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. 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.

    Case:
    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:
    [​IMG]
    Pic 2 - right forefoot post treatment:
    [​IMG]
    Pic 3 - right mid and rearfoot pre treatment:
    [​IMG]
    Pic 4 - right mid and rearfoot post treatment:
    [​IMG]

    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 :)

    Ed
     
  2. EdYip

    EdYip Active Member

    Here's pre and post pics of her Left foot:
    [​IMG]
    [​IMG]
    [​IMG]
    [​IMG]
     
  3. Bug

    Bug Well-Known Member

    Hmm....
    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.

    Ed
     
  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

    psoriasis?

    hi,
    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,
    rick
     
  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.

    Or

    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 ;)

    Ed
     
  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.

    Cameron
    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!

    Regards,

    Colin.
     
  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?

    Regards,

    Colin.
     
  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.

    cheers,

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

    Soton Pod Member

    Ppk?

    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

    www.pachyonychia.org
     
  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.
    Bizarre!
     
  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.
     
Loading...

Share This Page