Aquagenic wrinkling of the palms

Author: Dr Mathew Ludgate, Dermatology Registrar, Greenlane Hospital, Auckland, New Zealand, 2005. Updated by Dr Ebtisam Elghblawi, Tripoli, Libya. March 2017.


Aquagenic wrinkling of the palms is a rare condition that often occurs in patients with cystic fibrosis. It may also occur in carriers of the cystic fibrosis gene. A similar disorder may arise in the setting of marasmas and nephrotic syndrome.

Aquagenic wrinkling of the palms has previously been called transient reactive papulotranslucent acrokeratoderma, aquagenic palmoplantar keratoderma, aquagenic acrokeratoderma, aquagenic syringeal acrokeratoderma, and "the hand in the bucket" sign.

What is the cause of aquagenic wrinkling of the palms?

The cause of aquagenic wrinkling of the palms is unknown but relates to sweating. It may be caused by a salt imbalance in the skin cells, which results in increased water retention within these cells and increased transepidermal water loss.

Some cases have been related to medications, such as aspirin, non-steroidal anti-inflammatories and some antibiotics, and is possibly due to drug-induced dysregulation of skin aquaporin, a protein that is responsible for water transport across the cell membrane.

What are the clinical features of aquagenic wrinkling of the palms?

Aquagenic wrinkling of the palms resembles the exaggerated transient wrinkling of the palms that is caused by spending a prolonged period in a bath or pool.

It is characterised by the appearance or worsening of a palmar eruption following brief exposure to water (about 3 minutes). It takes longer to appear in mutation carriers (about 7 minutes) than in patients with cystic fibrosis (2–3 minutes). Wrinkling typically disappears within 10–60 minutes after drying, however, the eruption can persist for longer periods.

The palmar eruption is comprised of small, white or translucent papules that coalesce into plaques. The feet are unaffected. Patients may report an uncomfortable tight, burning or itchy sensation during an eruption.  

How is the diagnosis of aquagenic wrinkling of the palms made?

The diagnosis of aquagenic wrinkling of the palms is usually made on the basis of the clinical history and physical findings. The palmar eruption can usually be readily demonstrated by exposing the hands to water.

A biopsy may be taken to confirm the diagnosis.

What is the treatment for aquagenic wrinkling of the palms?

Some patients with aquagenic wrinkling of the palms have had relief with an antiperspirant such as 20% aluminium chloride hexahydrate applied to the palms at night. Other treatments include:

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