Quiz
Mixed diagnoses – 10 cases (2 of 11)

Keratolysis exfoliativa, also known as exfoliative keratolysis or focal palmar peeling.

The main complaint is the development of spontaneous 'air blisters' on palmar skin, as layers of epidermis separate and peels. A thick layer of dead skin can build up creating a numb sensation. Wet skin shears more readily so sweating aggravates the peeling. Manual activities such as gripping may rip off the stratum corneum revealing a thin, tender and pink epidermis.
Keratolysis exfoliativa may also affect the feet. It can easily be confused with tinea pedis, in which scaly skin between the toes (athlete's foot) and nail abnormalities are common (onychomycosis). They may co-exist.

The most important diagnostic test is skin scrapings for mycology, as fungal infection could be responsible for a similar appearance. Consider fungal infection if there is asymmetry, involvement of the feet and blistering or peeling skin.

The dry, sensitive skin should be protected, lubricated and soothed with emollients. Hand creams should be thick, and a thin amount should be applied frequently. They are not permitted in certain jobs (e.g. car painters), when they should be used liberally after hours.
Topical steroids are not effective, because the condition is not due to an inflammatory dermatosis.
Severe keratolysis exfoliativa may require specialist consultation. Phototherapy may help.