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A 34-year-old man comes to the office with a terrible foot odor problem. He is wearing cowboy boots and he says that his feet are always sweaty. He is embarrassed to remove his boots, but when the physician convinces him to do so the odor is overwhelming. While breathing through the mouth, the physician sees the typical pits of pitted keratolysis. His socks are moist and the skin is somewhat macerated from the hyperhidrosis. His foot has many crateriform pits on the heel (Figure 118-1). He is prescribed topical erythromycin solution for the pitted keratolysis and topical aluminum chloride for the hyperhidrosis. It is suggested that he wear a lighter and more breathable shoe until this problem improves.

Figure 118-1

Many crateriform pits on the heel of a foot in a man with pitted keratolysis and hyperhidrosis. (Courtesy of Richard P. Usatine, MD.)

Pitted keratolysis is a superficial foot infection caused by Gram-positive bacteria. These bacteria degrade the keratin of the stratum corneum leaving visible pits on the soles of the feet.

  • Seen more commonly in men.
  • Often a complication of hyperhidrosis.
  • Seen more often in hot and humid climates.
  • Prevalence can be as high as 42.5% among paddy field workers.1
  • May be common in athletes with moist, sweaty feet.2

  • Kytococcus sedentarius (formerly Micrococcus spp.), Corynebacterium species, and Dermatophilus congolensis have all been shown to cause pitted keratolysis.3
  • Proteases produced by the bacteria degrade keratins to give the clinical appearance.4
  • The associated malodor is likely secondary to the production of sulfur byproducts.3

Clinical Features

Pitted keratolysis usually presents as painless, malodorous, crateriform pits coalescing into larger superficial erosions of the stratum corneum (Figures 118-1, 118-2, 118-3, 118-4). It may be associated with itching and a burning sensation in some patients (Figure 118-3).

Figure 118-2

Pitted keratolysis on the pressure-bearing areas of the toes and the ball of the foot. (Courtesy of Richard P. Usatine, MD.)

Figure 118-3

Pitted keratolysis with hyperpigmented crateriform pits on the pressure-bearing areas of the foot. The patient complained of itching and burning on the feet. (Courtesy of Richard P. Usatine, MD.)

Figure 118-4

Pitted keratolysis with many crateriform pits on the heel. (Courtesy of Richard P. Usatine, MD.)

Typical Distribution

Pitted keratolysis usually involves the callused pressure-bearing areas of the foot, such as the heel, ball of the foot, and plantar great toe. It can also be found in friction areas between the ...

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