Palmoplantar keratodermas may present to the clinician with an extremely broad series of clinical findings. Management has also taken on a wide variety of medical and surgical modalities. The literature seems to provide evidence that optimum management consists of surgical excision with skin grafting. It is believed that this will eliminate all of the underlying tissue and associated skin appendages, which are believed to be the source of this abnormal skin entity. We present a case of a patient in which tangential excision with delayed split-thickness skin grafting was performed after initial application of an acellular dermal matrix (Integra). Unfortunately, there was nearly immediate recurrence of this disease, and we, therefore, suggest a more aggressive approach to the initial excision.