Plantar Eczema/Psoriasis - Callus Confusion

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Hi,
I know as soon as I post this that there will be demands for further details and photos - but please forgive me - but i didnt take a camera with me at this visit but will be at the next - so if needed there will be some on the way!

I saw a patient recently who has had chronic problems with callus build up and heel fissures - for which she was prescribed diprosalic but she's been using as prescribed but it has made no difference!

She has always suffered from dry skin and eczema on all other areas of her body but the foot problems started about 4 years ago following ahighly stressful period of her life. At the same time she noticed an increase in weight and other dermatological problems across the body. She is currently on no other medications (and has no other diagnosed medical conditions) she is 28.

Both feet are affected, with heavy callus to apices, heel and mtpj area, the callus is very 'glassy' with delicate skin beneath, and the fissures are very painful when they occur. Additionally they have the classic appearance of a tinea pedis infection (which she was previously diagnosed with - and treated but no relief or change to condition).

It is not the classic presentation of psoriasis but has parts that suggest that it may be - however, wondered whether it was eczema (havent really experienced eczema on the plantar surface so unsure) or whether it could be linked to hypothyroidism.

I know it is impossible with such a little amount of info and no pictures but just some ideas/avenues to investigate would be great - and next week when i see her i'll upload the pics!

Thanks

 

Head above parapet : Could you take a specimen of the skin for culture, to rule out mocassin type tinea? Is there a rash?

 

good suggestion about the specimen.

There isnt a classic rash (and it has previously been tx for TP but to no improvement - according to the pt) but there is erythema in a similar pattern so it was one of my differential diagnoses.

Thanks for the suggestion will looking into taking a specimen

 

Hi Pod@Home

Did you get a shifty at the pts hands?

Cheers,
Bel

 

i was wondering too...lol

 

nothing on the palmer area - and just dry skin elsewhere on the hands, no nail involvement by the way on hands or feet.

 

PPK?

(ok....been told this reply is too pithy, sooooo shall I tell you about the day I`ve had? OK. Well started off real bad. Only have one printer in the surgery, was carrying it from reception through to the treatment room, got the lead caught in door handle, hurt my hand, dropped printer on floor....now no printer in the surgery....couldn`t sign into MSN, laser scanner died, and my receptionist left early with a "cold" :boohoo:....enough?)

 

That sounds like day from hell - so thanks for taking the time out to reply

(i hope you've got a relaxing glass of wine :drinks (etc) at hand by now)

PPK was one of my thoughts (one that i keep coming back to) and the more comparative images i check out the more i think it might be

So next questions, anyone experienced this and found a fantastic treatment regime that i can try out/suggest.

 

Pod at Home!

Have you tried Baileys Liquiheel for the fissures? It is the same medical glue used for lacerations and whilst somewhat expensive, do actually help to keep the fissures together to encourage them to heal

Angie

 

Watch out for the case series where this was used in this months Pod Now

 

Have you considered Dyshydrosis? (Dishydrosis, Dishidrosis) Google images for it. Also go the yahoogroup for it, lots of better photos there. This is my favorite disease. 80%feet only, 10%hands only, 10% hands and feet. There is a drug available 'Toctino' only to be prescribed by dermatologists. (I know of another cure, just as effective, but untested, and I want to do a research project on it. I have had 6 total cures with it, but badly documented.) The presentation is various, but delicate skin under callus....mm...any little vesicles? A pathogen culture test of the fluid in the vesicles will come back sterile. This is an endogenous disease. A reaction by delayed hypersensitivity to toxins/wastes of a bacterial infection elsewhere in the body, (The stress, the weight gain...) But It is not caused by stress, I will personally throttle the next GP who says it is stress. I'm not kidding! GPs are so unwilling to do anything but Rx steriods for this condition, and there is circumstantial evidence that steriods make it worse. Carole, just a student.

 

All,
It's always difficult to make a diagnosis without a picture. I wonder if the patient has actually been diagnosed with eczema? A lot of patients claim they have eczema when in fact it's just a dry skin problem exacerbated by scratching ( which they deny !)
If there's no diagnosis of eczema then I'd go for bog standard hyperkeratosis with a tinea infection thrown in.

Dyshidrosis or acute vesiculobullous eczema, presents with excessive sweating and vesicleswith both the hands and feet affected.

Personally, I'd treat symptomatically and try and persuade the patient to visit the GP for a thyroid function test to rule out hypothyroidism.

I look foward to seeing a picture !

Curious Cat

 

Thanks for the suggestion - looking at the images it doesn't look like a classic presentation - but nothing ever does exactly - so will bear this in mind on next visit and also look further into in general. Thanks for the tip

 

Hi photos are on their way will be seeing her again next week - will get them up as soon as (if my technology works!)

I've been considering hypothyroidism due to facial appearance, weight gain and other things the patient mentioned during the treatment

After checking all the suggestions out and investigating it all - it does have a look of PKK with possible TP complications

and by the way, the patient has been diagnosed with eczema and i think that has led her GP to ignore other possibilities/complications - as he has just repeatedly prescribed steroid with no follow up!

Thanks again for all the ideas - this forum is so great when you practice on your own most of the time - helps to 'think out loud'

 

What treatment did she have? Moccassin foot type TP is very recalcitrant - for a start anything topical would have to work its way through the heavy callous you describe.

Any way, I'm interested to know what the definative diagnosis is...

 

Sorry Catfoot, Dyshydrosis does not present with excessive sweating. This is an error in the original thinking. Normal to less than normal sweating. and there is nothing acute about it. It is chronic and relapsing. As I said, 10% feet only, 10% handsandfeet. 80% hands only.
The reason I suspect this most interesting (to me anyway, and I am a sad case ...)disease is all the other symptoms point to a over infection/infestation by a fungal element, weight gain, youthful age, stressful period, or relatively minor illness. Tight glassy appearance under callus. Remove the callus and see if little vesicles pop up. Also, her GP diagnosed eczema? Has she been to see a dermatologist? Over there in the UK, the referral won't cost her. The problem may be pursuading the GP she needs a referral. (Write a letter?) There are certain drugs and treatments that only consultant dermatologists can prescribe. I am coming around to the radical thought that eczema is not really a disease, but a manifestation that something, some where else in the body, is annoying the immune system.
Please keep up informed and any fotos would be appreciated. Carole

 

CCL,
Yes, there are some cases of dyshidrosis that present without excessive sweating, however, it is listed as a symptom,

http://www.medicineonline.com/articles/d/2/Dyshidrosis/Dyshidrotic-Eczema.html


Here's some pictures

http://www.dermnet.com/Dyshidrosis

do they look familiar to anyone?

CF

 

Medicine online is just plain wrong, and goes against everything I have learnt about this condition since 2001, when I started studying it. I suspect Medicine online is where the GPs are getting their info from. I Have tried to attach Ruzika's study. the fotos are good but under callus it looks different. Let's see some fotos of the patient's feet.

 

C the CL,
Thanks for the info.
If you have different empirical information then I am sure that this would be very useful both to us who are observing the condition and those who are suffering from it.
Look forward to seeing some pix.

CF