List of Abbreviations
APPK – Acquired palmoplantar keratoderma
Terms and Definitions
Acquired palmoplantar keratoderma (APPK) is a heterogeneous group of keratinization disorders characterized by hyperkeratotic inflammatory thickening of the palms and/or soles.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Acquired palmoplantar keratoderma (APPK) is a heterogeneous group of keratinization disorders characterized by hyperkeratotic inflammatory thickening of the palms and/or soles.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Etiology and pathogenesis are unknown.
Primary acquired keratoses develop without a preceding dermatosis and are caused by numerous exogenous and endogenous factors [1-4]. They occur in association with endocrine disorders (e.g., myxedema, hypothyroidism, diabetes mellitus), nervous system disorders, gastrointestinal diseases (e.g., biliary cirrhosis), metabolic and hormonal disturbances (menopause, pregnancy, metabolic syndrome), and may be linked to autoimmune systemic diseases (systemic lupus erythematosus) [5-17].
Keratoderma can be associated with malignancies as a paraneoplastic phenomenon and a manifestation of predisposition to malignant tumors. Skin changes typically precede the detection of the neoplasm by several months, and metastases are usually present at the time of diagnosis. Keratodermias are associated with carcinomas of the esophagus, lungs, breast, uterus, stomach, pancreas, kidneys, urinary bladder, colon, blood, and skin [18-26].
APPK can be triggered by the use of certain medications (verapamil**, etodolac, methyldopa**, venlafaxine, tegafur, fluorouracil**, bleomycin**, hydroxycarbamide**, doxorubicin**, imatinib**, vemurafenib**, and capecitabine**) [27-29].
The development of secondary keratodermas is preceded by pathological skin changes, primarily various dermatoses. In these cases, the formation of palmoplantar keratoderma is only one of the possible symptoms of the disease. Secondary inflammatory hyperkeratosis is observed in psoriasis, eczema, pityriasis rubra pilaris, lichen planus, contact dermatitis, xerosis, etc., and may also be caused by infectious agents (e.g., Reiter's syndrome, Norwegian scabies, dermatophytosis, secondary syphilis) [1-4, 3034].
1.3 Epidemiology of the Disease or Condition
In the Russian Federation, statistical accounting of patients with acquired palmoplantar keratodermas is not maintained. The prevalence is unknown.
1.4 Features of Coding the Disease or Condition
Other epidermal thickenings:
L85.1 - Acquired palmoplantar keratosis [keratoderma]
L85.2 - Punctate keratosis (palmar-plantar)
L85.9 - Epidermal thickening, unspecified
1.5 Classification of the disease or condition
There is no universally accepted classification, however, the following main clinical varieties (types) of PPK can be distinguished [1, 3, 4, 35].
By prevalence:
1. Diffuse.
2. Focal.
3. Punctate.
By etiology:
1. Primary acquired palmoplantar keratodermas:
a) PPK associated with hormonal/metabolic disorders (Haxthausen syndrome);
b) Paraneoplastic PPK;
c) PPK associated with systemic autoimmune diseases;
d) PPK associated with diseases of the endocrine organs, nervous system, and gastrointestinal tract;
e) PPK caused by mechanical, chemical, and radiation (occupational) factors;
f) PPK caused by alimentary factors, including hypovitaminosis;
g) PPK caused by medicinal drugs.
2. Secondary acquired palmoplantar keratodermas caused by inflammatory and reactive dermatoses.
3. Secondary acquired (false) palmoplantar keratodermas caused by infections (Reiter's syndrome, Norwegian scabies, dermatophytosis, secondary syphilis).
4. Idiopathic PPK.
1.6 Clinical presentation of the disease or condition
Patients with PPK complain of localized or diffuse rashes on the skin of the palms and soles, which may be accompanied by itching, pain (including when walking), and burning. The main clinical manifestations of the disease are polymorphic and common to all PPKs. The clinical picture is formed by diffuse or focal areas of thickening of the stratum corneum against the background of erythema of varying severity, infiltration, desquamation, areas of dryness, fissures covered with serous-hemorrhagic crusts and/or with serous-purulent discharge, excoriations, and hemorrhagic crusts. In case of a pronounced inflammatory reaction, a tendency to exudation may be noted. The lesion of the palms and/or soles can be continuous/diffuse or focal, extending to the dorsal surfaces with (transgradient) or without their involvement in the pathological process (non-transgradient). PPK may be accompanied by nail plate changes.
Certain forms of PPK have clinical features.
