Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Everything that you are ever going to want to know about running shoes: Running Shoes Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
  2. Have you considered the Critical Thinking and Skeptical Boot Camp, for taking it to the next level? See here for more.
    Dismiss Notice
  3. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Dermatological Case - Help!?!

Discussion in 'General Issues and Discussion Forum' started by EdYip, Feb 1, 2005.

  1. EdYip

    EdYip Active Member

    Members do not see these Ads. Sign Up.
    Here's a lady that I've been seeing for 1.5 yrs for a strange hyperkeratoses on the plantar aspect of both feet. All I've been doing is reducing the callous and prescribing Lac Hydrin mixed with 10% salicylic acid. I know I'm just treating the symptom, but I'd be interested if any of you have seen or treated anything like this.

    44 yr old female presents with painful "callouses" on the bottom of both feet. Patient states that her feet have been calloused since childhood and that her two siblings (brother and sister) are also afflicted with the same condition. She also states that although her activity level has no effect on the condition, the callouses do get more painful during a change of season.

    Relevant medical history - Underactive thyroid (patient takes levothyroxin). MD has tried adjusting thyroid levels without success. Patient as also seen a dermatologist and a rheumatologist. Official diagnosis is Psoriasis, but cortisone creams have not worked. Rheumatologist gave a diagnosis of "undefined arthritis" and prescribed Celebrex in 2003.

    Patient works as a pharmacy assistant and wears runners mostly. She has found most comfort in Reebok DMX Walkers. She has tried stability footwear from New Balance without success.

    Pic 1 - right forefoot pre-treatment:
    Pic 2 - right forefoot post treatment:
    Pic 3 - right mid and rearfoot pre treatment:
    Pic 4 - right mid and rearfoot post treatment:

    Emollient/keratolytic therapy simply extends the time between visits. At best, we've been able to extend it to about 4 wks before the buildup becomes too painful.

    Any help / suggestions / anecdotes appreciated :)

  2. EdYip

    EdYip Active Member

    Here's pre and post pics of her Left foot:
  3. Bug

    Bug Well-Known Member

    Could just be a drastic presentation of the psoraisis.

    Did have a brother and sister coming for years though in a pvt practice I worked at with Keratoderma Punctata that appeared very similar to your photo's and was my first thought prior to reading her history you posted.
    What made it similar to these pics is the circular lesions of callous in the lesser weigh bearing regions.

    Only treatment for that was similar to what you are already doing as it was a genetic condition. Maybe check out her hands, or ask about any family/extended members if they have similar problems.
    Happy debriding!
  4. moe

    moe Active Member

    Do her feet have an excessive odour?
    Iona Millar
  5. EdYip

    EdYip Active Member

    Thanks for the responses so far.

    There is definitely some genetics at play here - both her brother and sister have also had this since childhood. Her brother was actually asked by his dermatologist to accompany him to a dermatology conference where he was presented as a case study. Even after all the humming and ha-ing there was still no clear diagnosis or successful treatment plan.

    Moe, there is no odour, really. Not even under the callouses. She tells me that she washes and uses a pumice daily, and that she moisturizes twice daily.

  6. Bug

    Bug Well-Known Member

    Maybe ask if that has ever been considered??

    It looks really similar to the cases I hard in a small country town so there was a real familial link, maybe google and do some reading - think the lady I saw also had Buschke-Fischer-Brauer (think that's how you spell it) syndrome which then as toenail involvment as well.
    Good luck!!!
  7. Sean Millar

    Sean Millar Active Member

  8. podrick

    podrick Active Member


    it may very well be psoriasis.i have had a couple a patients that have prsented with a similar clinical picture and yet without the classical signs of psoriatic lesions,i.e. koebnor's.

    i have treated them with both palliative care and intralesional steroid and lidocaine injections,using a 30 gauge tuberculin syringe.i learned this technique from a dermatologist.it has proven effective in keeping them smaller and less bothersome.you must also consider an accommodative orthosis that allows both comfort and absorption of moisture, anything with a carbon lining.

