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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.

First Trimester Pregnancy
  • Trimester Pregnancy ‑ Second Trimester Pregnancy ‑ Third Trimester View all Pregnancy Pregnancy Discussions Mums2Be Groups Ante Natal Classes Baby In This Section Baby Care Baby Development Breastfeeding Feeding Baby Help Baby to Sleep Life with a New[rollercoaster.ie]
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]

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].

Treatment

  • Dutch physicians prefer combined topical antibiotic therapy with non-pharmacological treatments and perceive the efficacy of topical antibiotic therapy superior to non-pharmacological treatments.[ncbi.nlm.nih.gov]
  • Appropriate treatment includes keeping feet dry with adequate treatment of hyperhidrosis, preventive measures, and topical antibiotic therapy.[ncbi.nlm.nih.gov]
  • CONCLUSION: Hyperhidrosis may be considered the major etiologic factor for pitted keratolysis that does not respond to treatment.[ncbi.nlm.nih.gov]
  • All patients underwent only topical treatment with erythromycin 3% gel twice daily. At the beginning of the study and after 5 and 10 days of treatment, a clinical evaluation and a gravimetric measurement of plantar sweating were assessed.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Several topical and oral treatments are available to successfully manage pitted keratolysis. Our patient confirms previous reports of pitted keratolysis resolving with mupirocin 2% ointment treatment.[ncbi.nlm.nih.gov]

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

  • CONCLUSION: 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, 2012 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]
  • Due to the interdisciplinary nature, dermatologists are not the only ones who should be aware of the disease, but also family medicine doctors, sports medicine specialists, and occupational health doctors who should educate patients about the etiology[ncbi.nlm.nih.gov]
  • 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]
  • Each entity is described using brief text that summarises its epidemiology, pathogenesis and clinical features. The diagnostic process is then described and illustrated using both clinical and histopathologic images.[books.google.de]
  • 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]
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]
  • Preventive measures, topical antibiotic therapy and adequate treatment of hyperhidrosis are the mainstay methods in the management of patients with PK. 2012 The Authors.[ncbi.nlm.nih.gov]
  • 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]

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: 2018-06-22 05:58