- Benjamin Barankin, MD, FRCPC
Benjamin Barankin, MD, FRCPC
- Dermatologist, Medical Director
- Toronto Dermatology Centre, Toronto, Canada
- Alexander KC Leung, MBBS, FRCPC, FRCP (UK & Ireland), FRCPCH, FAAP
Alexander KC Leung, MBBS, FRCPC, FRCP (UK & Ireland), FRCPCH, FAAP
- Clinical Professor of Pediatrics
- University of Calgary
Pitted keratolysis (also known as keratolysis sulcata, keratolysis plantare sulcatum, and ringed keratolysis) is a superficial bacterial skin infection confined to the stratum corneum. Clinically, pitted keratolysis is characterized by malodor and multifocal, discrete, superficial crateriform pits and superficial erosions primarily affecting pressure-bearing areas of the plantar surface of the feet (picture 1A-D). Topical antibiotic therapy usually leads to resolution of the disease.
The clinical features, diagnosis, and management of pitted keratolysis will be reviewed here.
Pitted keratolysis has a worldwide distribution but occurs most frequently in tropical and temperate regions with high humidity levels . The disorder is not uncommon; in a mass examination of 4325 Korean industrial workers in 1981, 1.5 percent had pitted keratolysis . In another study, 18 (2.6 percent) of 682 students (aged 14 to 25 years) from two Turkish boarding schools had pitted keratolysis . There is no racial predilection [4-6].
Pitted keratolysis is most common in the age group of 21 to 30 years, with approximately 80 to 96 percent of affected patients between 10 and 40 years of age [7,8]. The male to female ratio is approximately 4:1 [8,9]. Presumably, the male predominance is due to more frequent use of occlusive footwear among males and females' better foot hygiene [8,10-12].
Occupations at risk include athletes, industrial workers, miners, farmers, marine workers, and military personnel [13-15]. Predisposing factors include hyperhidrosis, prolonged use of occlusive footwear such as vinyl shoes or rubber boots, thickened skin of soles and palms, increased skin surface pH, hot and humid weather, poor foot hygiene, obesity, diabetes mellitus, and immunodeficiency [11,16,17].
- Tamura BM, Cucé LC, Souza RL, Levites J. Plantar hyperhidrosis and pitted keratolysis treated with botulinum toxin injection. Dermatol Surg 2004; 30:1510.
- Eun HC, Park HB, Chun YH. Occupational pitted keratolysis. Contact Dermatitis 1985; 12:122.
- Tuncel AA, Erbagci Z. Prevalence of skin diseases among male adolescent and post-adolescent boarding school students in Turkey. J Dermatol 2005; 32:557.
- Singh G, Naik CL. Pitted keratolysis. Indian J Dermatol Venereol Leprol 2005; 71:213.
- http://emedicine.medscape.com/article/1053078-overview (Accessed on January 20, 2017).
- 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 2009; 22:564.
- Narayani K, Gopinathan T, Lpe TP. Pitied Keratolysis. Indian J Dermatol Venereol Leprol 1981; 47:151.
- Pinto M, Hundi GK, Bhat RM, et al. Clinical and epidemiological features of coryneform skin infections at a tertiary hospital. Indian Dermatol Online J 2016; 7:168.
- Blaise G, Nikkels AF, Hermanns-Lê T, et al. Corynebacterium-associated skin infections. Int J Dermatol 2008; 47:884.
- Greywal T, Cohen PR. Pitted keratolysis: successful management with mupirocin 2% ointment monotherapy. Dermatol Online J 2015; 21.
- Kaptanoglu AF, Yuksel O, Ozyurt S. Plantar pitted keratolysis: a study from non-risk groups. Dermatol Reports 2012; 4:e4.
- Pranteda G, Carlesimo M, Pranteda G, et al. Pitted keratolysis, erythromycin, and hyperhidrosis. Dermatol Ther 2014; 27:101.
- Shenoi SD, Davis SV, Rao S, et al. Dermatoses among paddy field workers--a descriptive, cross-sectional pilot study. Indian J Dermatol Venereol Leprol 2005; 71:254.
- van der Snoek EM, Ekkelenkamp MB, Suykerbuyk JC. Pitted keratolysis; physicians' treatment and their perceptions in Dutch army personnel. J Eur Acad Dermatol Venereol 2013; 27:1120.
- Wohlrab J, Rohrbach D, Marsch WC. Keratolysis sulcata (pitted keratolysis): clinical symptoms with different histological correlates. Br J Dermatol 2000; 143:1348.
