What is Hyperkeratosis?
Hyperkeratosis is a condition where the outer layer of the skin, known as the stratum corneum, becomes thicker. This layer is made up of layers of skin cells called keratinocytes, which create a tough protein known as keratin as they mature and lose their internal structures. The end result is a protective layer of dead skin cells, without nuclei (cell centers), that resembles a basketweave pattern.
There are two types of hyperkeratosis: orthokeratotic and parakeratotic. Orthokeratotic hyperkeratosis refers to when the keratin layer thickens but retains its regular maturation process. Parakeratotic hyperkeratosis, on the other hand, retains the cell nuclei, indicating that the keratinocytes are maturing more slowly. Hyperkeratosis can also be linked to dyskeratosis, which is when the keratinocytes located beneath the granular cell layer begin to toughen up prematurely or abnormally.
When hyperkeratosis is seen with other irregularities in a skin biopsy, it can provide essential clues for making a final diagnosis. Epidermal hypertrophy, which is a harmless change in the skin that results in acanthosis (an increase in the thickness of the keratinocyte layers) and hyperkeratosis, is one such example.
What Causes Hyperkeratosis?
The outermost layer of your skin, called the stratum corneum, can sometimes thicken and this is usually due to an increase in the creation of a protein called keratin in this area. This can happen for various reasons.
In most cases, the thickening is a result of ongoing physical or chemical damage. This can be from things like constant friction or the use of harsh soaps, particularly those that are basic (the opposite of acidic). Other times, it could also be due to long-lasting inflammation or a side effect of certain medications, for instance, chemotherapy drugs.
The thickening of this skin layer, called hyperkeratosis, can also occur as a reactive response of the skin, and is a characteristic outcome of a condition called dermatitis. Additionally, a lack of certain nutrients in your diet can lead to hyperkeratosis. For example, if you don’t get enough vitamin A, you can develop a condition called phrynoderma. With this condition, your skin may show signs of hyperkeratosis around the hair follicles, and there can be clumps of keratin, skin atrophy (thinning or wasting away), and changes in oil-producing glands of the skin.
Risk Factors and Frequency for Hyperkeratosis
Hyperkeratosis is linked to a variety of health conditions, both harmless and serious. However, it’s hard to say how often it occurs because hyperkeratosis is a term used to describe changes seen under a microscope in many different diseases.
Signs and Symptoms of Hyperkeratosis
Hyperkeratosis is a medical term that describes a condition where the outermost layer of the skin becomes thickened. It can be present in many skin conditions, and there can be overlap between them. To manage such conditions effectively, a detailed history and a thorough physical examination of the patient are essential.
In gathering a patient’s history, doctors will consider age, family history, exposure to toxic substances, type of work carried out by the patient, existence of other health conditions, and previous treatments received. This information helps to determine the right treatment. For those who have been previously diagnosed, re-evaluating the state of their condition and tracking any changes is crucial.
Physical examination plays an integral role in the accurate diagnosis of the disease severity and extent. This includes a thorough check of the entire skin surface- including the scalp, eyelids, ears, and mucous membranes in the genital region. The hair and nails are also examined. The appearance of the skin lesion is described in terms of its color, texture, shape, and distribution. The skin around the affected area is also inspected for any changes, such as dryness, excessive oiliness, abnormal sweating, presence of age spots, and signs of skin aging like bruises or wrinkles.
For a condition like keratosis pilaris, small, rough bumps around hair follicles can be seen. These bumps may be accompanied by redness. A closer look may reveal a small coiled hair beneath each bump, formed by a plug of keratin, a skin protein.
Thick, rough, greyish, or bran-like scales on the skin are an important sign of hyperkeratosis. These scales should not be confused with crusts, which are dried bodily fluids on the skin. Crusts indicate a wound or infection rather than thickening of the skin. Skin thickening or lichenification can result from chronic damage to the skin such as repetitive scratching and commonly occurs in chronic eczema or conditions affecting the nerves.
Testing for Hyperkeratosis
Dermoscopy is a skin exam that uses a special magnified lens to check the surfaces of your skin. This test can help doctors see the top layers of your skin more clearly, including the outer skin layer (epidermis), where your skin connects to deeper layers (dermo-epidermal junction), and the surface layer of deeper skin (superficial dermis).
If your doctor isn’t certain about your condition based on your symptoms and the dermoscopy, they may take a skin biopsy. This involves removing a small piece of skin from the affected area for further analysis. The aim is to get a sample that extends deep enough into your skin to include a layer called the hypodermis. This typically requires a tool called a 3 mm punch, which is a good size for getting a useful sample with minimal scarring. Smaller samples might not be helpful for diagnosis.
