Pitted Keratolysis

Pitted Keratolysis

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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. [1, 46]

Pitted keratolysis has gone through several name changes. [2, 3] 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.

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. [4, 5, 6, 7] Under appropriate conditions (ie, prolonged occlusion, hyperhidrosis, increased skin surface pH), these bacteria proliferate and produce proteinases that destroy the stratum corneum, creating pits. [8] D congolensis liberates keratinases in appropriate substrate. [9, 10, 11] K sedentarius has been found to produce 2 keratin-degrading enzymes. They are protease P1 (30 kd) and P2 (50 kd). [7] The malodor associated with pitted keratolysis is presumed to be the production of sulfur-compound by-products, such as thiols, sulfides, and thioesters. [12]

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. [13]

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. [14, 15] A study of 142 homeless men in the Boston, Mass area revealed that 20.4% of 142 examined patients had pitted keratolysis. [16]


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 [17] to 2.25% (11 of 490 subjects randomly evaluated) in New Zealand. [5] In addition, 2.6% of 378 Turkish male adolescent and postadolescent boarding school students had pitted keratolysis, [18] and, in a 2-year study from Belgium, only 4.8 cases of pitted keratolysis occurred per 1000 dermatology visits. [19] In a study of 1012 patients with atopic dermatitis from Nigeria, only 19 (1.8%) had pitted keratolysis. [20] However, 66 (23.3%) of 283 Korean coal miners [17] and 341 (42.5%) paddy field workers in costal South India had pitted keratolysis due to persistent exposure to moist environments. [21]

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. [22] 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. [23] In 184 German athletes examined, 25 (13.5%) had pitted keratolysis. [24]

No race predilection is reported for pitted keratolysis.

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

Pitted keratolysis can affect patients of any age.

Pitted keratolysis is cured easily and has an excellent prognosis. 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. [25, 26] 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. [27] The mechanism is unknown and further studies are needed to confirm this association.

Educate patients with pitted keratolysis about the etiology of the disorder and regarding ways to prevent and treat pitted keratolysis. See Medical Care.

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Nordstrom KM, McGinley KJ, Cappiello L, Zechman JM, Leyden JJ. Pitted keratolysis. The role of Micrococcus sedentarius. Arch Dermatol. 1987 Oct. 123(10):1320-5. [Medline].

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. 1985 Apr. 26(1):29-35. [Medline].

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Amor A, Enríquez A, Corcuera MT, Toro C, Herrero D, Baquero M. Is infection by Dermatophilus congolensis underdiagnosed?. J Clin Microbiol. 2011 Jan. 49(1):449-51. [Medline]. [Full Text].

Nordstrom KM, McGinley KJ, Capiello L, Leyden JJ. The etiology of malador associated with pitted keratolysis. Journal of Investigative Dermatology. July/1986. 87:159.

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

Hsu AR, Hsu JW. Topical review: skin infections in the foot and ankle patient. Foot Ankle Int. 2012 Jul. 33(7):612-9. [Medline].

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 May 1. 42(5):399-413. [Medline].

Stratigos AJ, Stern R, Gonzalez E, Johnson RA, O’Connell J, Dover JS. Prevalence of skin disease in a cohort of shelter-based homeless men. J Am Acad Dermatol. 1999 Aug. 41(2 Pt 1):197-202. [Medline].

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

Tuncel AA, Erbagci Z. Prevalence of skin diseases among male adolescent and post-adolescent boarding school students in Turkey. J Dermatol. 2005 Jul. 32(7):557-64. [Medline].

Blaise G, Nikkels AF, Hermanns-Le T, Nikkels-Tassoudji N, Pierard GE. Corynebacterium-associated skin infections. Int J Dermatol. 2008 Sep. 47(9):884-90. [Medline].

Nnoruka EN. Current epidemiology of atopic dermatitis in south-eastern Nigeria. Int J Dermatol. 2004 Oct. 43(10):739-44. [Medline].

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. 2005 Jul-Aug. 71(4):254-8. [Medline].

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Rho NK, Kim BJ. A corynebacterial triad: Prevalence of erythrasma and trichomycosis axillaris in soldiers with pitted keratolysis. J Am Acad Dermatol. 2008 Feb. 58(2 Suppl):S57-8. [Medline].

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

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Takama H, Tamada Y, Yano K, Nitta Y, Ikeya T. Pitted keratolysis: clinical manifestations in 53 cases. Br J Dermatol. 1997 Aug. 137(2):282-5. [Medline].

Walling HW. Primary hyperhidrosis increases the risk of cutaneous infection: a case-control study of 387 patients. J Am Acad Dermatol. 2009 Aug. 61(2):242-6. [Medline].

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

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

Shelley WB, Shelley ED. Coexistent erythrasma, trichomycosis axillaris, and pitted keratolysis: an overlooked corynebacterial triad?. J Am Acad Dermatol. 1982 Dec. 7(6):752-7. [Medline].

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Papaparaskevas J, Stathi A, Alexandrou-Athanassoulis H, Charisiadou A, Petropoulou N, Tsakris A, et al. Pitted keratolysis in an adolescent, diagnosed using conventional and molecular microbiology and successfully treated with fusidic acid. Eur J Dermatol. 2014 Jul-Aug. 24(4):499-500. [Medline].

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Greywal T, Cohen PR. Pitted keratolysis: successful management with mupirocin 2% ointment monotherapy. Dermatol Online J. 2015 Aug 15. 21 (8):[Medline].

van der Snoek EM, Ekkelenkamp MB, Suykerbuyk JC. Pitted keratolysis; physicians’ treatment and their perceptions in Dutch army personnel. J Eur Acad Dermatol Venereol. 2012 Aug 7. [Medline].

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Tamura BM, Cuce LC, Souza RL, Levites J. Plantar hyperhidrosis and pitted keratolysis treated with botulinum toxin injection. Dermatol Surg. 2004 Dec. 30(12 Pt 2):1510-4. [Medline].

Bunyaratavej S, Leeyaphan C, Chanyachailert P, Pattanaprichakul P, Ongsri P, Kulthanan K. Clinical manifestations, risk factors, and quality of life in pitted keratolysis: A cross-sectional study in cadets. Br J Dermatol. 2018 Jun 28. [Medline].

Linda J Fromm, MD, MA, FAAD Private Practice, Fromm Dermatology at Health Concepts, Rapid City, South Dakota

Linda J Fromm, MD, MA, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for MOHS Surgery, Association of Military Dermatologists, 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, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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, United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

Joseph C English III, MD Clinical Vice-Chairman for Quality and Innovation, Professor of Dermatology, Department of Dermatology, University of Pittsburgh School of Medicine

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.

Pitted Keratolysis

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