Aquagenic syringeal acrokeratoderma

[Chris@ScubaBoutique]

Hi Everyone,

I received the most difficult question to answer from a prospective student a day ago. The gentleman in question suffers from a very rare skin condition called Aquagenic syringeal acrokeratoderma which is a reaction to water. They really really really want to learn how to scuba dive.

Given that their hands react painfully to immersion in water, the only suggestion I have managed to come up with is that the student learn to scuba dive in a drysuit where their hands are completely dry (barring their suit flooding, of course).

If anyone has any other ideas of how to train someone with this skin condition, I would be more than happy to share it with them.

Cheers,

Chris
Toronto Scuba Club

 

[Duke Dive Medicine]

Interesting question. There are only about 30 cases of this that have ever been reported in the literature. The latest is here: Dermatoscopy as an Adjunctive Diagnostic Tool in... [Dermatology. 2012] - PubMed - NCBI

How fast do his hands react when immersed? If it happens very quickly and impedes his ability to manipulate objects like a free-flowing regulator or flooded mask, he could be at risk if whatever waterproofing method you come up with fails.

Case reports in the literature seem to indicate that the condition abates as soon as the hands are dry, so if he's able to self-rescue in the event of a drysuit leak, it's unlikely that there will be any long-term damage.

That said, his dermatologist or primary care practitioner would be in a better position to make recommendations based on his individual condition. Do you know if he's consulted with a health care practitioner about this?

Best regards,
DDM

 

[Chris@ScubaBoutique]

Hi DDM,

Thanks for the response.

This was quite literally a telephone query, so I confess to not knowing the exact extent of his medical care to date. He did advise that the conditions are "sporadic", in that they occur for months at a time and then suddenly stop for a period, then return. Similarly, the length of exposure to water before a reaction starts varies as well.

Right now, he is experiencing incredible discomfort (he likened the sensation to gripping a hot iron, although I hope he hasn't tried to simulate that!) within three minutes if his hands get wet. When he dries his hands, the conditions abate, but the sensation still lingers for a little while longer, sometimes for hours. At other times, he has been able to immerse his hands fully and then the symptoms don't appear until an hour or so later. Additionally, he also used to experience this condition on his feet, but that stopped a couple of years ago and he hasn't had any further issues with his feet.

The one other point he made (as I had mentioned that dry suit diving was the only option I could think of where the hands could stay dry, but that he could still heat up and sweat) was that sweat does not create the same condition, unless it is copious.

He has talked to his dermatologist, but they advised that they have no dive knowledge and cannot help. I know a couple of hyperbaric specialists here in Toronto, but I'm hazarding a guess that they don't know anything specific about skin conditions and diving. I am more than happy to pass him on to the appropriate medical specialist (while I like to think I've done my homework regarding diving and medicine, I'm not a doctor, so I will gladly bow down to superior knowledge), but I cannot figure out who. My only other thought was to direct him to the DAN hotline.

Outside of a dry suit, I cannot think of another means of protecting his hands. Diving with plastic bags on the hands doesn't seem a particularly smart move and regardless, with wrist manipulation, water would still likely seep in. It seems to me that the risk factor of his hands getting wet at depth (even in a drysuit) is too high, because if there was a reaction and the diver needed to make a safe ascent (which, by the way for me at least for recreational levels is leaning towards a 9m/min ascent rate, with a 1 min deep stop and 2 min shallow stop), then the chances of panic, accident, or just the excruciating pain would be a recipe for disaster.

Even if a dry suit is an option, I am still humming and harring on promoting it, because a suit flood is always a possibility, the suit would need to have attached sealed gloves and it would pretty much rule out warm water diving. We're talking a lot of hassle just to try and get this guy in the water.

I really appreciate the response though, so I suppose my query boils down to:

a) from a dive equipment perspective, are there any alternatives to a dry suit that would still offer practicality and ease to adapt diving for this individual's disability; and,
b) what other medical expert could I redirect this gentleman to for a fuller answer other than his dermatologist?

Thanks again, DDM.

 

[TSandM]

the suit would need to have attached sealed gloves and it would pretty much rule out warm water diving

I don't have anything pertinent from the medical standpoint to add . . . but I wanted to address this comment. I have, over the last couple of years, simply gone dry, period. I don't dive a wetsuit anywhere. I don't USE my dry gloves in warm water, but I could if I wanted to -- I'd just not put a liner glove in them. (I have done this when doing class work in Lake Washington, where I didn't want water to wick up my wrist seals.) If you use a laminate dry suit, how warm you are depends entirely on what you wear under it. In the 86 degree water in the Red Sea, I wore just my Diving Concepts base layer.

Also, for dry glove, if it is critical that the hands stay dry, a system that is designed for hazmat divers should work. I use the Viking bayonet dry glove rings, which were designed for that purpose. I have had leaks (particularly if I don't keep the rings meticulously clean) but I have never had a glove leak late in a dive. The problem is always immediately apparent (or within the first five minutes) which should allow this diver to abort a dive safely.