    the good thing about these type of conditions, is that even if they are not psoriasis but some rare genetic condition.the treatment regimens are all pretty much the same.

    in most cases all we can do is treat the symptoms in order to provide pain free gait.

    best of luck,
  9. Marcia72759

    Marcia72759 Welcome New Poster

    I work for John F. Boyle, DPM in Chillicothe Ohio, he believes this is one of these two conditions:

    Syndrome, Thost-Unna
    An autosomal dominant disorder characterized by a widely distributed, well-demarcated hyperkeratosis of the palms and soles. There is more than one genotypically distinct form, each of which is clinically similar but histologically distinguishable. Diffuse palmoplantar keratoderma is distinct from palmoplantar keratoderma (KERATODERMA, PALMOPLANTAR), as the former exhibits autosomal dominant inheritance and hyperhidrosis is frequently present.


    Pitted Keratolysis
    a superficial bacterial infection of the skin of worldwide distribution usually involving the weight-bearing portions of the soles of the feet, and characterized by the formation of shallow asymptomatic discrete round pits, some of which become confluent and form fissures: the specific etiologic agent is unknown.
  10. EdYip

    EdYip Active Member

    Thanks for the great info, everyone.

    The more I read, the more I think my patient has keratoderma punctata, as mentioned by Bug.

    And now I'm also reassured that I am doing everything I can for her.

    I'm glad I posted this - I learned alot! :)

    Feel free to keep the comments coming ;)

  11. Cameron

    Cameron Well-Known Member

    Very interesting and would plump for either keratoderma punctata, or pitted keratolysis, myslef . No matter what it is however the skin pattern when linked to foot contact during stance phase is quite revealing by itself. The peak pressure profile would I guess match the hyperkeratic plaques. I would further suggest inspection of the outsole of the shoe would have comparable wearmarks complimented by the dynamic friction evidenced inside the shoe. If true this would indicate no matter the skin prediliction an external exciting factor was required to trigger the hyperkeratosis. Once the nuclear envelop of the affected keratin cells was damaged then the rate of keratinisation would be determined biomchemically by enzymes responsible for tissue specific epithelialisation. This would result in no reduction of the rate of keratinisation no matter the number of exfoliations undertaken and the conditon would reappear as same old same old.

    The discolouration of the skin probably is highlighted by the materia media used and the white maceration after reduction can be due to the hyplasticity of the ketin cells blotted with water. At best the prognosis is dire but the quality of life with increased phases of painlessness would be a welcome relief, albeit a source of frustration to the practitioner.

    A labour of love and something podiatrists do extremely well.

    Hey what do I know?
  12. Bug

    Bug Well-Known Member

    Great responses - and glad you are more confidence with you treatment - nive to be told you're doing the right thing :)

    Would be interested to hear of anyone that that had that much callous from Pitted Keratolysis, the ones I've seen have been quite macerated and the smell preceeds them as they walk in. Will file that one away for another time!!

    Happy scapelling :)
  13. C Bain

    C Bain Active Member

    Hi EdYip,
    Viewing your photographs it has occurred to me that I may have seen this type of psoriasis before.

    Has your patient been to see his/her doctor and mentioned thyroid to him. I believe a simple blood test may show this might need thyroxine? I have also been fooled once before where when I got mine (patient) eventually into her doctors' it turned out to be over active! She ended up on the radioactive iodine tablet. That sorted her feet out among other things!

    Another similar foot condition was not so fortunate. She ended up with a form of blood/lymph cancer? (Now I remember - Lymphoedema!). I hope yours is not that! She had lots of swelling, particularly in the legs with this type of psoriasis on the planter surfaces and painful with it. Again straight into the surgery. Aren't doctors wonderful!


  14. C Bain

    C Bain Active Member

    Hi Ed Yip,

    Postscript to above,
    Missed your diagnosis, to busy looking at the photographs! Still wonder whether thyroid is over or under, however?


