Rapid onset bilateral palmar keratoderma in a psoriasis patient wearing orthopaedic hand splints

A 37-year-old man with a history of chronic stable plaque psoriasis fractured both hands during a fall on his outstretched hands. Ten days later, following surgery and the application of tight fitting orthopaedic hand splints, the splints were removed because of a 7-day history of painful and pruritic palms. It was evident that the injury to his hands and the firm application of his splints had resulted in a dramatic flare of his psoriasis. This manifested in two clinical forms that he had not developed previously. He had a strikingly symmetrical palmar keratoderma that had köbnerized maximally in the regions where the splints apposed his palms firmly. In addition, he had pustular psoriasis affecting the fingertips of both hands. After removal of the splints he responded to a combination of oral acitretin, and 6% coal tar and 6% salicylic acid in aqueous cream applied topically.