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Granular Parakeratosis Clinical Presentation

  • Author: Noah S Scheinfeld, JD, MD, FAAD; Chief Editor: Dirk M Elston, MD  more...
Updated: Jan 25, 2016


Patients typically present with a 1- to 12-month history of axillary or intertriginous rash. Sometimes, the rash is pruritic; sometimes, it is not.

In 2005, Scheinfeld and Mones[9] demonstrated that granular parakeratosis usually occurs in women in their axillae. Patients may report a history of applying antiperspirants and deodorants in the immediate period before the rash started. In 2003, Contreras et al[16] noted that a 70-year-old man reported a burning sensation in the area of granular parakeratosis.

In another report, mothers reported changing their granular parakeratosis infants' diapers 5-7 times daily. The mothers reported thoroughly washing the area with liquid soap after every diaper change. The mothers also always applied zinc oxide powders and/or pastes to the affected areas.[13] Similarly, a report in 2012 from Chile noted granular parakeratosis occurring after axillary irritation due to an antiperspirant and perhaps the use of a zinc oxide paste, which resolved with calcipotriol and then reoccurred 2 years later in the patient, 20 kg greater in weight, in the bilateral axilla, with no presence of irritation but with use of the same antiperspirant.[17]

In 2002, Rodriguez[11] reported 3 cases in obese women.

A number of incidental incidences of granular parakeratosis have been reported, including associations with dermatomyositis[18] and molluscum contagiosum.[19] The case of molluscum contagiosum involved a woman with trunk and extremity involvement after a 4-month history of a slowly progressive pruritic papular eruption.

Reddy et al noted a case of granular parakeratosis of 20 years’ duration.[20]

Granular parakeratosis can be unilateral.[21]

In children, it can be caused by topical products that impair the integrity of the skin and is thus perhaps more common in atopic skin.[22]

Granular parakeratosis is a rare cause of vulvar dermatosis, accounting for 0.5% of cases in a series of 183 cases.[23]



Granular parakeratosis manifests with intertriginous (ie, axillary, groin, intermammary or submammary region, and abdominal folds) bilateral or unilateral brown- or red-crusted patches, papules, or plaques. The primary lesions are keratotic brownish-red papules that can have a conical shape. They can coalesce into larger well-demarcated plaques with various degrees of maceration secondary to local occlusion. The rash can be confluent or reticulated. Even when patches or plaques are present, discrete papules can also be present. Granular parakeratosis can appear as slightly erythematous and lichenified plaques.

In children, granular parakeratosis has been reported to occur in the groin, on the lower back, on the buttocks, and on the flanks. Granular parakeratosis can also occur in the groin area in adults.[24] Granular parakeratosis has also been reported under the breast.[25]

Granular parakeratosis reportedly can occur as a solitary keratosis, which is termed granular parakeratotic acanthoma. This appears to be in the same family as acantholytic dyskeratotic acanthoma and epidermolytic acanthoma.[26]

Granular parakeratosis manifesting as facial keratotic papules has been reported.[27]

Genebriera et al[28] noted a papillomatous axillary rash due to granular parakeratosis.

Axillary red-brown bilateral plaques can be a manifestation of granular parakeratosis.[29]



The cause of granular parakeratosis is uncertain. Although controversial, the following have been implicated as etiologies for granular parakeratosis:

  • Use of topical solutions or creams, in particular antiperspirants and deodorants [30]
  • Presence of an occlusive environment
  • Increased sweating
  • Local irritants

Importantly, because cases have been reported when these factors were not been present, their importance is not clear.

In children, excessive washing has been noted in a series of 4 patients.[13]

Several authors have postulated that in granular parakeratosis, a basic defect exists in the processing of profilaggrin to filaggrin. Filaggrin maintains the keratohyaline granules in the stratum corneum during cornification.

Contributor Information and Disclosures

Noah S Scheinfeld, JD, MD, FAAD Assistant Clinical Professor, Department of Dermatology, Weil Cornell Medical College; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Assistant Attending Dermatologist, New York Presbyterian Hospital; Assistant Attending Dermatologist, Lenox Hill Hospital, North Shore-LIJ Health System; Private Practice

Noah S Scheinfeld, JD, MD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Abbvie<br/>Received income in an amount equal to or greater than $250 from: Optigenex<br/>Received salary from Optigenex for employment.

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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Granular parakeratosis in an 82-year-old man who developed this yellowish, scaly plaque at his left infra-axillary area after changing deodorants. Pathology confirmed granular parakeratosis. Courtesy of David F. Butler, MD.
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