eMedicine Specialties > Dermatology > Bacterial Infections

Pitted Keratolysis

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

Updated: Sep 25, 2008

Introduction

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 are due to a superficial cutaneous bacterial infection.

Pitted keratolysis has gone through several name changes. It was described initially in the early 1900s as keratoma plantare sulcatum, a manifestation of yaws. It 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.

Pathophysiology

Pitted keratolysis is caused by a cutaneous infection with Micrococcus sedentarius1 (now renamed to Kytococcus sedentarius), Dermatophilus congolensis,2 or species of Corynebacterium and Actinomyces. Under appropriate conditions (ie, prolonged occlusion, hyperhidrosis, increased skin surface pH), these bacteria proliferate and produce proteinases that destroy the stratum corneum, creating pits.3 K sedentarius has been found to produce 2 keratin-degrading enzymes. They are protease P1 (30 kd) and P2 (50 kd).4 The malodor associated with pitted keratolysis is presumed to be the production of sulfur-compound by-products, such as thiols, sulfides, and thioesters.

In 2006, foot odor without pitted skin changes was discovered to be from isovaleric acid produced by Staphylococcus epidermidis, a normal skin flora.5

Frequency

United States

Pitted keratolysis occurs worldwide. It can be seen in both tropical and temperate environments. A study of 142 homeless men in the Boston area revealed that 20.4% of 142 examined patients had pitted keratolysis.6

International

Prevalence rates have ranged from 1.5% of 4325 Japanese industrial workers to 2.25% (11 of 490 subjects randomly evaluated) in New Zealand. In the tropical military setting, where heat, humidity, and boots combine to produce a microenvironment that predisposes to this disease, prevalence rates are much higher. Of the 387 volunteer soldiers evaluated in South Vietnam, 53% had pitted keratolysis. Recently, in Britain, 25 of 184 examined athletes had pitted keratolysis. In 341 paddy field workers in costal South India, 42.5% had pitted keratolysis.7

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. 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. The mechanism is unknown and further studies are needed to confirm this association.8

Race

No race predilection is reported.

Sex

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

Age

Pitted keratolysis can affect patients of any age.

Clinical

History

The patient with pitted keratolysis may complain of malodor, hyperhidrosis, sliminess, and, occasionally, soreness or itching associated with the pits9 ; however, the pits normally are asymptomatic. 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.10 In military personnel, whose long-term occlusive boot wearing exacerbates disease, lesions often become denuded, leading to foot pain and disability.11

The palms of the hand also have been reported to be involved in some patients with pitted keratolysis of the feet. Here, 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.12 In a 2008 study, 108 of 842 South Korean male soldiers were diagnosed with pitted keratolysis, of which 13 of 108 (13%) had the triad.13 Clinicians making a diagnosis of pitted keratolysis need to examine the patient for evidence of other corynebacterial infections.

The Medscape Exercise and Sports Medicine Resource Center may be of interest.

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 Media File 1). A variant of markedly enlarged lesions, called crateriform pitted keratolysis, also has been described.14 This affects the entire width of the plantar surface of the foot underlying the metatarsophalangeal joints. The pits rarely are seen on non–pressure-bearing areas of the plantar surface.

Causes

See Pathophysiology.

More on Pitted Keratolysis

Overview: Pitted Keratolysis
Differential Diagnoses & Workup: Pitted Keratolysis
Treatment & Medication: Pitted Keratolysis
Follow-up: Pitted Keratolysis
Multimedia: Pitted Keratolysis
References
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References

  1. 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].

  2. 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].

  3. 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].

  4. 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].

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

  6. Stratigos AJ, Stern R, González 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].

  7. 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].

  8. 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].

  9. 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].

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

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

  12. 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].

  13. 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].

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

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

  16. Tamura BM, Cucé 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].

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

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

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

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

  21. 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].

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

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Further Reading

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Keywords

keratoma plantare sulcatum, keratolysis plantare sulcatum, Micrococcus sedentarius, M sedentarius, Kytococcus sedentarius, K sedentarius, Dermatophilus congolensis, D congolensis, Corynebacterium species, Actinomyces species

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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.

Medical Editor

James W Patterson, MD, Director of Dermatopathology, Professor of Pathology and Dermatology, Departments of Pathology and Dermatology, 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 Medical Association, American Society of Dermatopathology, Medical Society of Virginia, Royal Society of Medicine, Society for Investigative Dermatology, and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.

Pharmacy Editor

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
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: 3M Pharmaceutical Grant/research funds Other; Graceway Pharmaceuticals Grant/research funds Other

Managing Editor

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.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine 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.

 
 
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