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The location of the patient's lesions, as well as her underlying conditions, pointed to the diagnosis.

A 48-year-old man, in a chronic hemodialysis program, had numerous skin lesions develop that consisted of follicular papules and small hyperkeratotic nodules, located on the trunk, hips, and upper and lower extremities (where the lesions were more numerous). The nodules measured 3 to 5 mm and had a dark discoloration (Figs 1 and 2). Four months previously, the patient noticed the appearance of disseminated papular and pruritic lesions. The lesions did not improve with the prescribed local nonspecific treatment. The patient had chronic renal failure during the previous 10 years, secondary to renal vein thrombosis. As a result, he has had periodic hemodialysis for 18 months. The clinical diagnosis of the skin lesion was Kyrle disease, and a skin biopsy was performed on a nodular lesion from the thigh. The histologic sections showed skin with hyperkeratosis, an invagination of the epithelium filled with keratin and amorphous material. In some sections, the invagination appeared to be a cyst, which in serial sections, showed partial rupture of the lateral wall. No evidence of hair was found inside the invagination.

We have noticed in eight male patients transepithelial keratotic plugs which appeared preferentially on zones of supporting points. These plugs evoked in a more or less accurate way, Kyrle's disease or other related syndromes, particularly reactive perforating collagenosis and perforating folliculitis. Seven cases were associated with chronic and severe renal failure complicating a serious diabetes in four cases, one of them with a viral hepatitis. One case has been observed during an important denutrition with digestive disorders.

Three patients with renal disease had hyperkeratotic follicular and parafollicular lesions on the extremities. Since all of these patients had renal disease, we hypothesize that an abnormality in the renal-calcium-vitamin D-parathyroid chain allows the pathologic accumulation of keratinous debris that characterizes Kyrle's disease. As with other diseases with abnormal keratin generation, the retinoids, specifically topical tretinoin, ameliorate this condition. Despite controversial reports about poor results with tretinoin therapy, our patients have had good results without recurrences and tolerated tretinoin well.