics.7 Finally, in severe or refractory cases, a course of an oral retinoid, such as acitretin (Soriatane, Stiefel Laboratories), may be warranted.2

References

1. Bishop PMF, Barber HW. Keratoderma climactericum (Haxthausen) treated with Oestrone. Proc R Soc Med. 1937; 30(6):738–40.

2. Patel S, Zirwas M, English JC III. Acquired palmoplantar keratoderma. Am J Clin Dermatol. 2007; 8(1):1–11.

3. Enta T. Dermacase. Keratoderma climactericum. Can Fam Phys. 1996; 42:629, 631.

4. Brincat M, Moniz CJ, Studd JW, et al. Long‐term effects of the menopause and sex hormones on skin thickness. Br J Obstet Gynaecol. 1985; 92(3):256–259.

5. Shuster S, Martin AM, Black M, McVitie EVA. The influence of age and sex on skin thickness, skin collagen and density. Br J Dermatol. 1975; 93(6):639–643.

6. Sehgal VN, Aggarwal A, Syed NH, et al. Palmoplantar keratoderma as a variant of lichen planus. Skinmed. 2016; 14(1):56–60.

7. Nair PA. Dermatosis associated with menopause. J Mid-Life Health. 2014; 5(4):168–75.

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