What could cause these asymptomatic bumps?

A 57-year-old female presented for evaluation of asymptomatic bumps on her palms and soles. 

What could be the cause?

A. Warts.

B. Pitted keratolysis.

C. Punctate keratoderma.

D. Psoriasis.

E.  Tylosis.

Bonus: Is there an association with internal malignancy?

(Answer and discussion on next page)

Answer—Palmar plantar punctate keratoderma

Palmar plantar punctate keratoderma is an autosomal dominant group of disorders characterized by abnormal thickening of the palms and soles. Onset is usually after the age of 20. There were no internal associations. 

There are 2 associated conditions to consider:

• Howell-Evans syndrome (also called tylosis) is an extremely rare autosomal dominant inheritance that affects the palms of the hands and soles of the feet. Onset of focal keratoderma can begin in childhood and develop into esophageal cancer in middle age.

• Richner-Hanhart syndrome is an autosomal recessive inheritance due to an enzyme deficiency. It is characterized by ulcers on the eye and a dislike of bright light in the first year of life. The onset of focal keratoderma is prevalent in late childhood or adolescence and most affected children develop mental retardation. ν