3 case reports of Arsenic Keratosis

Introduction

Arsenic poisoning is a medical condition, which occurs due to elevated levels of arsenic in the body.1   If arsenic poisoning occurs over a brief period of time, then patient suffers from abdominal pain, vomiting, diarrhea  mixed with blood, headache and confusion. It can even terminate in death.2 Long -term exposure to arsenic results in skin changes, and skin becomes thicker,  and darker with pointed skin elevations called arsenic keratosis.  It may even lead to skin cancer.2  The most common reason for long term exposure is contaminated drinking water.3  Groundwater most often becomes contaminated naturally; however, contamination may also occur from mining or agriculture.2  Prevention is by using water that does not contain high levels of arsenic. This may be achieved by the use of special filters or using rain water.2   In the Western world, arsenic compounds, such as Salvarsan, were used extensively to treat Syphilis before penicillin was introduced. In Ayurveda arsenic powder is used to treat chronic itchy skin conditions like eczemas. We report here 3 cases of arsenic ketatosis.

Case Reports: 

We describe three patients from Murshidabad district, West Bengal, who suffered from Arsenic Keratosis. All of them had similar skin lesions, hair changes and nail changes . All three patients stated that their family members, relatives and neighbors also had skin problems in their villages.

All three patients stated that they had soft, warm and normal skin of palms and soles, like any other fellow members. They later noticed their palmar and plantar regions of the skin becoming thicker and darker over a period of 3-5 years. They were feeling shy to shake hands with their friends. When they shook hands with their friends, friends complained that their hands were dry, rough and are having pointed elevations, which caused discomfort to them and this made them not to shake hands.

Case 1: 

A 30 year old man presented with dried, rough, less sensitive skin of both hands since 5 years. There were dry, rough, and pointed papules and plaques on the hands (Fig.1) which was diagnosed as Arsenic Keratosis. The patient had developed non-healing ulcers on palmer surface of hands (Fig,2)and squamous cell carcinoma (SCC) on his scalp (Fig,3).

Case 2:

A 40 year old male patient had developed rough and dry skin of both hands and feet. Similar lesions were observed on the chest (Fig.4).  Biopsy revealed Bowen’s disease.

Case 3:

A 35 year old male patient had developed dry, rough skin of feet and hands (Fig. 5, 6) since 3 years. There were non-healing ulcers in the feet and hands. Biopsy showed presence of SCC.

These patients exhibited excess hair fall and the remaining hairs were thin and lusterless. Nails were dry and showed pigmented lines (Mee’s lines). Blood arsenic levels were high in all three patients. All of them had generalized weakness and anemia. All of them drank water from bore wells.  

Investigations

All three patients had microcytic hypochromic anemia. Biopsy of one lesion showed features of SCC. Arsenic level in the patients– case 1 - 42 µg/L, case 3 – 48 µg/L, (Normal arsenic level –<20 µg/L).

Dyskeratosis and keratin pearls are noted, suggesting well differentiated keratinizing squamous cell carcinoma, Biopsy specimen of one of the non-healing ulcer showed hyperkeratosis,acanthosis and mild to moderate dysplasia in the stratified squamour epithelium. Tumor cells were seen infiltrating into the underlying sub epithelium in the form of tight clusters and nests. Cells were mildly pleomorphic with abundant eosinophilic glassy cytoplasm and vesicular nuclei. Dyskeratosis and keratin pearls were noted suggesting well differentiated keratinizing squamous cell carcinoma (Fig. 7).   

Discussion

Arsenical keratoses typically begins as pinpoint papules that are easier felt than seen. They develop into small, 2 to 10 mm, punctate, yellow, keratotic papules which are most commonly seen on the palms and soles in areas of constant pressure or repeated trauma. They preferentially arise on the thenar eminence, and lateral borders of the hands, the sides of fingers and sometimes on the dorsal surface of the fingers, overlying the joints.⁴ Arsenical keratoses can be found on more widespread body areas such as the trunk, extremities, eyelids and genitalia. Arsenical keratoses may also present as slightly elevated, erythematous, scaly or pigmented plaques. Arsenical keratoses may slowly progress to Bowen’s disease, BCC, and SCC.⁴

Treatment

Topical moisturizers and retinoic acid was given. Case 1 was not ready for surgical treatment of the scalp cancer. Case 2 and Case 3 agreed for surgical excision of skin cancers. All patients were advised to drink safe water and explained about the risk of cancer development.

Ground water is a major source of drinking water and elevated concentration of arsenic in ground water has been associated with various negative health effects in humans.⁵  The World Health Organization has recommended limits to the maximum concentration of arsenic in drinking water to 5-10 µg/L (5-10 parts per billion)in 1993.⁶

Contamination of ground water is one of the major pathways of human exposure to inorganic arsenic and the risk of arsenic contamination is generally much higher in ground water than in surface water.⁷ The most important action in affected communities is education of all the people of that village, village leaders and local Government officials about the hazards of drinking water contaminated with arsenic. Regularly arsenic levels should be checked, and should be informed to all villagers.

Community based arsenic removal water plants, last long only if they are maintained well. The mechanical components of the plant need to be replaced regularly. Household level arsenic filters are also good but they protect one family only. Rain water harvesting is very important. Rain water harvesting should be taught to school children, so that by the time, they become responsible citizens, they learn and practice Rain water harvesting.⁸