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Pitted Keratolysis

Keratoma Plantare Sulcatum

Pitted keratolysis is a skin disorder caused by certain Gram-positive bacteria such as Corynebacterium spp. Affected individuals typically present with foot odor and multiple small pits on weight-bearing parts of their soles. Treatment comprises a change of footwear as well as the topical application of antimicrobials. The condition is associated with an excellent prognosis.


Presentation

Pitted keratolysis (PK) has been observed in patients of any age, in shod and unshod populations distributed throughout the world [1]. Nevertheless, a thorough anamnesis often reveals that patients used to wear tight, poorly breathable shoes for prolonged periods of time. In this context, PK is more frequently diagnosed in soldiers, sailors and athletes [2]. Furthermore, barefooted people in tropical areas are prone to develop PK. The afore-described conditions favor growth and replication of the causative agents of the disease. In more than 90% of cases, both feet are involved [3].

As its name implies, the disease is associated with progressive proteolysis in the stratum corneum, which results in the appearance of characteristic pits on the plantar surface. Circular lesions appear as if they have been punched out, and they may measure up to 7 mm in diameter [4]. Coalescence of pits may result in larger, crateriform skin defects. Less profound lesions of distinct size may also be observed. Affected skin may take on a pale, whitish tone, or become erythematous. It may be traversed by fissures [2]. Lesions are most commonly located on the heels and weight-bearing metatarsal parts of the feet, although the disease tends to spread over the forefoot and towards the toes. Many patients describe an apparent exacerbation when soaking their feet in water [5] while the accentuation of skin lesions does indeed result from a swelling of the infected, eroded stratum corneum.

PK patients usually seek medical attention because of profuse sweating, sliminess of affected feet and socially unacceptable foot odor [2] [4]. Hyperhydrosis is, however, not a prerequisite for the diagnosis of PK. Some patients may claim an itching or burning sensation while walking, and the condition may also be associated with pain.

In rare cases, PK may also affect the palms of the hands [6] [7]. Here, scaling may be more pronounced than in plantar PK.

Military Personnel
  • Athletes and military personnel tend to develop this condition most commonly.[podiatry.org.mt]
  • But generally athletes and military personnel tend most to develop this.[almawiclinic.com]
  • As this condition is caused by bacteria, it should come as no surprise that it is often present in military personnel or people who wear tight or restrictive footwear for extensive periods of time.[medicalpoint.org]
  • Occupations at risk include: Farmers Athletes Sailors or fishermen Industrial workers Military personnel Females offering pedicure and foot care in a spa salon may also be affected by pitted keratolysis.[dermnetnz.org]
Weakness
  • My son had a decent case of this and it responded to a lovely old faishoned cure- i had him wash his feet straight after school, soak his feet in a weak soultion of Condy's crystals -potassium permanganate- for 5 minutes, then rub in Whitfields ointment.It[podiatryarena.com]
Plethora
  • A plethora of pictures, slides & information at my fingertips. Well worth a look Once again, thanks. Regards :drinks To Da Vinci I wish to say thank you for the picture google link.[podiatryarena.com]
Constipation
  • Most patients experience side-effects, such as dry mouth, and less often, headaches, blurred vision and constipation. Propantheline bromide is licensed for this indication.[gponline.com]
Blurred Vision
  • Most patients experience side-effects, such as dry mouth, and less often, headaches, blurred vision and constipation. Propantheline bromide is licensed for this indication.[gponline.com]
Skin Lesion
  • Many patients describe an apparent exacerbation when soaking their feet in water while the accentuation of skin lesions does indeed result from a swelling of the infected, eroded stratum corneum.[symptoma.com]
  • If you have a specific question or concern about a skin lesion or disease, please consult a dermatologist.[aocd.org]
  • Antifungal cream such as miconazole or clotrimazole With some combination of these treatments, the skin lesions and odor of pitted keratolysis usually disappear within 4 weeks.[podiatry.org.mt]
  • lesions and odor of pitted keratolysis usually disappear within 4 weeks.[skinsight.com]
  • With some combination of these treatments, the skin lesions and odour of pitted keratolysis usually disappear within 4 weeks.[almawiclinic.com]
Foot Rash
  • A foot rash with a foul odor. Phys Sport Med . 1998. 26:104-6. Burkhart CG. Pitted keratolysis: a new form of treatment. Arch Dermatol . 1980 Oct. 116(10):1104. [Medline] .[emedicine.medscape.com]
Anhidrosis
  • Injections of botulinum toxin have successfully induced cessation of sweating (anhidrosis) of the soles of the feet and led to resolution of pitted keratolysis.[en.wikipedia.org]
Palmar Hyperhidrosis
  • Associated plantar and palmar hyperhidrosis is seen in approximately 2/3 of cases. Figure 1. Pitted keratolysis. Small crateriform defects in the epidermis of the sole.[dermatologyadvisor.com]
Insect Bite
  • Bites Trichofolliculoma Keratoacanthoma Diagnosis Key Points *Diagnosis based on imaging tests of the affected area *Skin biopsy will be performed to confirm diagnosis and rule out other conditions Pitted keratolysis is typically diagnosed based on imaging[ozarkderm.com]
Confusion
  • Abstract Though pitted keratolysis of the foot is generally viewed to be caused by bacteria, there is confusion regarding the identity of the causative organism.[ncbi.nlm.nih.gov]
Hyperactivity
  • […] clindamycin and benzoyl peroxide. 9 Oral antibiotics such as clindamycin and erythromycin may be prescribed for resistant cases. 11 If there is associated hyperhidrosis, aluminum chloride hexahydrate can be applied at night on the plantar surface to block the hyperactive[consultant360.com]
Headache
  • Most patients experience side-effects, such as dry mouth, and less often, headaches, blurred vision and constipation. Propantheline bromide is licensed for this indication.[gponline.com]