Climacteric keratoderma (Haxthausen syndrome) is a form of diffuse keratoderma developing in women during the climacteric period. It is suggested that estrogen deficiency and a decrease in the functional activity of the thyroid gland contribute to the development of the disease. Many patients suffer from obesity and hypertension. The first symptoms of the disease appear during the climacteric period (or in the fifth decade of life) in the form of erythema on the skin of the soles, which becomes covered with horny layers, the amount of which gradually increases. The horny masses crack along the skin folds and in areas of pressure, especially on the heels, resulting in fissures and pain when walking. Then, in the central areas of the palms and fingers, focal hyperkeratoses appear against the background of inflammatory erythema. In later stages of the disease, the palmar lesions manifest as discrete and centrally localized inflammatory hyperkeratosis. Transgradientness of the rashes is usually absent. They may cause mild itching, and upon contact with water, household chemicals, etc., burning and pain in the skin lesions of the palms. The condition usually worsens in winter.
Among the obligate predictors of malignant neoplasms, which are important for their early diagnosis, certain nosological forms of PPK should be highlighted separately.
Bazex paraneoplastic acrokeratosis is considered an obligate paraneoplastic syndrome. It indicates the development of internal organ cancer and is primarily associated with squamous cell carcinoma of the gastrointestinal tract, although malignant neoplasms of other organs (cancer of the larynx, pharynx, pharyngeal ring, lungs, esophagus, tonsils, etc.) are possible. The onset of Bazex acrokeratosis occurs either simultaneously with the clinical symptoms of the malignant tumor or precedes them by 1-2 years. This disease most often occurs in Caucasian men aged 40 years and older. The clinical picture is characterized by the symmetrical appearance of psoriasiform, maculopapular pruritic lesions on the fingertips of the hands and feet, the tip of the nose, and the edge of the auricles. Psoriasiform skin changes of the fingers and toes are accompanied by dystrophy of the nail plates and spread to the palms and soles, and further to the skin of the limbs and trunk. The paraneoplastic nature of the disease is confirmed by the tendency of the severity of skin lesions to correspond to tumor size. Removal of the tumor leads to regression of the dermatosis, but relapses may occur, corresponding to tumor regrowth and pelvic organ metastases.
Palmar acanthosis, or acquired paraneoplastic pachydermatoglyphia (acanthosis palmaris), is a distinct cutaneous paraneoplastic syndrome most commonly associated with gastric or pulmonary malignancies. The palms are diffusely thickened, velvety in texture, and ridged in appearance. Malignant folding of the palms persists during antineoplastic therapy, with less than a third of patients responding to it. The appearance of malignant palmar folding may also be associated with bullous pemphigoid, exfoliative dermatitis, etc.
Punctate keratosis (palmar-plantar) is a rare disease characterized by thread-like keratotic lesions on the palms and soles. Hereditary forms of this disease exist, but the majority encountered are acquired. The latter variant can be idiopathic or associated with malignancies (e.g., endometrial carcinoma) and chronic systemic diseases.
Differential diagnosis with genetically determined forms of palmoplantar keratodermas. PPKs usually do not develop in infancy, and a corresponding family history is typically absent. However, it should be borne in mind that several variants of hereditary palmoplantar keratodermas do not manifest in early childhood, and in cases of de novo autosomal dominant mutations and in patients with autosomal recessive forms (carrier parents have no clinical manifestations), the family history may be negative. Unlike hereditary forms, which in most cases are characterized by a strictly symmetrical distribution of skin lesions, skin lesions in PPK are more often asymmetrical. Manifestations of PPK usually improve and may resolve with treatment of the underlying disease.
2. Diagnostics, medical indications and contraindications for diagnostic methods
The diagnosis is established based on a comprehensive assessment of complaints, anamnesis data, physical examination, the clinical picture of the disease, laboratory test data, and consultations by medical specialists. It is important to differentiate paraneoplastic types of PPK, considering that the malignant type may differ in lesion severity, intense progression, and torpidity to ongoing therapy [1-3].
2.1 Complaints and Anamnesis
Complaints and anamnesis are described in section 1.6. "Clinical picture".
2.2 Physical Examination
Physical examination data are described in section 1.6. "Clinical picture".
2.3 Laboratory Diagnostics
It is recommended for patients with PPK to assess the patient's general condition and identify contraindications to systemic therapy [1, 3, 4]: a complete blood count (CBC) with differential.
