A 57-year-old woman is referred for evaluation of scaly bumps on her feet and ankles. She states that the condition has been present for approximately 20 years. Aside from mild itch, she had no symptoms of significance associated with the lesions. The patient’s medical history is significant for hypertension but not thyroid disease. Examination reveals numerous brown-to-red papules with overlying adherent scale on the dorsal surfaces of both feet and ankles.
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Biopsy of the lesions was performed and revealed histopathologic findings consistent with hyperkeratosis lenticularis perstans (HLP), also known as Flegel disease. HLP is characterized by asymptomatic hyperkeratotic papules situated on the extremities. Individual papules exhibit adherent scale that reveals a bright red base accompanied by pinpoint bleeding upon removal.1 Lesions occur primarily on the extensor surfaces of the extremities but may uncommonly appear at other sites including the oral mucosa.2
Usually an autosomal-dominant disease, the etiology and pathogenesis of HLP remain largely unknown and some cases arise spontaneously. HLP typically manifests in late adulthood with no reported sex predilection.3 Once regarded as a variant of Kyrle disease, HLP is now considered a distinct entity.1,4
A variety of treatment modalities for HLP have been described with varying degrees of efficacy. These include topical retinoids, systemic retinoids, topical 5-fluorouracil, psoralen and ultraviolet A (PUVA) therapy, and topical vitamin D3 derivatives.5 Though patients affected by HLP may experience periods of exacerbation and remission, the overall prognosis remains excellent with no significant morbidity.1,6
Nelson Maniscalco, DPM, is a joint podiatry/dermatology fellow under the aegis of St. Luke’s Medical Center in Allentown, Pennsylvania, and the DermDox Center for Dermatology. Lawrence Schiffman, DO, is director of Miami Skin Dr in Doral, Florida. Stephen Schleicher, MD, is director of the DermDox Center for Dermatology in Pennsylvania, as well as an associate professor of medicine at Commonwealth Medical College and a clinical instructor of dermatology at Arcadia University and Kings College.
1. Krishnan A, Kar S. Hyperkeratosis lenticularis perstans (Flegel’s disease) with unusual clinical presentation. Response to isotretinoin therapy. J Dermatol Case Rep. 2012;6(3):93-95.
2. Miljkovic J. An unusual generalized form of hyperkeratosis lenticularis perstans (Flegel’s disease). Wien Klin Wocenschr. 2004;116 Suppl 2:28-80.
3. Jang KA, Choi JH, Sung KJ, Moon KC, Koh JK. Hyperkeratosis lenticularis perstans (Flegel’s disease): histologic, immunohistochemical, and ultrastructural features in a case. Am J Dermatopathol. 1999;21(4):395-398.
4. Metze D, Lübke D, Luger T. Hyperkeratosis lenticularis perstans (Flegel’s disease) – a complex disorder of epidermal differentiation with good response to a synthetic vitamin D3 derivate. Hautarzt. 2000;51(1):31-35.
5. Blaheta HJ, Metzler G, Rassner G, Garbe C. Hyperkeratosis lenticularis perstans (Flegel’s disease) – lack of response to treatment with tacalcitol and calcipotriol. Dermatology. 2001;202(3):255-258.
6. Fernandez-Flores A, Manjon JA. Morphological evidence of periodical exacerbation of hyperkeratosis lenticularis perstans. Acta Dermatovenerol Croat. 2009;17(1):16-19.