Palmoplantar Keratoderma as a Variant of Lichen Planus

A 52-year-old air conditioner mechanic presented with progressively itchy grayish white eruptions affecting the skin and mucous membranes, including his palms and soles for the past 2 months. The inner aspects of the palms and weight-bearing areas of the soles were the initial sites of presentation, resulting in a diffuse thickness of the palms and soles, which inhibited his everyday activity. The eruptions were asymptomatic but conspicuous. There was marked presence of multiple erythematous to grayish white (violaceous) flat-topped polygonal papules of varying sizes, with a few coalescing to form plaques. The papules varied in size from 5 mm to 4 cm and had prominent adherent scales on top when examined after smearing with mineral oil. Koebnerization was seen over the shin. The lesions were found on the wrists, forearms, ankles, legs, and thighs. There was a yellow to brown thick symmetric hyperkeratosis of the palms and soles, including the medial and lateral aspect of the fingers and toes, sparing the dorsal surfaces of the hands and feet (Figure 1). In addition, the medial arch and weight-bearing region of both soles were involved. The nails showed subungual hyperkeratosis, nail plate discoloration, and paronychia of the toes and fingers. Hyperkeratosis and scaly plaques were also identified in the web spaces (Figure 2). The buccal mucosa showed symmetrical white plaques with a lacy white pattern.