Persistent Bilateral Palmar Hyperkeratotic Papules in an Adolescent Male

A 14-year-old boy presented with a more than 3-year history of mildly pruritic keratotic papules on both palms, resembling punctate palmoplantar keratoderma, porokeratotic eccrine ostial and dermal duct naevus, and Darier disease. Lesions showed central depressions, brown keratin plugs and whitish collarettes. Histopathology revealed epidermal thinning, a diminished granular layer, basal vacuolar alteration, and a dense lymphohistiocytic infiltrate confined to widened dermal papillae embraced by adjacent rete ridges, forming a “claw clutching a ball” configuration.