aquagenic syringeal acrokeratoderma ( asa ) is an acquired or hereditary keratoderma of unknown etiology .
drug - induced cases of asa of the palms have been reported , associated with rofecoxib , celecoxib , aspirin , and in one case , tobramycin used for cystic fibrosis .
several pathogenic mechanisms have been proposed , including structural or functional defects of the horny layer during adolescence , primary disease of the sweat ducts , increased sodium concentration in the skin , thereby increasing the water - retention capacity of the horny layer or a reaction to drugs .
we present a case of a woman who used spironolactone for polycystic ovary syndrome ( pcos ) and developed asa 2 weeks later , after withdrawing the drug .
a 21-year - old woman presented to our outpatient clinic with complaints of palmar eruption .
she noted wrinkling and edema of the skin on the palms after soaking in water for 5 - 10 min , 3 weeks earlier . the wrinkling and edema were accompanied by sensations of tightness , tingling , and pruritus .
the condition became better 10 - 15 minutes after exposure to water had ceased , but did not completely resolve .
these findings regressed gradually after drying the hands , but were not completely resolved . on dermatological examination ,
whitish , keratodermic , macerated plaques , and dilated punctae were observed over the volar surface of the hands [ figure 1 ] . after soaking the hands in water for 5 min ,
the lesions became more translucent , noticeable , and symptomatic [ figure 2 ] . before soaking the hands in water , whitish keratodermic macerated plaques and dilated punctae
were observed after soaking the hands in water for 5 min , the lesions became more translucent , noticeable , and symptomatic from her medical history , we learned that she used spironolactone for pcos up to 2 months earlier .
she denied any concomitant hyperhidrosis , a personal or family history of cystic fibrosis , abnormal scalp hair , or atopic diathesis .
her cousin had similar lesions years ago , but her symptoms were completely resolved with treatment .
the disease had been treated at another center with 19% aluminum hydrochloride cream with no improvement .
the laboratory findings , including sweat chloride concentrations were within normal limits , except for very small elevation of prolactin levels .
we wanted to perform genetic testing to define cystic fibrosis transmembrane conductance regulator ( cftr ) mutations , but she would not accept any further tests .
the patient was treated with topical pomade containing 10% urea and salicylic acid twice a day and topical 10% urea lotion ( excipial lipo ; orva ) .
asa has been described in the literature under various names for similar conditions , patients with flat - topped , pitted , or translucent papules , with pebbly or white , prominent eccrine pores that are macerated in appearance and that appear on the hands and feet , exacerbated by water immersion . the disease was first reported as a  hereditary papulotranslucent acrokeratoderma  in 1973 by onwukwe et al .
they reported a condition that appeared soon after puberty , demonstrated an autosomal dominant mode of inheritance and associated with fine - textured scalp hair and an atopic diathesis . afterwards , in 1974 ,  aquagenic wrinkling 
was reported by elliot in a letter to the editor , describing an anecdotal observation in children with cystic fibrosis .
subsequently , several reports presented by several names , including transient reactive papulotranslucent acrokeratoderma , asa , aquagenic keratoderma , transient aquagenic palmar hyperwrinkling , and early aquagenic wrinkling .
histopathological changes include orthohyperkeratosis with increased thickness and abnormal staining of the stratum corneum , dilated acrosyringia , and dermal eccrine ducts with hyperplasia of eccrine glands , clear cell changes and vacuolations , and increased capillaries around and adjacent to the eccrine glands .
although asa is often related to cystic fibrosis , researchers have reported that it is not only specific for cystic fibrosis ; it is also seen in different conditions , such as marasmus and nephrotic syndrome .
drug - induced cases of asa of the palms have been reported in single case reports , associated with rofecoxib , celecoxib , aspirin , and , in one patient , with tobramycin used for cystic fibrosis .
the proposed mechanisms for the cases using rofecoxib , celecoxib , and aspirin involve an increase in the sodium retention of epidermal cells . in these cases , the proposed mechanism is cyclooxygenase-2 ( cox-2 ) inhibition in epidermal cells , which may cause increased sodium reabsorption in a mechanism similar to the effect of cox-2 inhibitors on kidney cells .
adrenal steroids have recently been shown to play an important role in the regulation of renal cox-2 expression . according to zhang et al . , blockade of mineralocorticoid receptors with spironolactone leads to upregulation of renal cortical cox-2 expression . in our patient , who was using spironolactone for pcos for approximately 2 months
withdrawing the drug may have caused increased sodium retention of epidermal cells . during treatment , 20% aluminum chloride solution , botulinum toxin injections , antihistamines , pomade containing 5% salicylic acid , a mixture of mometasone furoate and petroleum jelly , and a cream containing 20% urea were used for treatment .
our patient had not improved with 19% aluminum hydrochloride cream , perhaps because she had not suffered from palmar hyperhidrosis .
withdrawing spironolactone may have caused increased sodium retention of epidermal cells , thereby inducing asa .
 aquagenic syringeal acrokeratoderma is a rare , transient , and usually bilaterally symmetric , palmoplantar keratoderma . 
 patients complain of tingling and pain in the hands starting a few minutes after exposure to water and lasting for 20 - 30 minutes after removal . 
 clinically , there is marked wrinkling with edematous white papules on the palms or , less often , the soles . 
 we present the case of a 21-year - old woman who used spironolactone for polycystic ovary syndrome and had similar clinical features 2 weeks later , after withdrawing the drug . 
Introduction
Case Report
Discussion