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended for patients with PPK to use in vivo pathomorphological examination of skin biopsy (surgical) material from the lesion site if differential diagnosis is necessary, as well as to clarify the diagnosis [1-4].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended for patients with PPK to examine skin rash elements for pathogenic fungi using native preparation microscopy and Sabouraud medium culture methods if secondary infection is suspected [4].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
2.4 Instrumental Diagnostics
Not applicable.
2.5 Other Procedures
Establishing the type of PPK requires a phased interdisciplinary approach. An important criterion for diagnosing PPK is screening for systemic diseases, infections, medications taken, and neoplasms in patients with acquired PPK [1-4, 38].
It is recommended for patients with suspected PPK:
1) Initial/follow-up appointment (examination, consultation) by a dermatovenereologist for the diagnosis and treatment of the disease [29, 38];
GDR CLE 5Grade of recommendation C (level of evidence – 5)
2) Initial/follow-up consultation (examination) by a geneticist if differential diagnosis with hereditary forms of the disease is necessary [1].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
3) Initial/follow-up consultation (examination) by an adult endocrinologist for a comprehensive health assessment, including searching for probable causes of PPKC development (if necessary) to determine the scope and nature of additional investigations, as well as when planning phototherapy to rule out contraindications [5,6,7,62].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
4) For patients with a suspected paraneoplastic form of PPKC, initial/follow-up consultation (examination) by an oncologist to assess health status and determine the scope and nature of additional investigations to detect and radically treat malignant neoplasms of internal organs [26].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
Topical and systemic pharmacotherapy, as well as phototherapy, are used to treat patients with primary and idiopathic PPKC. The choice of therapy for PPKC patients is determined by the severity of clinical manifestations of the dermatosis and subjective sensations (itching), is carried out symptomatically, and may be modified in case of insufficient efficacy. Therapy should aim at resolving/reducing the severity of rashes: suppressing inflammation, hyperkeratosis, scaling, tendency to exudation, epithelialization of fissures, and subjective sensations. To achieve a successful therapeutic outcome, it is necessary to diagnose and treat the potential underlying etiological cause of PPKC and comorbid background using a phased interdisciplinary approach. Paraneoplastic keratodermas are usually refractory to local treatment and may only respond upon successful treatment of the underlying neoplasm.
3.1 Conservative Treatment
For PPKC patients with localized rashes, topical therapy alone may be sufficient. In case of its inefficacy for localized rashes, or in patients with subjective sensations and severe skin involvement, topical therapy is administered in combination with systemic therapy and/or phototherapy. Systemic therapy employs acne retinoids, systemic antihistamines, glucocorticoids, and agents with hyposensitizing, detoxifying, and anti-inflammatory properties.
It is recommended that patients with PPKC apply keratolytic agents to hyperkeratotic lesions in palmoplantar keratoderma [1-4, 29, 38-43].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: drugs should be used with caution, especially in children, due to the risk of absorption and systemic effects [44].
It is recommended to prescribe topical retinol-based agents to patients with PPKC accompanied by dry skin to improve keratinization and desquamation processes: retinol ointment 0.5% 2 times a day for up to 12 weeks;
or
Vitamin E + Cholecalciferol + Retinol ointment 2 times a day for 1 month [3-4, 38, 41, 45, 46].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended that patients with PPKC use dexpanthenol 5% ointment, 5% foam 2–3 times a day until clinical improvement is achieved in case of compromised skin integrity, prevention, and treatment of dry skin [47-49].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended that patients with PPKC apply topical cosmetic products (creams containing petrolatum, paraffin, silicone, mineral and vegetable oils) and emollients (with urea, glycerin, ceramides, and physiological lipids) 2–5 times a day until clinical improvement is achieved to restore the epidermal barrier and improve keratinization [43, 50-52, 54].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
It is recommended that patients with PPKC use topical dermatological corticosteroids to reduce the severity of the inflammatory reaction and pruritus [1, 3, 4, 29, 55, 56].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Corticosteroids in combination with other topical agents are recommended for patients with PPKC in case of infected lesions [3, 4, 55, 56].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended that adult patients with PPKC undergo local ultraviolet skin irradiation or photochemotherapy with topical photosensitizers if topical therapy is ineffective [1, 3, 4, 38, 57].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Systemic therapy
It is recommended to prescribe systemic antihistamines to patients with PPKC to reduce the intensity of pruritus [29].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
3.2. Diet therapy
The organization of therapeutic dietary nutrition for patients with acquired palmoplantar keratosis (keratoderma) during inpatient treatment in medical organizations is carried out in accordance with the orders of the Russian Ministry of Health No. 330 dated August 5, 2003, "On measures to improve therapeutic nutrition in healthcare institutions of the Russian Federation", No. 395n dated June 21, 2013, "On approval of therapeutic nutrition standards", and No. 1008n dated September 23, 2020, "On approval of the procedure for providing patients with therapeutic nutrition" (see Appendix A3).
