Tag Archives: Photo Quiz

Answer: Photo Quiz #6

Pitted keratolysis

ISSN 1941-6806
doi: 10.3827/faoj.2008.0109.0005

Pitted keratolysis or PK was first described in a Ceylonese patient in 1910, by Castellani as keratoma plantare sulcatum secondary to yaws. [1,2] The condition is caused by a cutaneous gram positive bacterial infection linked to both the Corynebacterium and Actinomyces species. [1,2] This disorder is characterized by keratomatous pitting of the skin usually to weightbearing regions of the foot, such as the forefoot and heels.

The condition has no age or sex predilection and can affect individuals at any age. The condition is associated with athletics and individuals who prefer going bare-footed in tropical regions. The condition may or may not be associated with underlying hyperkeratosis. It can be malodorous and pruritic in nature. It is also known to be associated with hyperhidrosis and perfuse sweating of the feet. In association with hyperhidrosis, the punched-out pits can coalesce and form white clusters. [3,6] The keratin pits associated with this condition are usually small in the diameter range of 0.5-7mm. Larger pitting and lesions are associated with a variant form called crateriform pitted keratolysis. [1] It is suggested that the pitting is caused by proteases secreted by the bacteria and alter the structure of both the corneodesmosomes and the keratohyalin granules. The corneodesmosomes at the bottom of the pits were in part cleaved leading to partial corneocyte dissociation. [4]

The differential diagnosis in our quiz included arsenical keratosis, keratosis punctata, keratosis pilaris, intractable plantar keratosis, porokeratosis plantaris discreta, hyperhidrosis and bromohidrosis.

Arsenical keratosis present as yellow-brown lesions usually seen on the sole of the feet after exposure to arsenic. [6]  It is also involves the hand. Although the brown discoloration of arsenical keratosis may appear similar to pitted keratolysis, arsenical keratosis is extremely rare and only occurs after long-term exposure to arsenic. It has been shown to cause Bowen’s disease or in-situ squamous cell carcinoma. [7]

Keratosis punctata is a dominantly inherited disorder that develops between the ages of 15 and 30. [6] The condition will last a lifetime. [6]  These lesions are more punctuate, as the name implies and will not disappear when superficially debrided as in pitted keratosis.

Keratosis pilaris is not a condition that involves the plantar surface of the foot. It is commonly associated with atopic dermatitis. [6] It is associated with kertinization of hair follicles. It is an extremely common benign condition that manifests as small, rough folliculocentric keratotic papules, often described as chicken bumps, chicken skin, or goose bumps, in characteristic areas of the body, particularly the outer-upper arms and thighs. [8]

Intractable plantar keratosis or IPK is usually an isolated hyperkeratotic lesion under a metatarsal head. These lesions are large and measure up to 20-30mm in diameter. [9]  These lesions are sometimes confused with porokeratosis plantaris discreta, however, porokeratosis is a much smaller hyperkeratotic lesion that can reach a depth of 1.5mm or more.  It can also be associated with non-weightbearing surfaces, unlike the IPK.

Hyperhidrosis is a local condition of sweaty feet or excessive perspiration. This condition can certainly lead to and is commonly associated with pitted keratolysis. Bromohidrosis is the termed used to describe the pungent odor of malodorous feet. Bromohidrosis is commonly associated with hyperhidrosis, ingestion or exposure to heavy metals such as arsenic and the odor associated with fungal and bacterial infections of the feet. [6]

Treatment of pitted keratolysis can include localized debridement of the overlying epidermis and topical drying agents with oral and topical antibiotics. Topical drying agents can include Drysol or aluminum chloride hexahydrate. Roll-on antiperspirants such as aluminum chloride have also been described. [1]  Zeasorb super absorbent powder to address the hyperhidrosis can also be useful. Oral antibiotics to treat the underlying infection are also indicated when treating PK if the condition is resistant to topical antibiotic treatments. The oral and topical antibiotic of choice is clindamycin. Antibacterial gels or creams such as clindamycin, erythromycin and mupirocin has also been described. [5]  Twice daily applications of these topicals for 2-3 weeks will usually clear the lesions. In other cases, botulinum toxin injections have been shown to be effective. The overall prognosis is excellent when properly treated.