  15. EdYip

    EdYip Active Member

    Thanks Colin

    She is currently being treated for an underactive thyroid. As mentioned, her family doctor had tried closely monitoring her thyroid levels and made several attempts at varying her dosages, but nothing seemed to affect her foot condition.

    Yes, fortunately this is not lymphoedema. I make housecalls to a lady who is bed-ridden due to lymphoedema. Certainly is gruesome. At her worst, her calves had swollen to 34 inches in circumference! She joked that that was likely bigger than my pant size! (She was right :eek: )
  16. Felicity Prentice

    Felicity Prentice Active Member

    Memories of student days

    Looking at the photos reminded me of 23 years ago when I was a student here in Melbourne. We had a mother-daughter team of patients at our student clinic who had exactly these feet (we classified their condition as keratoderma punctata). As students, we were painfully slow and inexperienced in the reduction of hyperkeratosis, so to pick up the file of one of these delightful ladies caused a rapid sinking feeling in the stomach. We were going to be there debriding away for hours, until RSI set in and all conversation had been exhausted.

    But a remarkable thing happened. As we discovered, the routine debridement of these extensive lesions gave these patients such comfort, mobility and independence that we were able to see what good old-fashioned skillful Podiatry can do (as Cameron mentioned). Sure, it wasn't rocket science, but we improved the quality of some-one's life - and hell yeah, we improved our scalpel technique.

    In terms of medicaments, we tried everything to no avail. But I do believe someone (possibly me) suggested sandpaper insoles, so the patients could debride themselves as they walked along. This was not a therapeutic option taken up by my clinical supervisors.


    Felicity "I'm back in the saddle again" Prentice
  17. Soton Pod

    Soton Pod Member


    Sorry, bit late in on this one but looking at the history, I think you have a case of focal palmo-plantar keratoderma (PPK), as has been suggested through the medical history. As expected with this disease you would not see Koebner phenomenon. Also the length of time the patient has suffered this suggests it has a genetic component.

    The difficulty is often identifying the variety as there are over 50 types including the previously mentioned Unna-Thost, BFB disease etc., with some weird sounding names so diagnosis is often difficult. A good paper to read on classification of ther PPKs is by Stevens HP, Arch Dermatol 1996:132: 640-651 which gives a good overview. Generally, to get a definitive diagnosis you would have to do an analysis of DNA which is not always easy or cheap but most all wouldn't really help your treatment plan! Does the patient have problems with her teeth, hearing or sweating? This would suggest an element of ectodermal dysplasia - a more serious form of the disease.

    I ran a PPK clinic for a number of years and I would say that reduction of these lesions made such a difference to patients lives and should not be under-estimated, along with specialist footwear. Also the use of retinoids could be considered although they should be used with extreme caution. About 50% of PPK cases will benefit from them but many patients cannot take the drugs because of side effects such as dry mouth, nose bleeds and altered taste. Liver function and other things should also be monitored.
  18. sooz

    sooz Member

    have a look at this site, there are images which look very similar.

    there is also a support group for patients

  19. Peter

    Peter Well-Known Member

    Seen this quite a few times. In the UK we call it Hyperkeratosis Punctata, and is probably the same term for Keratoderma Punctata. Rx typically is what you are doing now, although aggressive emollients should help with reduction of debridement time, but not intervals. Interestingly, I know of one patient who didn't complain of any symptoms, and declined Rx. The build up of keratosis didn't worsen, and she stayed asymptomatic.
  20. One Foot In The Grave

    One Foot In The Grave Active Member

    I remember them...one treatment was all it took!! Then we hid until someone else got the file the next time!
  21. John Spina

    John Spina Active Member

    This sounds like Unna Thost syndrome.What you can try to do is just keep debriding them and prescribing Carmol cream(Carmol 40 is good).If this is not available in your country,you can have the patient apply Crisco to her foot,cover with a plastic bag and leave it on overnight.See if this helps.
  22. Edward5225

