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| CASE REPORT |
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| Year : 2021 | Volume
: 5
| Issue : 1 | Page : 117-119 |
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Arsenical keratoses: Case report from nonendemic area of Amritsar
Tejinder Kaur1, Jyoti Budhwar2
1 Department of Dermatology, Venereology and Leprosy, Goverment Medical College, Amritsar, Punjab, India
2 Department of Dermatology, Venereology and Leprosy, Sri Guru Ramdas Institute of Medical Sciences and Research, Amritsar, Punjab, India
| Date of Submission | 13-Dec-2019 |
| Date of Decision | 30-May-2020 |
| Date of Acceptance | 08-Jul-2020 |
| Date of Web Publication | 19-Feb-2021 |
Correspondence Address:
Jyoti Budhwar
#138, Smile Enclave, Opposite Vrindawan Gardens, Fatehgarh Churian Road, Amritsar - 143 001, Punjab
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/CDR.CDR_49_19
Arsenic occurs naturally in the earth's crust, widely distributed in the environment, in drinking water, used in various industrial, agricultural & medicinal substances & is a occupational hazard for miners and glass workers. Arsenic impairs nucleotide excision repair, affect DNA methylation. Chronic exposure of arsenic leads to arsenical keratosis, which usually presents as multiple hyperkeratotic, punctuate lesions, occurs at sites of friction and trauma especially on palms and soles and on chronically light exposed skin. They resemble Bowen's disease microscopically and may progress to squamous cell carcinoma or basal cell carcinoma. Topical 5-FU, 5% Imiquimod and oral retinoids may be helpful in treating arsenic induced cutaneous lesions. Arsenical keratosis in a patient of non endemic area of Amritsar region, makes this case worth reporting.
Keywords: Arsenic, arsenical keratoses, Bowen's disease
How to cite this article:
Kaur T, Budhwar J. Arsenical keratoses: Case report from nonendemic area of Amritsar. Clin Dermatol Rev 2021;5:117-9 |
| Introduction | |  |
Arsenic is a naturally occurring metalloid, an abundant element found in many types of rocks. It is a ubiquitous element that has no color, taste, or odour. Arsenical compounds are used in industrial, agricultural, and medicinal substances. Before Western medicine was introduced, traditional medicine played an important role in curing diseases and arsenic compounds were widely used in them.[1] It is also an environmental contaminant in drinking water (well water) and in food chain and is an occupational hazard for miners and glass workers. Arsenite impairs nucleotide excision repair, and it may also affect gene expression by increasing or decreasing DNA methylation. The high affinity of arsenic for sulfhydryl groups makes keratin-rich cells (e.g., epidermal keratinocytes) a sensitive target for arsenic-induced toxicity. Arsenic has been shown to alter epidermal keratinocyte differentiation processes, induce overexpression of growth factors, enhance proliferation of human keratinocytes, induce apoptosis, and inhibit tumor growth, thus in September 2000, arsenic trioxide was approved to be used in the treatment of acute promyelocytic leukemia.[2] Arsenical keratoses are the most characteristic skin feature of long-term arsenic exposure. Numerous reports have since confirmed that ingested arsenic can cause Bowen's disease (squamous cell carcinoma in situ); invasive squamous cell carcinoma; basal cell carcinoma of the skin; and (less frequently) internal cancers of the lung, the kidney, the bladder, and the liver.