- www.consultant360.com/articles/pitted-keratolysis (Accessed on February 02, 2017).
- Walling HW. Primary hyperhidrosis increases the risk of cutaneous infection: a case-control study of 387 patients. J Am Acad Dermatol 2009; 61:242.
- Fernández-Crehuet P, Ruiz-Villaverde R. Pitted keratolysis: an infective cause of foot odour. CMAJ 2015; 187:519.
- Gillum RL, Qadri SM, Al-Ahdal MN, et al. Pitted keratolysis: a manifestation of human dermatophilosis. Dermatologica 1988; 177:305.
- 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; 93:810.
- Nordstrom KM, McGinley KJ, Cappiello L, et al. Pitted keratolysis. The role of Micrococcus sedentarius. Arch Dermatol 1987; 123:1320.
- Leung AK, Barankin B. Pitted Keratolysis. J Pediatr 2015; 167:1165.
- Stanton RL, Schwartz RA. Pitted keratolysis: a common foot problem. Am Fam Physician 1983; 27:183.
- Takama H, Tamada Y, Yokochi K, Ikeya T. Pitted keratolysis: a discussion of two cases in non-weight-bearing areas. Acta Derm Venereol 1998; 78:225.
- Ramsey ML. Pitted keratolysis: a common infection of active feet. Phys Sportsmed 1996; 24:51.
- De Luca JF, Adams BB, Yosipovitch G. Skin manifestations of athletes competing in the summer olympics: what a sports medicine physician should know. Sports Med 2012; 42:399.
- de Almeida HL Jr, Siqueira RN, Meireles Rda S, et al. Pitted keratolysis. An Bras Dermatol 2016; 91:106.
- Zaias N. Pitted and ringed keratolysis. A review and update. J Am Acad Dermatol 1982; 7:787.
- Bristow IR, Lee YL. Pitted keratolysis: a clinical review. J Am Podiatr Med Assoc 2014; 104:177.
- Emmerson RW, Jones EW. Ringed keratolysis of the palms. Trans St Johns Hosp Dermatol Soc 1967; 53:165.
- Lamberg SI. Symptomatic pitted keratolysis. Arch Dermatol 1969; 100:10.
- Shah AS, Kamino H, Prose NS. Painful, plaque-like, pitted keratolysis occurring in childhood. Pediatr Dermatol 1992; 9:251.
- Sehgal VN, Ramesh V. Crateriform depression--an unusual clinical expression of pitted keratolysis. Dermatologica 1983; 166:209.
- Shelley WB, Shelley ED. Coexistent erythrasma, trichomycosis axillaris, and pitted keratolysis: an overlooked corynebacterial triad? J Am Acad Dermatol 1982; 7:752.
- Takama H, Tamada Y, Yano K, et al. Pitted keratolysis: clinical manifestations in 53 cases. Br J Dermatol 1997; 137:282.
- Sheth AP. Pitted keratolysis, erythrasma and erysipeloid. In: Harper’s Textbook of Pediatric Dermatology, Irvine AD, Hoeger PH, Yan AC (Eds), Wiley-Blackwell, Oxford 2011. p.56.1.
- Lockwood LL, Gehrke S, Navarini AA. Dermoscopy of Pitted Keratolysis. Case Rep Dermatol 2010; 2:146.
- Papaparaskevas J, Stathi A, Alexandrou-Athanassoulis H, et al. Pitted keratolysis in an adolescent, diagnosed using conventional and molecular microbiology and successfully treated with fusidic acid. Eur J Dermatol 2014; 24:499.
- Kim B, Park K, Kim J, et al. Comparative study of benzoyl peroxide versus clindamycin phosphate in treatment of pitted keratolysis. Korean J Med Mycol 2005; 20:144.
- Leung AK, Chan PY, Choi MC. Hyperhidrosis. Int J Dermatol 1999; 38:561.
- Leung AK, Barankin B. Palmar hyperhidrosis. J Neonatol Clin Pediatr 2014; 1:1.
- Leung AK. Botulinum toxin therapy for hyperhidrosis. Int J Dermatol 2000; 39:160.
- CLINICAL MANIFESTATIONS
- Clinical variants
- ADDITIONAL EVALUATION
- DIFFERENTIAL DIAGNOSIS
- First-line therapy
- - Topical antibiotics
- - Benzoyl peroxide
- Adjunctive measures
- - Foot hygiene
- - Treatment of hyperhidrosis
- Refractory disease
- SUMMARY AND RECOMMENDATIONS