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Arsenical Keratosis Clinical Presentation

  • Author: Chih-Shan Jason Chen, MD, PhD; Chief Editor: Dirk M Elston, MD  more...
Updated: Mar 30, 2016


Arsenical keratoses, skin hyperpigmentation, and several types of skin cancers, including basal cell carcinoma, squamous cell carcinoma, and Merkel cell carcinoma,[27] are skin lesions characteristic of long-term arsenic exposure. A long latency period (years to decades) occurs before the development of these cutaneous lesions. A study in West Bengal, India, has shown an average latency for skin lesions was 23 years from first exposure to arsenic.[18, 20] Chronic arsenic exposure usually does not cause symptoms, and the skin lesions are usually the first sign to manifest clinically.



Arsenical keratoses are usually multiple and typically occur at sites of friction and trauma, especially on the palms and the soles. Keratoses usually manifest as small, punctate, nontender, horny, hard, yellowish, often symmetric, corn-like papules. The diameter of the papule ranges from 0.2-1 cm.

A mild form of the arsenic keratoses may manifest as diffuse thickening or small (<2 mm) keratoses with sand paper–like texture. Moderate-sized lesions (2-5 mm) may coalesce into larger (>5 mm) verrucous papules or plaques. These lesions are most frequently seen on the thenar and lateral borders of the palms; the base and lateral aspect of the digits; the soles, heels, and toes of the feet, as demonstrated in the image below. Keratoses may also develop on the dorsum of the hands, the arms, and the legs.

Arsenical keratosis on the sole of a carpenter. Arsenical keratosis on the sole of a carpenter.

Another type of arsenical keratosis seen in most patients with arsenical cancers manifests as scaly erythematous or pigmented patches on unexposed body areas.

Mee lines (transverse white bands) on the fingernails are seen in acute and chronic arsenic toxicity.

Other skin manifestations of chronic arsenic toxicity include hyperpigmented and hypopigmented macules on the torso and limbs. The pigmented lesions often present as finely freckled or raindroplike macules distributed bilaterally symmetrically. Diffuse hyperpigmented patches in the intertriginous, genital, and acral areas may be an early sign of chronic arsenic toxicity.

Contributor Information and Disclosures

Chih-Shan Jason Chen, MD, PhD Associate Attending, Dermatology Service, Memorial Sloan-Kettering Cancer Center; Director, Dermatologic Surgery and Mohs Micrographic Surgery Unit, MSK Skin Cancer Center; Chief, Dermatologic Surgery, Northport Veterans Affairs Medical Center

Chih-Shan Jason Chen, MD, PhD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, Association of Professors of Dermatology, American Society for Dermatologic Surgery, Society for Investigative Dermatology

Disclosure: Nothing to disclose.


Daniel Mark Siegel, MD, MS Clinical Professor of Dermatology, Department of Dermatology, State University of New York Downstate Medical Center

Daniel Mark Siegel, MD, MS is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Association for Physician Leadership, American Society for Dermatologic Surgery, American Society for MOHS Surgery, International Society for Dermatologic Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steven R Feldman, MD, PhD Professor, Departments of Dermatology, Pathology and Public Health Sciences, and Molecular Medicine and Translational Science, Wake Forest Baptist Health; Director, Center for Dermatology Research, Director of Industry Relations, Department of Dermatology, Wake Forest University School of Medicine

Steven R Feldman, MD, PhD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, North Carolina Medical Society, Society for Investigative Dermatology

Disclosure: Received honoraria from Amgen for consulting; Received honoraria from Abbvie for consulting; Received honoraria from Galderma for speaking and teaching; Received consulting fee from Lilly for consulting; Received ownership interest from for management position; Received ownership interest from Causa Reseasrch for management position; Received grant/research funds from Janssen for consulting; Received honoraria from Pfizer for speaking and teaching; Received consulting fee from No.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Arash Taheri, MD Research Fellow, Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine

Disclosure: Nothing to disclose.

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Arsenical keratosis on the sole of a carpenter.
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