Workup

PK is diagnosed clinically. The presence of multiple small pits on irritated, hyperhidrotic soles is considered pathognomonic of PK [8]. The examination of affected skin with a Wood lamp typically reveals a pale yellowish or coral red fluorescence, but it has been pointed out that this is not an exclusion criterion [3] [9]. Skin scrapings may be obtained for microscopic analysis. In the case of dermatomycosis like tinea pedis, treatment of specimens with potassium hydroxide should facilitate the observation of dermatophytes and spores. Of note, patients may suffer from PK and concomitant tinea pedis [2]. If samples are taken for bacterial cultures, Gram-positive bacilli or coccobacilli (corresponding to Corynebacterium spp., Kytococcus sedentarius, or Dermatophilus congolensis) may be isolated [10] [11]. Such procedures are rarely necessary, though. This also applies for the histopathological examination of biopsy specimens. If electron microscopy scanning is carried out for scientific purposes, hypokeratosis of the plantar skin and sweat gland ducts may be observed [10].

Gram-Positive Bacteria
  • Pitted keratolysis is a skin disorder that affects the stratum corneum of the plantar surface and is caused by Gram-positive bacteria. A 30-year-old male presented with small punched-out lesions on the plantar surface.[ncbi.nlm.nih.gov]
  • Pitted keratolysis is a skin disorder caused by certain Gram-positive bacteria such as Corynebacterium spp. Affected individuals typically present with foot odor and multiple small pits on weight-bearing parts of their soles.[symptoma.com]
  • When it comes to bacterial skin infections, Pitted Keratolysis is a gram positive bacteria caused by the Micrococcus sedentarius. Pitted Keratolysis usually affects the soles of the feet and occasionally the palms of the hands.[skincareguide.com]
Corynebacterium Diphtheriae
  • Indian J Dermatol Venereol Leprol 2005;71:213-5 The Corynebacteria are a diverse group of gram-positive bacilli which include Corynebacterium diphtheriae as well as a bewildering number of species that are found on the skin as part of the normal flora[ijdvl.com]

Treatment

  • Appropriate treatment includes keeping feet dry with adequate treatment of hyperhidrosis, preventive measures, and topical antibiotic therapy.[ncbi.nlm.nih.gov]
  • Therefore, the optimal treatment approach for pitted keratolysis remains unclear as the condition has not been well-studied.[en.wikipedia.org]

Prognosis

  • The condition is associated with an excellent prognosis. Pitted keratolysis (PK) has been observed in patients of any age, in shod and unshod populations distributed throughout the world.[symptoma.com]
  • Interdigital intertrigo and paronychia may coexist with pitted keratolysis. 8 A corynebacterial triad of pitted keratolysis, erythrasma, and trichomycosis axillaris has been reported. 11,20 The prognosis for pitted keratolysis is good.[consultant360.com]
  • Prognosis Pitted keratolysis is cured easily and has an excellent prognosis. No mortality is associated with pitted keratolysis. However, the excessive foot odor from this disorder may be socially unacceptable.[emedicine.medscape.com]

Etiology

  • Hyperhidrosis may be considered the major etiologic factor for pitted keratolysis that does not respond to treatment.[ncbi.nlm.nih.gov]
  • (Nice short review of the condition, with a short discussion on epidemiology, etiology, and therapeutic options.) Copyright 2017, 2013 Decision Support in Medicine, LLC. All rights reserved.[dermatologyadvisor.com]
  • The etiology is unknown but may involve infection with Corynebacterium or Actinomyces. It occurs mostly in barefooted adults in the tropics.[medical-dictionary.thefreedictionary.com]
  • The etiology of pitted keratolysis is attributed to a gram-positive bacterial infection. It could be Kytococcus sedentarius, Dermatophilus congolensis, Corynebacterium species or Streptomyces.[podiatrytoday.com]

