Pitted Keratolysis Clinical Presentation

  • Author: Joseph C English III, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jul 1, 2010
 

History

Patient with pitted keratolysis may report malodor, hyperhidrosis, sliminess, and, occasionally, soreness or itching associated with the pits[23] ; however, the pits normally are asymptomatic. Patients with primary hyperhidrosis have been shown to have a significant increase in pitted keratolysis compared with controls.[24]

The etiology of the tenderness in symptomatic cases of pitted keratolysis is unknown. In addition to pits, erythematous-to-violaceous macules to plaquelike lesions may be present.[21] In military personnel, whose long-term occlusive boot wearing exacerbates disease, lesions often become denuded, leading to foot pain and disability.[25] The palms of the hand also have been reported to be involved in some patients with pitted keratolysis of the feet.[26] Of the paddy field workers, 1.5% were diagnosed with palmar lesions in addition to foot lesions.[16] With hand involvement, a collarette forms around the keratolysis, rather than pits.

A triad of concurrent corynebacterial diseases (ie, erythrasma, trichomycosis axillaris, and pitted keratolysis) has been reported.[27] In a 2008 study, 108 of 842 South Korean male soldiers were diagnosed with pitted keratolysis, of which 13 (13%) of 108 had the triad.[18] Clinicians making a diagnosis of pitted keratolysis need to examine the patient for evidence of other corynebacterial infections.

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Physical

The primary lesions of pitted keratolysis are pits in the stratum corneum ranging from 0.5-7 mm, with some development of confluence, irregular erosions, or sulci (see the images below).

A large plaque-like lesion of Pitted keratolysis oA large plaque-like lesion of Pitted keratolysis on the large toe. Pitted keratolysis with hyperkeratosis on the heelPitted keratolysis with hyperkeratosis on the heel. Classic pits of pitted keratolysis on the plantar Classic pits of pitted keratolysis on the plantar aspect of the phalanges. Pitted keratolysis forming sulci on the heel. Pitted keratolysis forming sulci on the heel.

A variant of markedly enlarged lesions, called crateriform pitted keratolysis, also has been described.[28] This affects the entire width of the plantar surface of the foot underlying the metatarsophalangeal joints. The pits are rarely seen on non–pressure-bearing areas of the plantar surface, but this has been reported in the literature.[29]

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Causes

See Pathophysiology.

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Contributor Information and Disclosures
Author

Joseph C English III, MD  Clinical Vice-Chairman for Quality and Innovation, Associate Professor of Dermatology, Department of Dermatology, University of Pittsburgh

Joseph C English III, MD is a member of the following medical societies: American Academy of Dermatology and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

James W Patterson, MD  Professor of Pathology and Dermatology, Director of Dermatopathology, University of Virginia Medical Center

James W Patterson, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Society of Dermatopathology, Royal Society of Medicine, Society for Investigative Dermatology, and United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Edward F Chan, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Department of Dermatology, Geisinger Medical Center

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. Zaias N, Taplin D, Rebell G. Pitted keratolysis. Arch Dermatol. Aug 1965;92(2):151-4. [Medline].

  2. Rubel LR. Pitted keratolysis and Dermatophilus congolensis. Arch Dermatol. Apr 1972;105(4):584-6. [Medline].

  3. Nordstrom KM, McGinley KJ, Cappiello L, Zechman JM, Leyden JJ. Pitted keratolysis. The role of Micrococcus sedentarius. Arch Dermatol. Oct 1987;123(10):1320-5. [Medline].

  4. Woodgyer AJ, Baxter M, Rush-Munro FM, Brown J, Kaplan W. Isolation of Dermatophilus congolensis from two New Zealand cases of pitted keratolysis. Australas J Dermatol. Apr 1985;26(1):29-35. [Medline].

  5. Valente NY, Ribeiro Costa A, Pessoa Mendes J. [Pitted keratolysis. Presentation of 2 cases with culture of lesions positive for bacteria of the genus Corynebacterium]. Med Cutan Ibero Lat Am. 1983;11(1):61-4. [Medline].

  6. 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):810-6. [Medline].

  7. Holland KT, Marshall J, Taylor D. The effect of dilution rate and pH on biomass and proteinase production by Micrococcus sedentarius grown in continuous culture. J Appl Bacteriol. May 1992;72(5):429-34. [Medline].

  8. Hanel H, Kalisch J, Keil M, Marsch WC, Buslau M. Quantification of keratinolytic activity from Dermatophilus congolensis. Med Microbiol Immunol. 1991;180(1):45-51. [Medline].

  9. Nordstrom KM, McGinley KJ, Capiello L, Leyden JJ. The etiology of malador associated with pitted keratolysis. Journal of Investigative Dermatology. July/1986;87:159.

  10. Ara K, Hama M, Akiba S, et al. Foot odor due to microbial metabolism and its control. Can J Microbiol. Apr 2006;52(4):357-64. [Medline].

  11. Stratigos AJ, Stern R, Gonzalez E, Johnson RA, O'Connell J, Dover JS. Prevalence of skin disease in a cohort of shelter-based homeless men. J Am Acad Dermatol. Aug 1999;41(2 Pt 1):197-202. [Medline].

