Pitted Keratolysis Clinical Presentation

Updated: Jul 30, 2018
  • Author: Linda J Fromm, MD, MA, FAAD; Chief Editor: Dirk M Elston, MD  more...
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Presentation

History

Patient with pitted keratolysis may report malodor, hyperhidrosis, sliminess, and, occasionally, soreness or itching associated with the pits [28] ; however, the pits normally are asymptomatic. Patients with primary hyperhidrosis have been shown to have a significant increase in pitted keratolysis compared with controls. [29]

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. [26] In military personnel, whose long-term occlusive boot wearing exacerbates disease, lesions often become denuded, leading to foot pain and disability. [30] The palms of the hand also have been reported to be involved in some patients with pitted keratolysis of the feet. [31] Of the paddy field workers, 1.5% were diagnosed with palmar lesions in addition to foot lesions. [21] 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. [32] 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. [23] Clinicians making a diagnosis of pitted keratolysis need to examine the patient for evidence of other corynebacterial infections.

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Physical Examination

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 o A large plaque-like lesion of Pitted keratolysis on the large toe.
Pitted keratolysis with hyperkeratosis on the heel Pitted 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. [33] 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. [34]

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