The patient was prescribed erythromycin 2% cream for two weeks.  She was advised to keep her feet dry and use talcum powder after the application of erythromycin cream.  After having the condition for over a year, the condition resolved promptly after 2 weeks of topical treatment.


1. English, J.C.: Pitted Keratolysis eMedicine, [online], 2006
2. Singh, G., Naik, C.L.: Pitted Keratolysis Indian Journal of deratology, Venereology and leprology, 71(3), 213-215, 2005 [open access].
3. DermNet NZ: Pitted keratolysis, [online], 2008.
4. Hermanns-Le, T., et al.: Pitted keratolysis: New Ultrastructural Insight in Keratohyalin Granule and Corneodesmosome Alterations. Exogenous Dermatology, 3(3), 2004.
5. American Osteopathic College of Dermatology: Pitted Keratolysis [online], 2008.
6. Dockery, G., Crawford, M.E.: Color Atlas of Foot & Ankle Dermatology, Lippincott-Raven, 1999.
7. Chen, Chi-Shen J.: Arsenical Keratosis, eMedicine, [online], 2008.
8. Alai, N.: Keratosis Pilaris, eMedicine [online], 2008.
9. Kline, A. Keratotic Skin Lesions of the Foot, The Foot Blog, [online], 2006.

Address correspondence to: Al Kline, DPM. 3130 South Alameda, Corpus Christi, Texas 78404.

Adjunct Clinical Faculty, Barry University School of Podiatric Medicine. Private practice, Chief of Podiatry, Doctors Regional Medical Center. Corpus Christi, Texas, 78411.

© The Foot & Ankle Journal, 2008

Photo Quiz: Unusual pits to the bottom of the foot

by Al Kline, DPM 1

The Foot & Ankle Journal 1 (9): 5

ISSN 1941-6806
doi: 10.3827/faoj.2008.0109.0005

Case History

A 21 year old female presents with unusual ‘pits’ along the bottom of the forefoot. (Figs. 1) The patient states that she has had the condition for over a year. She relates to going bare-footed and wearing sandals whenever possible. There is an associated pungent odor to her feet. She relates to having to wash her feet often. The patient initially thought it was just dirt that “didn’t wash off” in the bath. She became more concerned when the lesions and dark brown pits would not go away.


Figures 1    Dark-stained appearing pits to the bottom of the forefoot.   The patient attributed this condition to her feet getting dirty while going bare-footed.   However, it appeared that the ‘dirt’ would not wash off.

The patient’s medical history is unremarkable. She is allergic to Ceclor®. She does not take any prescription or over-the-counter medications.

The lesions or pits appear to be confined to the epidermis and seem to disappear with superficial debridement. (Figs. 2)


Figures 2    Closer clinical examination reveals tiny hollow pits and small craters within the epidermis.  Simple debridement does not reveal deeper keratosis. 

Question: Based on the patient’s clinical history, which of the following is the correct diagnosis?

A. Arsenical keratosis
B. Pitted keratolysis
C. Keratosis punctata
D. Keratosis pilaris
E. Intractable plantar keratosis
F. Porokeratosis plantaris discreta
G. Hyperhidrosis
H. Bromohidrosis

Address correspondence to: Al Kline, DPM. 3130 South Alameda, Corpus Christi, Texas 78404.

1 Adjunct Clinical Faculty, Barry University School of Podiatric Medicine. Private practice, Chief of Podiatry, Doctors Regional Medical Center. Corpus Christi, Texas, 78411.