    Edward5225 Member

    The information in this reply is from my own personal experimentation in which I have found a cure that works. The medical establishment is at a loss for both the cause and the treatment of this condition. The best they can do is steroids to ramp up your physiology, but they cannot cure the disease. I have found a cure that works, after years of experimentation and thousands in lab equipment to find out what is happening. This cure might not work for everyone.
    This disease (Palmoplantar Hyperkeratosis) is caused by an algae.
    That is why it is contagious – a person can pick this up by surface contact.
    However, not all humans can get algae infections. At first I thought it was genetic or perhaps related only to races from land-locked geographies, such as Germans, but that is not the case.
    Normally, humans are generally immune to algae infections, however, having too much magnesium in your body allows algae to grow and infect deep into skin tissue.
    Therefore, too much Magnesium allows the algae infection and the algae infection causes your body to react to keep the algae out of your tissue by thickening the skin – hyperkeratosis.
    Palms and the soles of feet are more susceptible due to higher moisture content and they touch surfaces with algae.
    The disease can be treated with anti-algae preparations, but most of those are also harmful to humans.
    Alternatively, chlorine bleach (sodium hypochlorite) in the formula for pools and hot tubs is effective. Apply at least twice daily in full concentration and wear bamboo moisturizing gloves afterward to keep chlorine in contact with skin.
    If you currently have fissures or cracks in your skin, yes, this treatment will hurt like the dickens, but it is critical to continue treatment.
    The more often it is applied, the quicker the algae will die.
    For full recovery, cut Magnesium out of your diet, especially if you are taking Magnesium supplements. In healthy adults, Magnesium supplementation is not necessary.
  23. blinda

    blinda MVP

    Hi Edward5225,

    First of all :welcome: to the Arena!

    I would would be very interested to read more on your findings, do you have any published material that I could source?

    Also, as I am sure you are aware, PPK can occur as a primary, inherited disorder of the volar surfaces, or as part of a generalized disorder, such as psoriasis, cutaneous T-cell lymphoma, or ichthyosis, to name just a few. I have never read anywhere that it is contagious? Can you point me in the direction of any evidence of this, please? Call me synical (as I said to my ex sister-in-law last night, who declared that she cures people of cancer with homeopathy....) but I`m quite keen on looking at the evidence before accepting recommendations for using, what I would consider, rather aggressive treatments.

  24. Edward5225

    Edward5225 Member

    Hello Bel,

    Thank you - glad to be here. Just Edward will be fine.

    I do not believe my findings are "publishable". To be published, clinical trials would be necessary with double blind standards (how you would cloak chlorine aroma is a tough one). As you know, this disease is rare and curing a half dozen patients is meaningless. Further, since the cure involves no pharmaceuticals, and no pharmaceutical company is going to develop a human-safe anti-algae preparation for a very rare nuisance disease, there is no funding for clinical trials. I have spent enough on this, mostly out of my own curiosity, but if the cure works and the solution spreads by word of mouth, then I am happy.

    Yes, I am aware that PPK can have a genetic component, which is why I first suspected a racial propensity. Perhaps there is a racial propensity, but it does not seem to effect the cure. If you have a patient with this disease, inquire if they are taking magnesium supplements, or eating a diet rich in magnesium - halibut, almonds, cashews, soybeans, spinach, etc. Or even eating algae in supplements.

    Evidence of contagion is anacdotal, but with enough frequency to be believable. Again, specific tests are needed to confirm and I would have a difficult time asking for volunteers for a disease that is officially incurable.

    LOL! Ah, yes, the swinging rubber chicken cure. We've all heard Simillar.

    I can send you copies of my images were I was able to culture and stain the algae, but the specic genus is hard to classify as algae goes into this spore state very easily and makes classification a pain. I did some library research on magnesium and I wrote up a four page white paper on that.

    What I am suggesting is this. If you have a patient or patients with this disease that has defied all your efforts, what have you, or your patient, got to lose? Check their magnesium intake, and tell them to visit a pool store. Note that blood serium tests for magnesium are not accurate, a tissue biopsy is necessary.

    Best Regards,

  25. Hey Edward.

    Dermatology is not my thing, however I have picked up a few things about research over the years.