4. Medical Rehabilitation and Sanatorium-Resort Treatment
It is recommended to consider medical rehabilitation for PPKC patients (physiotherapy and health resort methods: therapeutic mineral baths, iodine-bromine baths, therapeutic hydrogen sulfide baths, mud baths, etc., in accordance with indications and contraindications) [60,61].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
5. Prevention and Dispensary Observation
Methods for the prevention of PPKC have not been developed.
6. Organization of Medical Care
Indications for hospital admission to a medical organization:
1) Indications for providing medical care in a day hospital setting:
insufficient efficacy of treatment administered on an outpatient basis;
2) Indications for inpatient medical care:
insufficient efficacy of treatment administered on an outpatient basis;
disease progression with the appearance of new rashes;
severe course of palmoplantar keratoderma.
7. Additional Information
None.
Criteria for Evaluating the Quality of Medical Care
№ | Quality assessment criteria | Performance evaluation |
|---|---|---|
1. | Initial appointment (examination, consultation) by a dermatovenerologist | Yes/No |
2. | External therapy performed using cosmetic products (creams containing petrolatum, paraffin, silicone, mineral and vegetable oils) and emollients (with urea, glycerin, ceramides, and physiological lipids) (depending on medical indications and in the absence of medical contraindications) | Yes/No |
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58. Albanova V.I., Ivanova I.A., Prokhorov A.Yu. et al. Retinol palmitate in the treatment of patients with impaired keratinization. Coll. Retinoids. M.: Retinoids JSC Publishing House, 1994. - P. 15-19.
59. Nozdrin K.V., Kokolina V.F., Kartelishchev A.V., Albanova V.I., Rodionova G.M. Technologies of systemic retinotherapy in pediatric practice. Guidelines. M.: Retinoids; 2016. P. 18–39.
60. Naatyzh Zh.Yu. Balneotherapy and thalassotherapy for patients with palmoplantar keratosis. / Zh.Yu. Naatyzh // Bulletin of New Medical Technologies. - peer-reviewed scientific and practical journal, approved by the VAK List. - 2012. - No. 1. - P. 86-88 (0.0 printer's sheets).
61. Naatyzh Zh.Yu. Innovations in rehabilitation treatment in health resorts of the Russian Black Sea region for patients with various nosological forms of palmoplantar keratosis and other epidermal thickenings. Monograph. - Sochi: Research Center for Balneology and Rehabilitation of the FMBA of Russia, 2012. - 100 p. (5.7 printer's sheets).
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Appendix A1. Working Group Composition
Nikolay N. Potekaev – Doctor of Medical Sciences, Professor, President of the All-Russian Public Organization "National Alliance of Dermatovenereologists and Cosmetologists", Member of the European Union against STIs (IUSTI/WHO), Honorary President of the Euro-Asian Association of Dermatovenereologists (EAAD), Member of the Board of Directors of the European Academy of Dermatology and Venereology (EADV), Corresponding Member of the German Dermatological Society (DDG), Honored Doctor of the Russian Federation, Chief freelance specialist in dermatovenereology and cosmetology of the Russian Ministry of Health, Chief freelance specialist in dermatovenereology and cosmetology of the Department of Health of Moscow, Director of the Moscow Center for Dermatovenereology and Cosmetology, Head of the Department of Skin Diseases and Cosmetology at the Faculty of Continuing Professional Education, Pirogov Russian National Research Medical University of the Russian Ministry of Health.
Olga V. Dolya – Doctor of Medical Sciences, Member of the All-Russian Public Organization "National Alliance of Dermatovenereologists and Cosmetologists", Member of the European Union against STIs (IUSTI/WHO), Member of the European Academy of Dermatology and Venereology (EADV), Member of the Guild of Sexually Transmitted Infection Specialists "YUSTI RU", Deputy Director for Research at the Moscow Center for Dermatovenereology and Cosmetology.