Epidemiology

  • Prevalence PK is likely a common problem, although sparse epidemiologic data include general prevalence rates of only 0.48–2.6%.[unboundmedicine.com]
  • A national survey of the epidemiology of skin infections among US high school athletes conducted by Ashack et al. supported the prevalent theory that contact sports are associated with an increased risk of skin infections.[ncbi.nlm.nih.gov]
  • However, very few studies are available on the clinical characteristics and epidemiological features of this disorder from India and abroad. Materials and Methods: Fifty patients from rural area of Kolar at Sri R.L.J.H. and S.N.R.[e-ijd.org]
  • Current epidemiology of atopic dermatitis in south-eastern Nigeria. Int J Dermatol. 2004 Oct. 43(10):739-44. [Medline]. Shenoi SD, Davis SV, Rao S, Rao G, Nair S. Dermatoses among paddy field workers--a descriptive, cross-sectional pilot study.[emedicine.medscape.com]
  • […] pressure-bearing areas of the soles. 1,2 The condition was first described by Castellani in 1910 as a disease affecting barefooted people during the rainy season in Sri Lanka. 3 The term "pitted keratolysis" was coined by Zaias and colleagues in 1965. 4 EPIDEMIOLOGY[consultant360.com]
Sex distribution
Age distribution

Pathophysiology

  • Case Overview pitted keratolysis Member Rated 0 Patient case no. 3177 Date added 01 July 2003 Patient details Age --Undetermined-- Localisation Lower limbs / feet / soles Description Primary Lesions Pits Pathophysiology infectious diseases / bacterial[dermquest.com]
  • Covering all athletes throughout their lifespan, this 2-volume reference explores the pathophysiology, diagnosis, and treatment of the full spectrum of sports-related injuries and medical disorders.[books.google.de]
  • Pathophysiology As the causative bacteria is felt to be part of the normal flora, local microenvironment changes at the level of the skin involved appear to be causative. Hyperhidrosis is found in approximately 70% of cases.[dermatologyadvisor.com]
  • Etiology and Pathophysiology Causative agents include gram-positive organisms: Corynebacterium species, Kytococcus sedentarius, Dermatophilus congolensis, and Actinomyces keratolytica ( 3 ).[unboundmedicine.com]
  • Pathophysiology Pitted keratolysis is caused by a cutaneous infection with Micrococcus sedentarius (now renamed to Kytococcus sedentarius ); Dermatophilus congolensis ; or species of Corynebacterium, Actinomyces, or Streptomyces. [4, 5, 6, 7] Under appropriate[emedicine.medscape.com]

Prevention

  • Appropriate treatment includes keeping feet dry with adequate treatment of hyperhidrosis, preventive measures, and topical antibiotic therapy.[ncbi.nlm.nih.gov]
  • Prevention There are ways to prevent developing Pitted Keratolysis. The best way to prevent developing an infection is to change your socks frequently if your feet sweat excessively.[skincareguide.com]
  • General Prevention Prevention strategies revolve around avoiding conditions that are hospitable to causative organisms.[unboundmedicine.com]
  • It is also recommended that affected persons keep the area dry to prevent recurrence.[ozarkderm.com]
  • You need to take active measures to prevent foot friction and avoid occlusive footwear.[med-health.net]

References

Article

  1. Bristow IR, Lee YL. Pitted keratolysis: a clinical review. J Am Podiatr Med Assoc. 2014;104(2):177-182.
  2. Kaptanoglu AF, Yuksel O, Ozyurt S. Plantar pitted keratolysis: a study from non-risk groups. Dermatol Reports. 2012; 4(1):e4.
  3. Blaise G, Nikkels AF, Hermanns-Lê T, Nikkels-Tassoudji N, Piérard GE. Corynebacterium-associated skin infections. Int J Dermatol. 2008;47(9):884-890.
  4. Fernández-Crehuet P, Ruiz-Villaverde R. Pitted keratolysis: an infective cause of foot odour. Cmaj. 2015;187(7):519.
  5. Leung AK, Barankin B. Pitted Keratolysis. J Pediatr. 2015; 167(5):1165.
  6. Lee HJ, Roh KY, Ha SJ, Kim JW. Pitted keratolysis of the palm arising after herpes zoster. Br J Dermatol. 1999; 140(5):974-975.
  7. López-Cepeda LD, Alonzo L, Navarrete G. Focal acral hyperkeratosis associated with pitted keratolysis. Actas Dermosifiliogr. 2005; 96(1):37-39.
  8. Lockwood LL, Gehrke S, Navarini AA. Dermoscopy of Pitted Keratolysis. Case Rep Dermatol. 2010; 2(2):146-148.
  9. Singh G, Naik CL. Pitted keratolysis. Indian J Dermatol Venereol Leprol. 2005; 71(3):213-215.
  10. de Almeida HL, Jr., Siqueira RN, Meireles Rda S, Rampon G, de Castro LA, Silva RM. Pitted keratolysis. An Bras Dermatol. 2016;91(1):106-108.
  11. Longshaw CM, Wright JD, Farrell AM, Holland KT. Kytococcus sedentarius, the organism associated with pitted keratolysis, produces two keratin-degrading enzymes. J Appl Microbiol. 2002;93(5):810-816.

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Last updated: 2019-06-28 11:33