A Case of Idiopathic Aquagenic Wrinkling of the Palms Successfully Treated with 20% Aluminum Chloride Hexahydrate

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A healthy 23-year-old male patient presented with itchy, whitish papular eruptions and plaques on both his palms for three months. This symptom only occurred when the patient placed his hands in water. Any other part of the body was not affected. To confirm the complaint of the patient, we asked him to place his hands in water. After 20 minutes, whitish papules and wrinkling appeared (Fig. 1). We received the patient’s consent form about publishing all photographic materials. He reported accompanying pruritus but denied any pain or burning sensation. There was no medical history or history of similar diseases, such as hand eczema or hyperhidrosis. Family history was negative for similar skin findings, hyperhidrosis, or cystic fibrosis. A 3-mm punch biopsy of an affected area was performed on his right palm. A histopathological review showed hyperkeratosis, dilated eccrine ostia, and vascular ectasia in the dermis, findings consistent with aquagenic wrinkling of palm (AWP) (Fig. 2). The initial treatment plan was to apply 20% aluminum chloride hexahydrate solution, and it proved sufficient for controlling the patient’s symptoms.

Fig. 1
Clinical photograph of the palms. (A) The 1st image (left) is 30 minutes before immersion, the 2nd image (center) is immediately after immersion, and the last image (right) is an enlarged version of the photo immediately after immersion. (B) Patient’ hands after immersion in water and topical 20% aluminum chloride hexahydrate. We received the patient’s consent form about publishing all photographic materials.

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Fig. 2
Histopathologic image of the lesion with H&E staining. (A) Hyperkeratosis (H&E, original magnification ×100). (B) Dermis shows dilated eccrine ostia (original magnification ×100).

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AWP is a rare condition that presents as wrinkling, whitish papules, and occasionally pruritus or pain in the palms upon immersion in water irrelevant of temperature1. Although AWP is generally idiopathic, genetic predisposition such as possession of cystic fibrosis transmembrane conductance regulator (CFTR) gene mutation may be a causal factor. While AWP is often diagnosed in Caucasians in association with cystic fibrosis, it is rarely found in Asia where CFTR gene mutation is uncommon2. So far, 4 cases of AWP have been reported in Korea, 2 males and 2 females in their 10 s and 20 s1, 2, 3. Skin biopsy was performed in all four cases, and all cases had histopathologic findings consistent with AWP. Of these four cases could be considered idiopathic. In our case, there were no findings suggestive of a medical history of cystic fibrosis. We therefore report the fifth case of idiopathic AWP in Korea.

Treatment is necessary for AWP because it can cause burning sensation, pain, pruritus, and palmar hyperhidrosis and thus reduce the patient’s quality of life. It has been reported that AWP occasionally resolves spontaneously, but the rate of spontaneous improvement has not been studied4. Furthermore, there is no consensus on the treatment of AWP. Various treatments have been attempted, including an occlusive barrier agent, 20% salicylate in petrolatum, and 20% aluminium chloride hexahydrate with some success4. There are also reports of botulinum injection achieving symptom improvement in refractory cases in which topical treatment was ineffective5. Of the 4 cases reported in Korea to date, 3 cases showed spontaneous improvement in symptoms, and 1 case showed improvement after treatment with topical 20% aluminum chloride hexahydrate1, 2, 3. Our patient did not improve naturally; hence, 20% aluminum chloride hexahydrate treatment was prescribed, and treatment outcome was favorable especially on pruritus. Our report reinforces the claim made in previous reports that topical 20% aluminum chloride hexahydrate can be used as a primary treatment for AWP that does not improve spontaneously. Further studies on the pathogenesis of idiopathic AWP are needed to refine the treatment strategy.