  12. Eun HC, Park HB, Chun YH. Occupational pitted keratolysis. Contact Dermatitis. Feb 1985;12(2):122. [Medline].

  13. Tuncel AA, Erbagci Z. Prevalence of skin diseases among male adolescent and post-adolescent boarding school students in Turkey. J Dermatol. Jul 2005;32(7):557-64. [Medline].

  14. Blaise G, Nikkels AF, Hermanns-Le T, Nikkels-Tassoudji N, Pierard GE. Corynebacterium-associated skin infections. Int J Dermatol. Sep 2008;47(9):884-90. [Medline].

  15. Nnoruka EN. Current epidemiology of atopic dermatitis in south-eastern Nigeria. Int J Dermatol. Oct 2004;43(10):739-44. [Medline].

  16. Shenoi SD, Davis SV, Rao S, Rao G, Nair S. Dermatoses among paddy field workers--a descriptive, cross-sectional pilot study. Indian J Dermatol Venereol Leprol. Jul-Aug 2005;71(4):254-8. [Medline].

  17. Gill KA Jr, Buckels LJ. Pitted keratolysis. Arch Dermatol. Jul 1968;98(1):7-11. [Medline].

  18. Rho NK, Kim BJ. A corynebacterial triad: Prevalence of erythrasma and trichomycosis axillaris in soldiers with pitted keratolysis. J Am Acad Dermatol. Feb 2008;58(2 Suppl):S57-8. [Medline].

  19. Wohlrab J, Rohrbach D, Marsch WC. Keratolysis sulcata (pitted keratolysis): clinical symptoms with different histological correlates. Br J Dermatol. Dec 2000;143(6):1348-9. [Medline].

  20. Lamberg SI. Symptomatic pitted keratolysis. Arch Dermatol. Jul 1969;100(1):10-1. [Medline].

  21. Shah AS, Kamino H, Prose NS. Painful, plaque-like, pitted keratolysis occurring in childhood. Pediatr Dermatol. Sep 1992;9(3):251-4. [Medline].

  22. Dogan B. Dermatological manifestations in hepatitis B surface antigen carriers in east region of Turkey. J Eur Acad Dermatol Venereol. May 2005;19(3):323-5. [Medline].

  23. Takama H, Tamada Y, Yano K, Nitta Y, Ikeya T. Pitted keratolysis: clinical manifestations in 53 cases. Br J Dermatol. Aug 1997;137(2):282-5. [Medline].

  24. Walling HW. Primary hyperhidrosis increases the risk of cutaneous infection: a case-control study of 387 patients. J Am Acad Dermatol. Aug 2009;61(2):242-6. [Medline].

  25. Schissel DJ, Aydelotte J, Keller R. Road rash with a rotten odor. Mil Med. Jan 1999;164(1):65-7. [Medline].

  26. Zaias N. Pitted and ringed keratolysis. A review and update. J Am Acad Dermatol. Dec 1982;7(6):787-91. [Medline].

  27. Shelley WB, Shelley ED. Coexistent erythrasma, trichomycosis axillaris, and pitted keratolysis: an overlooked corynebacterial triad?. J Am Acad Dermatol. Dec 1982;7(6):752-7. [Medline].

  28. Sehgal VN, Ramesh V. Crateriform depression--an unusual clinical expression of pitted keratolysis. Dermatologica. 1983;166(4):209-11. [Medline].

  29. Takama H, Tamada Y, Yokochi K, Ikeya T. Pitted keratolysis: a discussion of two cases in non-weight-bearing areas. Acta Derm Venereol. May 1998;78(3):225-6. [Medline].

  30. Vlahovic TC, Dunn SP, Kemp K. The use of a clindamycin 1%-benzoyl peroxide 5% topical gel in the treatment of pitted keratolysis: a novel therapy. Adv Skin Wound Care. Dec 2009;22(12):564-6. [Medline].

  31. Singh G, Naik CL. Pitted keratolysis. Indian J Dermatol Venereol Leprol. May-Jun 2005;71(3):213-5. [Medline].

  32. de Almeida HL Jr, de Castro LA, Rocha NE, Abrantes VL. Ultrastructure of pitted keratolysis. Int J Dermatol. Sep 2000;39(9):698-701. [Medline].

  33. Gardner TL, Elston DM. A foot rash with a foul odor. Phys Sport Med. 1998;26:104-6.

  34. Burkhart CG. Pitted keratolysis: a new form of treatment. Arch Dermatol. Oct 1980;116(10):1104. [Medline].

  35. Vazquez-Lopez F, Perez-Oliva N. Mupirocine ointment for symptomatic pitted keratolysis. Infection. Jan-Feb 1996;24(1):55. [Medline].

  36. Tamura BM, Cuce LC, Souza RL, Levites J. Plantar hyperhidrosis and pitted keratolysis treated with botulinum toxin injection. Dermatol Surg. Dec 2004;30(12 Pt 2):1510-4. [Medline].

 
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A large plaque-like lesion of Pitted keratolysis on the large toe.
A case of inflammatory pitted keratolysis
Pitted keratolysis with hyperkeratosis on the heel.
Classic pits of pitted keratolysis on the plantar aspect of the phalanges.
Pitted keratolysis forming sulci on the heel.
Histopathology reveals a crater limited to the thick stratum corneum of the epidermis.
 
 
 
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