A 12-year old boy, presented with skin colored raised lesions on dorsum of his hands for 2 years. There were multiple, 1 to 4-mm, skin-colored, firm, discrete, smooth surfaced papules, present on the dorsal aspect of both hands. Skin biopsy revealed hyperkeratosis, hypergranulosis, acanthosis and a normal dermis. Elastin stain did not reveal any degeneration. The child was diagnosed with focal acral hyperkeratosis. The differential diagnosis include verruca vulgaris, acrokeratoelastoidosis of Costa, degenerative collagenous plaques of the hands, keratoelastoidosis marginalis of the hands, punctate palmoplantar keratoderma, digital papular calcinosis, acral mucinosis, acrokeratosis verruciformis of Hopf and xanthoma. The skin lesions in hereditary papulotranslucent acrokeratoderma are characteristically exacerbated after exposure to water. Marginal papular acrokeratoderma encompasses a group of disorders that share crateriform, keratotic papules along the margins of the hands and feet. Warts exhibit verrucous surface as compared to smooth papules of focal acral hyperkeratosis. Punctate palmoplantar keratoderma is associated with thickened palms and soles, acral mucionosis and xanthoma have a shiny white coloured appearance. Probably a biopsy with special staining (presence of elastorrhexis, mucin, fat, calcium deposits) would aid in their definite differentiation.

Fig.1 Multiple skin -colored papules.