Olga V. Zhukova – Doctor of Medical Sciences, Professor, Executive Director of the All-Russian Public Organization "National Alliance of Dermatovenereologists and Cosmetologists", Member of the European Union against STIs (IUSTI/WHO), Member of the Guild of Sexually Transmitted Infection Specialists "YUSTI RU", Chief freelance specialist in dermatovenereology and cosmetology of the Central Federal District of the Russian Ministry of Health, Chief Physician of the Moscow Center for Dermatovenereology and Cosmetology, Head of the Department of Dermatovenereology and Allergology with a Course of Immunology at the Medical Institute of the Peoples' Friendship University of Russia.
Aida G. Gadzhigoroeva – Doctor of Medical Sciences, President of the Interregional Public Organization of Trichologists and Hair Research Specialists "Professional Association of Trichologists", Member of the All-Russian Public Organization "National Alliance of Dermatovenereologists and Cosmetologists", Member of the European Hair Research Society (EHRS), Head of the Department of Clinical Dermatovenereology and Cosmetology at the Moscow Center for Dermatovenereology and Cosmetology.
Irina V. Zavarina – Candidate of Medical Sciences, Member of the All-Russian Public Organization "National Alliance of Dermatovenereologists and Cosmetologists", Member of the European Academy of Dermatology and Venereology (EADV), Senior Researcher at the Department of Clinical Dermatovenereology and Cosmetology at the Moscow Center for Dermatovenereology and Cosmetology.
Aleksandr A. Baranov – Academician of the RAS, Professor, Doctor of Medical Sciences; Honorary President of the Union of Pedians of Russia, Advisor to the Head of the Research Institute of Pediatrics and Child Health at the Petrovsky National Research Centre of Surgery, Professor at the Department of Pediatrics and Pediatric Rheumatology at the Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University), Chief freelance pediatric specialist of the Russian Ministry of Health.
Leyla S. Namazova-Baranova – Academician of the RAS, Professor, Doctor of Medical Sciences, President of the Union of Pediatricians of Russia; Past President of EPA/UNEPSA; Head of the Research Institute of Pediatrics and Child Health at the Petrovsky National Research Centre of Surgery, Head of the Department of Faculty Pediatrics at the Institute of Maternity and Childhood, Pirogov Russian National Research Medical University of the Russian Ministry of Health (Pirogov University), Chief freelance children's specialist in preventive medicine of the Russian Ministry of Health.
Eduard T. Ambartchyan – Candidate of Medical Sciences, Dermatovenereologist, Member of the Union of Pediatricians of Russia.
Aleksandr I. Materikin – Candidate of Medical Sciences, Head of the Department of Pediatric Dermatology, Head of the Dermatology Department with Day Patient Care at the Research Institute of Pediatrics and Child Health, Petrovsky National Research Centre of Surgery, Member of the Union of Pediatricians of Russia.
There is no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience of these clinical guidelines:
Dermatovenereologists.
Residents and trainees of continuing professional education cycles in the specialty "Dermatovenereology".
Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for assessing levels of evidence (LE) for methods of prevention, treatment, and medical rehabilitation, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)
LoE | Definitions |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for evaluating the levels of recommendation certainty (LRC) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural healing factors (preventive, diagnostic, therapeutic, and rehabilitation interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Order of the Ministry of Health of the Russian Federation No. 330 dated August 5, 2003, "On measures to improve therapeutic nutrition in medical and preventive institutions of the Russian Federation."
Order of the Ministry of Health of the Russian Federation No. 395n dated June 21, 2013, "On approval of therapeutic nutrition standards".
Order of the Ministry of Health of the Russian Federation No. 1008n dated September 23, 2020, "On approval of the procedure for providing patients with therapeutic nutrition".
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Palmoplantar keratoderma (keratosis) is a group of diseases that cause abnormal thickening of the skin on the palms and/or soles.
Palmoplantar keratoderma can be genetic (hereditary) or acquired.
Hereditary palmoplantar keratoderma occurs when an error (mutation) in the gene encoding the keratin protein is passed from parent to child or can occur spontaneously.
Acquired palmoplantar keratoderma may develop against the background of endocrine, nervous, and gastrointestinal diseases, metabolic and hormonal disorders, autoimmune diseases, and may be caused by medications, infections, or serve as a symptom of other skin conditions.
Therefore, if localized or widespread patches of thickened skin, excessive pathological desquamation, or fissures located on areas of skin induration and inflammation appear on the palms and/or soles—which may be accompanied by itching, burning, or pain, including when walking—it is necessary to consult a dermatovenereologist who will determine further diagnostic and therapeutic tactics for the dermatosis and provide necessary skin care recommendations.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
No.