| Case Report | | |
A 65-year-old male farmer presented with asymptomatic, multiple hyperkeratotic papules and plaques of varying sizes (2–5 mm) on bilateral palms and soles; multiple hyperpigmented plaques with irregular borders, measuring 1–2 cm in diameter on non sun-exposed skin surfaces from the last 8 years; nodulo-ulcerative growth on the ring finger; and nodular growth on the little finger of the left hand from the last 5 years [Figure 1] and [Figure 2]. Moreover, hyperpigmentation with smaller areas of hypopigmentation resembling “rain-drops on a dusty road” was evident on his trunk [Figure 3]. The remainder of the physical examination was normal. He was using fertilizers in fields and ground water since 30 years and did not have any drug history. Family history was unremarkable. All routine investigations, including serum lipid profile and liver profile, were within normal limits. Estimation of arsenic levels in blood and water was not done. Histopathological examination from nodulo-ulcerative lesion was consistent with features of Bowen's disease [Figure 4]. Due to a high index of suspicion owing to distribution of the lesions, palmo-plantar involvement, and supported by histopathological findings, a diagnosis of arsenic-induced Bowen's disease with arsenical keratosis was made. The patient was put on 25 mg of acitretin with topical 1% 5-fluorouracil (5-FU). He was regularly followed at 2-weekly intervals with regular routine investigations. Remarkable improvement was noticed in the morphology of the lesions [Figure 5] and [Figure 6]. The patient was regularly followed up for 3 months, after which he lost to follow-up. | Figure 1: Nodulo-ulcerative growths on the ring finger and little finger
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 | Figure 2: Hyperkeratotic papules and plaques on the palms (a) and (b) soles
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 | Figure 3: Raindrop pigmentation on the trunk and back (a and b) and hyperpigmented plaques on the back (b) (inset)
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 | Figure 4: Histopathology showing features of squamous cell carcinoma in situ (a) inset showing mitoses and (b) inset showing koilocytes (H&Ex10)
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 | Figure 6: Mild improvement in lesions of palms (a) and soles (b) after 3 months
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| Discussion | | |
Arsenic is a naturally occurring element that is widely distributed in the earth's crust. It can leach into groundwater through rocks and soil, and is used in pesticides, wood preservatives, and tobacco. It is also released into the environment by volcanoes and mining process. Arsenic in groundwater is a widespread problem. Arsenic levels tend to be higher in drinking water that comes from ground sources, such as wells, than from water from surface sources such as lakes or reservoirs. Most arsenic gets into the body through ingestion of food or water and this by far is the most common cause of chronic arsenic poisoning worldwide. Arsenic in drinking water is a problem in many countries around the world including Bangladesh, Chile, China, Vietnam, Taiwan, India, and the USA.[3]
Arsenicosis, as defined by the WHO, is “a chronic health condition arising from prolonged ingestion of arsenic above the safe dose for at least 6 months, usually manifested by characteristic skin lesions of melanosis and keratosis, occurring alone or in combination, with or without the involvement of internal organs.” Chronic arsenic exposure has an insidious course and might take 30–50 years before becoming clinically apparent. Diagnosis of arsenicosis relies mainly on clinical features, but in doubtful cases, laboratory investigations can help. Chronic exposure to inorganic arsenic has been associated with prominent cutaneous features with myriads of internal organ involvement as well as cancers.[4] Skin lesions are found to be the most common and earliest manifestations in arsenicosis patients. Pigmentary changes (melanosis) and hyperkeratosis are the predominant cutaneous effects. At higher centers, facilities of newer biomarkers of arsenic exposure are available to provide early information about arsenic intoxication, of which urinary porphyrin levels and blood metallothionein have shown promising results.[5]
Arsenic keratoses are usually multiple, punctuate keratoses, which occur at sites of friction and trauma, especially on palms and soles, from long-term arsenic ingestion. Induration, inflammation, and ulceration occur when the lesion becomes malignant, resembles Bowen's disease microscopically, and may progress to squamous cell carcinoma or basal cell carcinoma.[6] There are great individual variations in tolerance, and it is not possible, on present data, to construct a precise dose–response curve. The multiplicity of the keratosis makes treatment difficult. Where it is necessary, the use of a keratolytic ointment and trimming down of the surface is helpful. All the affected patients should be examined periodically for evidence of malignant change and for signs of visceral malignancy. A chelating agent (e.g., dimercaprol) may be helpful to correct acute arsenic exposure, but it has minimal or no effect for patients who had arsenic exposure a long time ago. Topical 5-FU, 5% imiquimod, and oral retinoids may be helpful in treating arsenic-induced cutaneous lesions and in reducing the risk of cutaneous and internal malignancy formation, especially in Bowen's disease.[7],[8] Our patient was treated with acitretin 25 mg daily and topical 1% 5-flourouracil. He has responded well with considerable improvement in his lesions.
As clinical presentation of this condition is variable, these patients can present to multiple specialists and the diagnosis of arsenic keratosis is often missed. A high index of suspicion is required especially in nonendemic areas. The distinct cutaneous manifestations enable the clinician to correctly diagnose the condition, even in nonendemic areas. Perennial scarcity of water in many parts of the country led to digging of deep bore wells for irrigation; the increasing use of fertilizers and pesticides in fields to yield bumper crops coupled with increasing migration of population from the areas endemic for arsenicosis increases the number of cases of chronic arsenicosis even in nonendemic areas.[9] Our case highlighted that dermatologists should be aware of cutaneous manifestations of chronic arsenicosis even if working in nonendemic areas. Thus, arsenic-induced Bowen's disease with arsenical keratosis in a patient from Amritsar region, makes this case worth reporting.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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