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Multiple Minute Digitate Hyperkeratoses Workup

  • Author: Annie Wester, MS; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Oct 30, 2015
 

Laboratory Studies

The extent of examination and laboratory tests ordered in cases of minute digitate hyperkeratosis (spiny hyperkeratosis) should be guided by the history and physical examination findings. Some physicians recommend a CBC count, a comprehensive metabolic panel, and age-appropriate cancer screening for sporadic cases. Many reported associations exist, including chronic lymphocytic leukemia. However, none is proven to be beyond coincidental co-occurrence.[9]

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Imaging Studies

Age- and symptom-appropriate appropriate examinations should be ordered in the workup of minute digitate hyperkeratosis (spiny hyperkeratosis). The finding of multiple minute digitate hyperkeratosis alone may be incidental. In current practice, multiple minute digitate hyperkeratosis findings do not indicate the need for specific imaging tests.

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Other Tests

No other tests are needed for minute digitate hyperkeratosis (spiny hyperkeratosis).

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Procedures

Skin punch or shave biopsy may be needed to diagnose and differentiate minute digitate hyperkeratosis (spiny hyperkeratosis) from other similar-appearing punctate keratoses.

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Histologic Findings

Histopathology reveals compact orthokeratotic hyperkeratotic projections that may be perifollicular but overall should be a non-follicular process. This focal column of hyperkeratosis resembles a cornoid lamella.[10] Of note, some reports in the literature list parakeratosis as a finding, rather then orthokeratosis.

The granular layer appears intact and no changes are noted in the epidermis other than the hyperkeratosis. Some reports have described granular layer changes that include increased or decreased granulation, but these may be a distinct histoclinical entity. The dermis shows no major alterations.

A clinicohistologic-based classification has been proposed, although it is not yet universally established.[11] It is divided as follows:

  • Type I minute digitate hyperkeratosis (spiny hyperkeratosis) (parakeratotic columns): It is referred to as type Ia if it is palmoplantar and type Ib if it is disseminated. Rather than random number assignment, it may be more clear and simple to name it using its description. For example, Ia could best be called palmoplantar parakeratotic columnar.
  • Type II minute digitate hyperkeratosis (spiny hyperkeratosis) (orthokeratotic columns): It is referred to as type IIa if it is palmoplantar and type IIb if it is disseminated.
  • Type III minute digitate hyperkeratosis (spiny hyperkeratosis) (porokeratotic eccrine ostial and dermal duct nevus): This type is clinically linear in presentation and histologically shows parakeratosis associated with sweat duct structures.

This proposed classification brings to light the lack of clarity in the literature on this disease process. Types I-III may be related, or they may be different entities that have somewhat similar appearances. At this point, the literature does not yet favor the use of the criteria proposed above. In fact, new criteria and algorithms are regularly proposed[8]

Other proposed divisions include the following[12] :

  • Disseminated orthokeratotic
  • Disseminated parakeratotic
  • Palmoplantar orthokeratotic
  • Palmoplantar parakeratotic

Immunoglobulin G deposits have been noted in multiple minute digitate hyperkeratosis associated with paraproteinemia, but these lesions do not typically occur on the extremities.[13] These lesions may also be a different entity known as spicules, which is seen in myeloma patients.

The finding of hyperkeratosis has also been described in 2 manners, as either spiked/digitiform or as columns. The authors proposed a potential difference in etiology and pathologic trigger based on the difference in histology. The most probable explanation is that the spiked/digitiform type is a different process altogether and not actual multiple minute digitate hyperkeratosis.

Ultrastructural studies show smaller-than-normal keratohyalin granules. Lamellar (Odland) bodies are normal.[14] Desmosome and basement membrane density is not known to be altered but has not been studied in detail.

Multiple minute digitate hyperkeratosis. Published Multiple minute digitate hyperkeratosis. Published with permission granted from and with copyright retained by the American Medical Association. Clark JL, Davis G, Bennett DD. Arch Dermatol. 2008 Aug;144(8):1051-6.
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Staging

Staging may be needed if an associated pathology is noted, as indicated in Pathophysiology.

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Contributor Information and Disclosures
Author

Annie Wester, MS Loyola University, Chicago Stritch School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Rashid M Rashid, MD, PhD Director, Mosaic Clinic Hair Transplant Center of Houston

Rashid M Rashid, MD, PhD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Texas Dermatological Society, International Society of Hair Restoration Surgery, Council for Nail Disorders, Houston Dermatological Society

Disclosure: Nothing to disclose.