 

[Duke Dive Medicine]

Hi Chris,

Since this is such a rare condition, his dermatologist would be the best source of information. I can't imagine that the disorder would be aggravated by the pressure changes of diving, so a local diving medical specialist would likely defer to the dermatologist.

Fortunately, Dr. Moon is here at the moment with an IPE test subject so I asked him about it. Short version of our conversation:

Me: Have you ever heard of aquagenic syringeal acrokeratoderma?
Dr. Moon: God bless you.

We talked a bit more after that, and his concerns were essentially the same as mine. If he can keep his hands dry he's probably ok to dive, but he has to think through the consequences of getting them wet. From the sound of it, he would be at a reduced capacity to respond to emergencies if his gloves leaked.

Cystic fibrosis is also associated with this disorder. I made a big assumption earlier in thinking that he'd have told you if he had CF, but for the record, cystic fibrosis would be an absolute contraindication to diving. Any other systemic disorders or comorbidities would of course have to be addressed as well.

I personally don't know of anything that would be better at keeping his hands dry than TSandM's suggestion of the Viking dry gloves with cuff rings. They're reliable enough that commercial hazmat divers depend on them in sewage treatment plants and pulp mills, but of course nothing is 100%. Maybe the conservative thing to do would be to recommend he go through either HSA or DiveHeart, which would mandate that he have buddies capable of helping him if something went wrong and he was unable to rescue himself.

Best regards,
DDM

 

[Chris@ScubaBoutique]

Hi DDM and TSandM,

First, a huge thanks to both of you for very helpful and informative answers. I have a friend who shoots a TV series on diving and he uses precisely the same gloves on his suit, TSandM, so that was the way I was thinking too, but to have you clarify was extremely helpful. DDM, your additional comments on the hazmat nature of the usage (which TSandM alluded to) of those gloves further confirmed my initial reaction.

I am also particularly concerned about the ability to respond to an emergency situation and the suggestion as to HSA and DiveHeart was appreciated. I actually emailed a colleague who works through the HSA.

TSandM, thanks for your point of view on diving dry in tropical waters. My confession is that I hate being cold, so I always dive in a thicker wetsuit than most would for the local conditions, but I have always thought I'd boil in a dry, so your statement is certainly causing me to rethink that.

DDM, I had discovered the link between aquagenic syringeal acrokeratoderma and CF, so that was going to be one of my follow-up questions with the gentleman, but good to know I am thinking along the right tracks.

It sounds like it would be a hill to climb for this gentleman to pursue diving, but armed with this information, as well as full clearance from his medical practitioners (particularly barring CF), at least he can now investigate options (and hopefully bring us along for the education).

Yours,

Chris
Toronto Scuba Club

 

[John C. Ratliff]

TS&M,

I'll only add that a dry suit, of the shell variety, provides no thermal protection and so could be used in any environment (the thermal protection comes from what is worn under the shell). I had a Sargent when in the USAF who wanted to try a USAF survival suit in a reservoir in Korea in 1969 in February. I could not talk him into wearing anything other than a flight suit (about equivalent of wearing jeans) under the suit. We let him jump into the reservoir (he was a Pararescueman, and so this was part of the job). We went around in the helicopter and picked him up about ten minutes later, and he was very hypothermic (water temperature was in the 30s F).

Any water temperature less than body temperature will cause heat loss, because of the properties of water. A dry suit would also provide sun protection in tropical areas, but would be uncomfortable in the sun prior to a dive. So there are a few minuses.

Chris,

If there are no more contraindications, I would also recommend a full-face mask for this person. That way, all the skin is covered.

By the way, I was in Toronto last week on vacation with my wife. I should have looked you guys up!

SeaRat

 

[Chris@ScubaBoutique]

Hi John,

We love saying hello to new faces!! Hopefully you had a good trip to Toronto and didn't find it too chilly (the weather has dropped quite a few degrees the last couple of weeks).

Your suggestions about the shell make perfect sense too. I've sent the gentleman off to his dermatological team. He remains keen and was very thankful for the information.

Thanks to all three of you.

Chris
Toronto Scuba Club

 

[pasley]

NOT A DOCTOR and the below is not medical advice. Contact DAN for an informed opinion.

Drysuit with drygloves and a dry hood and full face mask are the only options aka full hazmat outfit. With only a drysuit, his hands, neck, head and face would still get wet. In full hazmat outfit, I would imagine he would sweat his a$$ off in warm weather or water.

Interesting about sweat not causing a problem unless it is huge amounts. I wonder if salt water would be a different reaction than tap or fresh water? Don't know, but if you have an allergy to water then I would say diving would not be my first choice for a sport. For other allergies, continued exposure to the allergen sometimes causes the reaction to become more severe over time. Don't know if that would apply to him, but he should be cautious.