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 sedentarius (now renamed to Kytococcus sedentarius,) Dermatophilus congolensis, 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. K sedentarius has been found to produce 2 keratin-degrading enzymes. They are protease P1 (30 kd) and P2 (50 kd). The malodor associated with pitted keratolysis is presumed to be the production of sulfur-compound by-products, such as thiols, sulfides, and thioesters.
Foot odor without pitted skin changes has recently been discovered to be from isovaleric acid produced by Staphylococcus epidermidis, a normal skin flora.
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.
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.
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.
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.
Добавлено (20.08.2008, 22:36)
---------------------------------------------
History
The patient with pitted keratolysis may complain of malodor, hyperhidrosis, sliminess, and, occasionally, soreness or itching associated with the pits; 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. In military personnel, whose long-term occlusive boot wearing exacerbates disease, lesions often become denuded, leading to foot pain and disability.
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 corynebacterial disease also has been reported in 2 male patients. They had erythrasma, trichomycosis axillaris, and pitted keratolysis simultaneously. Clinicians making a diagnosis of pitted keratolysis need to examine the patient for evidence of other corynebacterial infections.
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. A variant of markedly enlarged lesions, called crateriform pitted keratolysis, also has been described. 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.
Добавлено (20.08.2008, 22:36)
---------------------------------------------
Procedures
Skin biopsies are not performed routinely, as the diagnosis can be made easily by means of visual examination and recognition of the characteristic odor.
Histologic Findings
If a cutaneous biopsy is performed, histological evaluation of hematoxylin and eosin (H&E)–stained plantar skin reveals a crater limited to the stratum corneum (see Image 2). The microorganisms, cocci, and filamentous forms may be seen with H&E but will be detected more easily with Gram stain, periodic acid Schiff, or methenamine silver stains. In patients with associated foot pain and with erythematous to violaceous macular lesions and pits, histological examination reveals only a mild dermal inflammatory reaction.
Добавлено (20.08.2008, 22:37)
---------------------------------------------
Medical Care
Limit the use of occlusive footwear and reduce foot friction with properly fitting footwear. Absorbent cotton socks must be changed frequently to prevent excessive foot moisture. Wool socks tend to whisk moisture away from the skin and may be helpful. In some cases, reducing any associated hyperhidrosis with the application of a roll-on antiperspirant, 20% aluminum chloride solution, may be helpful.
Many clinicians find that topical antibiotics are effective, even without the preceding steps. They are certainly easy to use and well accepted by patients. Twice daily applications of erythromycin or clindamycin are effective. Either solutions or gel formulations may be used. Topical mupirocin (Bactroban) also has been effective. Oral erythromycin is another option. For cases resistant to topical antibiotic treatments and/or associated with hyperhidrosis, the use of botulinum toxin injections has been effective.
Effective treatment of pitted keratolysis clears both the lesions and odor in 3-4 weeks.
Добавлено (20.08.2008, 22:37)
---------------------------------------------
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Drug Category: Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Drug Name Clindamycin (Cleocin)
Description Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest. Many clinicians find topical antibiotics to be effective, even without other measures. They are easy to use and well accepted by patients. Either solution or gel formulations may be used.
Adult Dose Apply topically bid
Pediatric Dose Apply as in adults
Contraindications Documented hypersensitivity
Interactions None reported
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Superinfections may occur with prolonged or repeated antibiotic therapy
Drug Name Erythromycin (E.E.S., E-Mycin, Ery-Tab)
Description Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.
In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double the dose.
Adult Dose Topical: Apply bid to affected area
Oral: 250 mg erythromycin stearate/base (or 400 mg ethylsuccinate) PO q6h, or 500 mg q12h (1 h ac or 2 h pc); alternatively, 333 mg PO q8h; increase to 4 g/d depending on severity of infection
Pediatric Dose Topical: Apply as in adults
Oral: 20 mg/kg PO 2 h prior to procedure, followed by 10 mg/kg 6 h after initial dose
Contraindications Documented hypersensitivity; hepatic impairment
Interactions Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI side effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Drug Name Mupirocin (Bactroban)
Description Inhibits bacterial growth by inhibiting RNA and protein synthesis.
Adult Dose Apply thin film to affected area 2-5 times/d for 5-14 d
Pediatric Dose Administer as in adults
Contraindications Documented hypersensitivity
Interactions None reported
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Prolonged use may result in the growth of nonsusceptible organisms
FOLLOW-UPSection 8 of 11 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Multimedia References
Further Outpatient Care
Instruct the patient to return to the clinic if therapy is unsuccessful. Otherwise, care proceeds on an as needed basis.
Prognosis
Pitted keratolysis is cured easily and has an excellent prognosis.
Patient Education
Educate the patient about the etiology of the disorder and regarding ways to prevent and treat pitted keratolysis. See Medical Care
Добавлено (20.08.2008, 22:38)
---------------------------------------------
Medical/Legal Pitfalls
Failure to make the correct diagnosis is the only area in which a health care provider may find difficulty with a patient with this disorder. Patients may complain of undue mental anguish due to foot odor from pitted keratolysis, which could have resolved easily with proper identification and treatment of the disorder.
Главная 
, но это помогало лишь на некоторое время 
. А бывают такие, которые вообще не моются 
, но "воняют" во всех возможных местах, кроме этого. Какие еще будут версии? 