James W Swan, MD Associate Professor of Medicine, Division of Dermatology, Loyola University Stritch School of Medicine; Attending Physician, Loyola University Medical Center; Attending Physician, Section of Dermatology, Hines Veterans Affairs Medical Center

James W Swan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, Chicago Dermatological Society

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

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

Timothy McCalmont, MD Director, UCSF Dermatopathology Service, Professor of Clinical Pathology and Dermatology, Departments of Pathology and Dermatology, University of California at San Francisco; Editor-in-Chief, Journal of Cutaneous Pathology

Timothy McCalmont, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society of Dermatopathology, California Medical Association, College of American Pathologists, United States and Canadian Academy of Pathology

Disclosure: Received consulting fee from Apsara for independent contractor.

References
  1. Caccetta TP, Dessauvagie B, McCallum D, Kumarasinghe SP. Multiple minute digitate hyperkeratosis: a proposed algorithm for the digitate keratoses. J Am Acad Dermatol. 2012 Jul. 67 (1):e49-55. [Medline].

  2. Weibel L, Berger M, Regenass S, Kamarashev J, Hafner J, French LE. Follicular spicules of the nose and ears--quiz case. Arch Dermatol. 2009 Apr. 145(4):479-84. [Medline].

  3. Benoldi D, Zucchi A, Allegra F. Multiple minute digitate hyperkeratoses. Clin Exp Dermatol. 1993 May. 18(3):261-2. [Medline].

  4. Mueller KK, Yeager JK. Clinical considerations in digitate dermatosis. Int J Dermatol. 1997 Oct. 36(10):767-8. [Medline].

  5. Miller A, Aires D, Fraga G. Multiple minute digitate hyperkeratoses: a case report. Dermatol Online J. 2011. 17(5):1. [Medline].

  6. Ramselaar C, Toonstra J. Multiple minute digitate hyperkeratoses report of two cases with an updated review and proposal for a new classification. Eur J Dermatol. 1999 Sep. 9(6):460-5. [Medline].

  7. Holzer AM, Hughey LC. Trichodysplasia of immunosuppression treated with oral valganciclovir. J Am Acad Dermatol. 2009 Jan. 60(1):169-72. [Medline].

  8. Caccetta TP, Dessauvagie B, McCallum D, Kumarasinghe SP. Multiple minute digitate hyperkeratosis: A proposed algorithm for the digitate keratoses. J Am Acad Dermatol. 2010 Nov 1. [Medline].

  9. Bordel-Gomez M. Palmoplantar spiny keratoderma associated with chronic lymphoid leukaemia. J Eur Acad Dermatol Venereol. 2008 Dec. 22(12):1507-8. [Medline].

  10. Takagawa S, Satoh T, Yokozeki H, Nishioka K. Multiple minute digitate hyperkeratoses. Br J Dermatol. 2000 May. 142(5):1044-6. [Medline].

  11. Zarour H, Grob JJ, Andrac L, Bonerandi JJ. Palmoplantar orthokeratotic filiform hyperkeratosis in a patient with associated Darier's disease. Classification of filiform hyperkeratosis. Dermatology. 1992. 185(3):205-9. [Medline].

  12. Torres G, Behshad R, Han A, Castrovinci AJ, Gilliam AC. "I forgot to shave my hands": A case of spiny keratoderma. J Am Acad Dermatol. 2008 Feb. 58(2):344-8. [Medline]. [Full Text].

  13. Sriprakash K, Yong-Gee S. Multiple minute digitate hyperkeratoses associated with paraproteinaemia. Australas J Dermatol. 2008 Nov. 49(4):233-6. [Medline].

  14. Balus L, Donati P, Amantea A, Breathnach AS. Multiple minute digitate hyperkeratosis. J Am Acad Dermatol. 1988 Feb. 18(2 Pt 2):431-6. [Medline].

  15. Cox NH, Ince P. Transient post-inflammatory digitate keratoses. Clin Exp Dermatol. 1989 Mar. 14 (2):170-2. [Medline].

  16. Rubegni P, De Aloe G, Pianigiani E, Cherubini-Di Simplicio F, Fimiani M. Two sporadic cases of idiopathic multiple minute digitate hyperkeratosis. Clin Exp Dermatol. 2001 Jan. 26(1):53-5. [Medline].

  17. Goldstein N. Multiple minute digitate hyperkeratoses. Arch Dermatol. 1967 Dec. 96(6):692-3. [Medline].

 
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Multiple minute digitate hyperkeratosis. Published with permission granted from and with copyright retained by the American Medical Association. Clark JL, Davis G, Bennett DD. Arch Dermatol. 2008 Aug;144(8):1051-6.
Multiple minute digitate hyperkeratosis. Published with permission granted from and with copyright retained by the American Medical Association. Clark JL, Davis G, Bennett DD. Arch Dermatol. 2008 Aug;144(8):1051-6.
 
 
 
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