    This is quite untrue. Double blinded RCTs are certainly the gold standard of evidence, but we would be in a parlous state if that was ALL there was. Case studies, case series and bench data all have value as well.

    Consider also the nature of a hypothesis / null hypothesis. If you are treating lower back pain it is a mare to work out what of your efficacy is down to the treatment and what is placebo effect (or indeed hawthorn effect). That is because placebos have been shown to improve back pain by around 40%. PPK on the other hand is, as you have said, is officially considered incurable. Therefore one has less to worry about in terms of the placebo effect. A cure of PPK is significant because it can only be caused by the theraputic agent. Previous tests (which will have incorperated the placebo element) have failed to cure it.

    To borrow ben Goldacres example, traveling to mars and growing a third eye in the middle of your forhead are both highly unusual. If the first man on mars comes back with a third eye in his forehead this will therefore be a significant piece of data, even if it is N=1. You don't need to send 500 people to mars to know that something odd is going on.

    So if you have affected cures like PPK then for goodness sake publish them! We can argue the toss about how the cure works but if hithertoo cure has been impossible then a cure is massively significant! Although not as good as an RCT sometimes we can "borrow" placebo data from other trials.

    Not sure about continuing using bleach on open wounds mind :eek:. Pretty sure you could get sued for that.

    Whats not to celebrate! She's found a cure.
  26. Edward5225

    Edward5225 Member

    Hello Robert,

    Thank you so much for your kind words of encouragement! Years ago I worked with teams that were doing clinical trials and even with perfect data and perfect conditions, there are a subset of individuals that just love tearing apart other people's work. I suppose that is necessary, but I really do not want to go through that. Also, until a pharmaceutical backs you, well, you know. I would rather write a book and be called a wacko! But, that has licensing problems. Maybe one day.

    Still, if we can help people that suffer with this incurable disease and the risk is minimal, then I feel we are obligated to try. Sodium Hypochlorite is usually sold in 10% solution for pools and hot tubs. This is far safer than Sodium Hydorxide, but, yes, in any treatment there are risks. If you know patients with this disease, they are usually to the point they will try anything, and as long as you make clear the situation your practice risks are minimal. Since the primary cure is to cut magnesium from the diet, and especially supplementation, there are almost no risks with that course. Note that Magnesium is stored in bone and tissue, with very little in blood and it can take weeks or even months for Magnesium levels to return to non-algae growing levels.

    Other anti-algae formulations are usually either for surfaces, which are quite dangerous, or include Simazine (or similar) to block photosynthesis, which are safe for fish tanks, but still harmful to humans.

    Alternatively, you can have patients soak their limbs in warm solutions that are just a bit heavier than what you would use for your backyard pool, and this seems to work to a degree, never fully eliminates the algae. My thought is that the algae is below the epidermis and skin absorbs the water and becomes "baggy" before it absorbs the chlorine, preventing lower layer penetration, but that is merely a thought.

    Results can be dramatic with 10% twice a day treatment. In one case, virtually cleared in three weeks. In the longest, a little over two months, but he was talking a Magnesium Chloride supplement, to the point he was suffering nausea and other toxicity symptoms. I ask they continue treatment one week beyond indications, and then they can stop with no recurrence.

    You can test the Magnesium hypothesis with no risks whatsoever. Inquire to patient's use of supplements and diet. Note that some multi-vitamins have a lot of Magnesium and you may have to visit your local pharmacy to be sure. They might grumble that they no longer get to eat their daily tin of cashews, or switch to a different multi-vitamin, but to end this, they usually comply without too much fuss.

    Best Regards,

  27. carolethecatlover

    carolethecatlover Active Member

    Dear EdYip and Edward 5225,Thank you for a MOST interesting thread. I love dermatology, and I would love to do a clinical study with DYSHIDROSIS, for which I have a cure, a cheap cure, (8 out of 10 patients with complete remission) So please, email me if you have a persistant case of dyshidrosis.

    Mr Yip, could you send a photo of the palms of her hands?
  28. Edward5225

    Edward5225 Member

    Hello Everyone,

    I continue to have good results with this treatment.

