Consultations in Dermatology

“I've tried a dozen creams and lotions on him but nothing helps” was the plaintiff comment of the mother of an eight-year-old boy. The boy's upper arms were as rough as sandpaper, studded with numerous tiny plugs of keratin, the protective outer skin protein. On skin biopsy they were seen as compact plugs filling the hair pores, with no inflammation. Most of the doctors had dismissed it as trivial and insignificant, hardly worthy of a prescription. Actually, they did not know of an effective remedy, prescription or otherwise. Here was another orphan patient, not because his disease was rare, but because it was so common as to be accepted as a mundane non-disease.

Rough skin due to dry keratotic material in the upper hair follicles can be the presenting complaint of at least ten dermatologic disorders. We ruled out the rough skin colleague, keratosis follicularis (Darier's disease), by both biopsy and its localization. Another diagnostic possibility, pityriasis rubra pilaris, was similarly discarded, for this rare disease is, as its name indicates, red and scaly. Since the lesions had no spines in the hair follicles, lichen spinulosus was dropped from consideration. To continue the polysyllabic diagnostic litany, he did not have keratosis pilaris decalvans or keratosis pilaris atrophicans, for there was no hair loss or scarring. It was also not the Vitamin A deficiency of phrynoderma, seen in the malnourished.