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Unknown Crusty Skin Condition

Discussion in 'General Issues and Discussion Forum' started by Steve5572, May 28, 2012.

  1. Steve5572

    Steve5572 Active Member

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    Hi All

    I would appreciate your opinion on a 'unknown' skin condition one of my patients is suffering from.
    He is an 80 year old man suffering from dry crusty callus like skin covering a large proportion of the plantar surface of both feet. (See attached photo's) The lesions are not painful however they are uncomfortable to walk on. They range from 2 mm up to 1cm in thickness, the thinner ones can be peeled off with some persuasion.

    The patient first some noticed some cracking 12 months ago while on holiday in Queensland. The condition progressed to its current state within a few months. This is the first episode and no other part of the body is affected apart from dry hands.

    The patient has seen two dermatologists none of which have been able to diagnose (to the patient) what the condition is. One dermatologist prescribed a cream the other an oral medication, none of which were successful. Apologies for the lack of detail here, it was difficult to get accurate information from the patient.

    My initial impression was Psoriasis, however i would have expected the numerous medical practitioners who have treated the man to have been able to diagnose this.

    If anyone has seen this before and can offer advise it would be much appreciated.


    Attached Files:

  2. collypete

    collypete Welcome New Poster

    Sorry i can't shed any light on your diagnoses trouble. Although I have seen similar skin conditions to this - psoriasis, excema 'plaques' the names used from different specialists. In these cases their was some good improvement with Advantan Fatty Ointment daily (prescribed by specialist, and then GP after) to use with socks.
  3. Catfoot

    Catfoot Well-Known Member

    Hi Steve5572,
    I have no idea what this could be, although I have seen similar presentations. I would guess at Chronic Mucocutaneous Candidosis but I would have thought that a dermatologist would have picked that up?

    I notice a thickened area over the 3rd met head which could indicate that pressure is playing a part here?

    Perhaps it would be best to treat symptomatically ?


  4. jos

    jos Active Member

    Looks like keratoderma to me- have had a couple of Pts with this over the years. The skin is not able to shed effectively and so builds up layers of "crust", which often form deep fissures on the heels.
    Takes monthly heavy debridement, daily use of Heel Balm (or similar) slathered on, to control it (not cure it).
    This Pt is with you for a VERY long time.
  5. davsur08

    davsur08 Active Member

    Hi Steve,
    i Agree with the rest. keratoderma climactericum. "Typical distribution of hyperkeratotic patches with thickening of the skin and deep fissures localised to the weight bearing plantar surfaces sparing the medial loongitudinal arch" (Dockery, 1997). Typical patient is obese with Hypertension. This condition is mostly seen in women in menopause, your patient is however a Man. See the articles enclosed.

    Attached Files:

  6. Catfoot

    Catfoot Well-Known Member

    I did consider Keratoderma Climacticum but that condition is confined to post menopausal women - hence the name


  7. davsur08

    davsur08 Active Member

    that was my thought too. The thick crusty appearance and also that the patient recently had been exposed to another climatic condition made me consider Keratoderma Climacticum. All keratoderma disorders tend to spare non-weight bearing areas, and is on both hands and feet, that a pattern seen in keratoderma disorder. I wonder if the patient has Gynecomastia?? steve, any idea?

    Iam anxiosly waiting for Belindas input.
  8. Steve5572

    Steve5572 Active Member

    Thank you all for your help.

    I saw the patient again today, this time with additional medical history. The patient is suffering from high BP and has a history of excema. So maybe Keratoderma fits??? He will attend Monash Hospital shortly so hopefully they can confirm the diagnosis.

    David I did not notice any enlargement of his breast tissue, but it wasn't something i was actively looking for.

    His feet did appear slightly better today, after the last consult my advice was to soak his feet in warm water with some washing powder, then gently run his feet over an old door mat. The patient noted that pieces of the thick crust were falling away.

    During the consult today i was able to remove most of the crusty layer with blunt (finger) debridement. The crusty layer was much softer, i expect to remove 95% at the next consult in 3 weeks.

    The patient is off to Queensland again for two weeks, i have advised him to go for some long walks/shuffles on the beach to exfoliate the skin.

    Sorry no photo's today i was under extreme time pressure but i will update with photos next consult.


  9. blinda

    blinda MVP


    Any news on follow up with this pt? I`ve just received a nudge from someone whom I was talking to about a similar presentation of PPK.

    Couple of years ago, I had a delightful gentleman present with hyperkeratosis very similar to these. He was undergoing cancer treatment and the PPK was a documented side effect of Sorafenib, an oral multikinase inhibitor used in the treatment of renal cell carcinoma. Treatment consisted of palliative care in the form of regular reduction of callus, painful fissures were glued together with Liquiheel and copious amounts of emollient applied daily.

    As I`m sure you know, the multiple manifestations of PPK can be either congenital or acquired, but the treatment is basically the same; palliative. Did the Monash Hospital come to any conclusions?
  10. podhugh

    podhugh Member

    I've got a patient with the same symptoms and she suffers from psoriasis. She's been trying to manage the really hard crusty lesions on her feet for years. She's not obese, doesn't have high blood pressure but she is post menopausal.

    I'd like some help with the first tx, as I understand the ongoing palliative aim is to debridement frequently and use emollient copiously! Is there a comfortable way of removing the initial painful really hard crusty plaques? Does the washing powder tx really work? Would soaking in warm water then using a water burr be better? Are there foot soaks available that would loosen them so they don't bleed as they become detached?

    Any suggestions would be gratefully received.

  11. Steve5572

    Steve5572 Active Member

    My patient was prescribed a cream containing salacylic acid. The acid softens the crusty skin and allows it to be debrided with a blade or by peeling of gently with your fingers. I encourage the patient to regularly exfoliating his feet with coarse door mat in between visits. Since using the cream in combination with regular debridement the crusty skin has reduced to a manageable level.

    Nothing else i tried work with any success.
  12. davsur08

    davsur08 Active Member

    Steve, have you tried venegar? Apparently vit c in venegar exfoliates. Ive not personally had any experience in it but ive seen picture's of feet before and after. Am not sure the exact mechanism of action. If salicylate works than urea 40% should work too. Jus a thought.

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