Pitted Keratolysis 

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

Background

Pitted keratolysis is a skin disorder characterized by crateriform pitting that primarily affects the pressure-bearing aspects of the plantar surface of the feet and, occasionally, the palms of the hand as collarettes of scale. The manifestations of pitted keratolysis are due to a superficial cutaneous bacterial infection.

Pitted keratolysis has gone through several name changes.[1, 2] Pitted keratolysis was described initially in the early 1900s as keratoma plantare sulcatum, a manifestation of yaws. Pitted keratolysis was identified in the 1930s as a unique separate clinical entity, and the name was changed to keratolysis plantare sulcatum. The current name, pitted keratolysis, describes the clinical presentation well and has remained the modern nomenclature to describe this entity.

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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.[3, 4, 5, 6] Under appropriate conditions (ie, prolonged occlusion, hyperhidrosis, increased skin surface pH), these bacteria proliferate and produce proteinases that destroy the stratum corneum, creating pits.[7]D congolensis liberates keratinases in appropriate substrate.[8]K sedentarius has been found to produce 2 keratin-degrading enzymes. They are protease P1 (30 kd) and P2 (50 kd).[6] The malodor associated with pitted keratolysis is presumed to be the production of sulfur-compound by-products, such as thiols, sulfides, and thioesters.[9]

In 2006, foot odor without pitted skin changes was discovered to be from overgrowth of Bacillus subtilis and specifically an isovaleric acid produced by Staphylococcus epidermidis overgrowth, a normal skin flora.[10]

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Epidemiology

Frequency

United States

Pitted keratolysis occurs worldwide. Pitted keratolysis can be seen in both tropical and temperate environments, and it can be related to occupation or sport activity. A study of 142 homeless men in the Boston, Mass area revealed that 20.4% of 142 examined patients had pitted keratolysis.[11]

International

International incidence rates of pitted keratolysis vary significantly based on the environment and occupation. Prevalence rates of pitted keratolysis have ranged from 1.5% of 4325 Korean industrial workers[12] to 2.25% (11 of 490 subjects randomly evaluated) in New Zealand.[4] In addition, 2.6% of 378 Turkish male adolescent and postadolescent boarding school students had pitted keratolysis,[13] and, in a 2-year study from Belgium, only 4.8 cases of pitted keratolysis occurred per 1000 dermatology visits.[14] In a study of 1012 patients with atopic dermatitis from Nigeria, only 19 (1.8%) had pitted keratolysis.[15] However, 66 (23.3%) of 283 Korean coal miners[12] and 341 (42.5%) paddy field workers in costal South India had pitted keratolysis due to persistent exposure to moist environments.[16]

In the tropical military setting, where heat, humidity, and boots combine to produce a microenvironment that predisposes to pitted keratolysis, prevalence rates are much higher. Of the 387 volunteer United States soldiers evaluated in South Vietnam, 53% had pitted keratolysis.[17] However, the incidence of pitted keratolysis in all military soldiers may not be so high because only 108 (12.8%) of 842 Korean soldiers were diagnosed with pitted keratolysis.[18] In 184 German athletes examined, 25 (13.5%) had pitted keratolysis.[19]

Mortality/Morbidity

No mortality is associated with pitted keratolysis. However, the excessive foot odor from this disorder may be socially unacceptable. Pitted keratolysis may be symptomatic; producing secondary painful feet, which can limit function.[20, 21] In 2005 in Turkey (East region), a study of dermatologic manifestations in 88 hepatitis B surface antigen carriers compared with 84 controls demonstrated a significantly higher prevalence of oral lichen planus and pitted keratolysis.[22] The mechanism is unknown and further studies are needed to confirm this association.

Race

No race predilection is reported for pitted keratolysis.

Sex

Theoretically, both males and females should be affected by pitted keratolysis; however, most written case reports or studies have involved male patients.

Age

Pitted keratolysis can affect patients of any age.

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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].

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  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].

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  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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