For suspected skin allergies, a patch test might be used to find out which substances you’re allergic to. This test can be useful when you have skin reactions that look like eczema and are itchy and persist for a long time, and no other cause can be found. If the test shows you’re allergic to a particular substance, you’ll be asked to avoid it. After a few weeks without contact with the allergen, you should follow up with your doctor to see if your skin has improved.
Treatment Options for Hyperkeratosis
Keeping your skin moisturized and exfoliatated is key in preventing overly dry skin. This can be achieved by using soaps designed for your specific skin pH, non-soap cleansers, and avoiding hot baths. Lotions and creams (emollients) and treatments that help shed excess skin (topical keratolytic agents such as lactic acid, salicylic acid, urea) can also be applied to affected areas.
In mild cases, like calluses and corns, a simple procedure using a chisel-shaped blade to remove the build-up of toughened skin can reduce discomfort and pressure. However, surgeries are usually not the preferred method for treating skin hardening (hyperkeratosis).
Significantly problematic cases where there’s a daily restriction, such as untreatable tough skin (plantar keratosis) on the soles of the feet, may see benefits from skin grafts with rotation skin flap procedure.
Inflammatory skin conditions like lichen planus and psoriasis are typically managed with a type of anti-inflammatory medication called corticosteriods. The cream version of the medication is usually the best for conditions limited to specific areas and should be used for one to two weeks.
Severe recurring conditions may require the usage of medications that suppress or modify the body’s immune response (like cyclosporin, hydroxychloroquine, mycophenolate mofetil, sulfasalazine, alefacept, efalizumab).
Moreover, topical calcineurin inhibitors (such as tacrolimus or pimecrolimus), which help reduce inflammation, can be utilized.
Retinoids, another type of medication useful for skin conditions, are usually used for disorders that involve abnormal skin cell production, such as ichthyoses, keratosis folliculitis, and psoriasis. They can be applied topically (on the skin) or taken orally, depending on the specific situation. The duration of treatment usually lasts from 8 to 12 weeks.
Additonally, non-surgical methods such as laser therapy (like pulsed-dye laser, 755-nm alexandrite laser, 810-nm diode laser, 1064-nm Nd:YAG laser) and microdermabrasion (a technique of removing the outermost layer of dead skin) are techniques currently being explored for different hard skin conditions.
What else can Hyperkeratosis be?
Diagnosing hyperkeratosis, a condition that causes skin to become thick and rough, can be pretty tricky. This is due to the fact that there’s a long list of conditions, both harmless and serious ones, that could possibly trigger hyperkeratosis. Figuring out exactly what’s causing the issue often involves a careful review of the patient’s medical history and a thorough physical examination. Sometimes, a skin biopsy might be needed to arrive at a conclusion.
Here are some conditions the doctors look for when diagnosing hyperkeratosis:
- Callus and Corns
- Keratosis plantare (a disease that affects the feet’s skin)
- Chronic folliculitis (persistent inflammation of hair follicles)
- Atopic dermatitis (commonly referred to as eczema)
- Psoriasis and a similar condition called psoriasiform dermatitis
- Lichen planus and lichenoid dermatitis (skin conditions resulting in bumps or rashes)
- Keratosis pilaris (a condition causing small, rough patches on the skin)
- Ichthyoses (a group of skin disorders leading to dry, scaly skin)
- Seborrheic keratosis (harmless skin growths)
- Actinic keratosis (skin lesions caused by sun exposure)
- Keratoacanthoma (a fast-growing, non-cancerous skin tumor)
- Paraneoplastic syndromes (symptoms caused by cancer-related hormones or substances)
- Squamous cell carcinoma (a type of skin cancer)
- Basal cell carcinoma (another type of skin cancer)
What to expect with Hyperkeratosis
The future health outcome often depends on the specific skin condition causing hyperkeratosis, which is a type of skin disorder leading to an abnormal thickening of the skin’s outer layer. Usually, hyperkeratosis gets better with proper treatment. However, in some situations, it might persist or keep coming back.
Possible Complications When Diagnosed with Hyperkeratosis
Psychological distress can often result from the visible rough skin patches, especially when they appear on highly visible areas like the face, head, and neck. Another possible complication is that scars can form when the patient tries to treat the skin patches themselves. It’s crucial for medical professionals to explain to patients the importance of using the prescribed skin creams and lotions, and avoiding touching or picking at the skin patches.
Common Effects and Complications:
- Psychological distress due to visible rough skin patches
- Scarring from self-treatment or touching the skin patches
- Importance of using prescribed skin creams and lotions
- Importance of not touching or picking at the skin patches
Preventing Hyperkeratosis
It’s important for patients to understand that basic skin care steps like keeping the skin clean, keeping it well-hydrated, and gently removing dead skin cells are key to keeping their skin healthy. This holds true even for areas of skin that may be affected by a skin condition. Depending on the specific skin diagnosis, the doctor will also provide guidance on other skincare do’s and don’ts to help manage the condition.