    Of course, independent confirmation would be most assuring. Has anyone else tried this course of treatment? What are your results?

    Best Regards,

  29. Edward5225

    Edward5225 Member

    If the dry, scaling, peeling, thickening and cracking skin is only on the palm of the hands or the soles of the feet, then the skin in those areas has stopped producing the fats and glycerols skin needs to be healthy.

    Sebaceous glands are microscopic exocrine glands in the skin that secrete an oily or waxy matter, called sebum, to lubricate and waterproof the skin and hair of mammals. In humans, they occur in the greatest number on the face and scalp, but also on all parts of the skin except the palms of the hands and soles of the feet. The type of secretion of the sebaceous glands is referred to as holocrine.

    Sebaceous glands secrete the oily, waxy substance called sebum (Latin: fat, tallow) that is made of triglycerides, wax esters, squalene, and metabolites of fat-producing cells.

    Sebum, secreted by the sebaceous gland in humans, is primarily composed of triglycerides (~41%), wax esters (~26%), squalene (~12%), and free fatty acids (~16%).

    Sex steroids are known to affect the rate of sebum secretion; androgens such as testosterone have been shown to stimulate secretion, and estrogens have been shown to inhibit secretion. Hence why treatment for this condition often includes cortisone, which is a steroid.

    If steroids are ineffective at stimulating sebum production, you can replace the missing fats and glycerols directly. Some patients might find direct replacement more effective or preferred over steroids.

    Apply a thin layer, just enough to cover the skin, of organic lard and wear light cotton socks or white parade gloves while sleeping. Pig fat is very close to human fat in composition and using organic will keep pesticides and herbicides away from your skin.

    During the day, you can use a glycerin based hand lotion, or if you prefer, pure glycerin, just enough to cover the skin (one drop is usually enough). Some adult personal lubricants are pure glycerin and add cinnamon oil, which is a natural antibacterial and adds a pleasant aroma.

    Applying lard and glycerin can have a dramatic effect - often clearing the condition in days, sometimes helping patients that have suffered for years.
  30. blinda

    blinda MVP

    I`m not sure why you have provided the above info on sebaceous gland activity, when by your own admission, plantar surface lack these. This thread was about plantar lesions. However, if you wish to discuss anhidrosis and hyperkeratosis...

    Yes, Natural Moisturising Factors (NMFs) in the epidermis can reduce in certain systemic conditions (eg eczema and keratoderma climactericum ) and with the maturing process, but they don`t “stop”. These inter and intra cellular components are actively produced and assist in sustaining water content (i.e. are humectant in effect), which is vital for resistance to shear and desquamation. Thus, water content is essential in maintaining skin integrity. Which is what I guess you were trying to say.

    Pig fat? We have moved on a tad in the last century for effective and ethical treatment of dermatological treatments for anhidrosis. Not to mention the growing population of vegetarians, vegans and the avoidance of haram products. Also “organic” does not equate to “no pesticides” https://www.geneticliteracyproject.org/2015/12/07/myth-busting-on-pesticides-despite-demonization-organic-farmers-widely-use-them/

    Evidence clearly demonstrates that regular application of emollients with added humectants - such as synthetic urea, which is also an effective keratolytic agent - improves elasticity, hydration and desquamation rates of the stratum corneum. An emollient is a lipid based product that occludes the skin surface, preventing trans epidermal water loss (TEWL) and come as ointments, sprays, creams, gels & lotions. Ideally, these are used as both a soap-substitute in cleansing and then applied as a leave-on moisturiser after washing. I agree that wearing a sock overnight will assist delivery of the emollient on the foot, particularly if the sock is damp, then a dry sock put on top and left overnight.

    However, I wouldn’t recommend the use of an essential oils. The anti-microbial activity of cinnamon oil is down to the volatile peroxides, which are produced during oxidisation – not a great idea to put bleach on anhidrotic skin, IMO. "Natural" does not equate to `safe`.

Share This Page