© The Foot & Ankle Journal, 2008

Answer: Photo Quiz #4

Answer: All of the above

ISSN 1941-6806
doi: 10.3827/faoj.2008.0105.0007

Pediatric Atopic Dermatitis (PAD) or eczema is a term commonly used to describe inflamed, dry and itchy skin. The hallmark of the condition includes excessive skin dryness and itching causing lichenification primarily to the flexural regions of the arms and legs. The condition most commonly occurs in infants, children and young adults. The condition is particularly pruritic in nature and can be associated with other conditions such as asthma, allergic rhinitis, allergies to food and increased IgE. [1] Food allergy to eggs, milk, peanuts, soy, wheat, tomatoes, oranges, chocolate and seafood can cause PAD. [1,3] The condition is of unknown origin, but is thought to be familial in nature. The condition affects about 10 percent of children and 3 percent of the US population. [2] Onset typically begins within the first year of life in 60 percent of the cases and 85 percent within the first five years. [3] It is particularly severe in the winter months and often is referred to as “winter’s itch.” The condition most often resolves spontaneously in children as they enter adulthood.

Atopic dermatitis (AD) typically occurs in three distinct age-related stages that may be separated by periods of remission and overlap. [3]

1) In infancy to two years of age, the skin is manifested by red, weeping, crusted lesions to the face, scalp and extremities.
2) In childhood (2-12 years of age), atopic dermatitis typically appears in the skinfold areas, especially the front of the elbow, back of the knee, inside the wrist and depressions along the ankles and neck.
3) In the adult stage, from puberty onward, people with atopic dermatitis may either have a few or no skin problems since infancy, or may have suffered a chronic relapsing course with periods of remission. There are often regions of thick, red skin caused by frequent scratching. In this stage, atopic dermatitis typically appears behind the elbows and knees, on the eyelids, neck, hands and wrists.

Atopic dermatitis is not contagious. It is a genetic disorder influenced by environmental factors. The mode of inheritance and genes involved are not clear. Research shows that a family history of allergic disorders, including hay fever and asthma, significantly increases a child’s risk of developing atopic dermatititis. Children with one parent with allergies have a 30 percent risk of developing atopic dermatitis; if both parents have allergies, the risk is greater than 70 percent. [3]

Fare-ups are most common during the fall and winter when the air is dry and cool. Humid and warm weather also poses a challenge to children with atopic dermatitis. Chemicals in pools and the drying action of pool water can cause excessive skin dryness, exacerbating atopic dermatitis. Flare-ups can also be induced by skin infections, allergens and wool garments and can worsen by sudden changes in temperature and humidity or emotional stress. To minimize flare-ups, patients should avoid irritants, including soaps, solvents and other drying compounds, chlorinated water and salt water. Patients should always wear clothes that “breathe”, like cotton. [3]


Treatment of AD consists of daily skincare hydration and decreasing inflammation. Skin hydration can be achieved by applying a variety of skin moisturizers. Avoid lotions that contain water and alcohol as these tend to increase skin dryness. Patient’s suffering AD should never shower or bathe in hot water. Always wash the skin in luke warm water applying the moisturizer within three minutes of washing. This helps the moisturizer penetrate the skin up to ten times better than applying it directly to dry skin.

Special soaps can also be used including Cataphil®, Oilatum, Aveeno® and Neutrogena®. Lotions that help moisturize the skin include Eucerin®, Neutraderm, Lubriderm®, Keri®, Curel®and Moisturel®.

Children should avoid sudden changes in temperature or contact with harsh chemicals and fragrances in waters, soaps and lotions. Children should also wear breathable fabrics such as cotton to avoid flare-ups. When sleeping, avoid wool, electric and heavy blankets that may cause night sweats that can irritate AD.

Topical corticosteroid creams and sprays are the mainstay of treatment in PAD. We have found two topical corticosteroids that work the best. Clobex® spray 0.05% (clobetasol propionate) works best in areas of acute inflammation, especially in the flexural regions of the skin of the lower and upper extremities. For PAD in sensitive regions of the skin such as the face and groin, Desonide Lotion 0.05% applied twice daily works wonders.

Remember, most children will improve over time with proper treatment. It is important to keep a moisturizing treatment regime as a daily routine. If is also important to see your dermatologist or extremity skin specialist in cases of severe AD. If treatment fails, see your allergist to determine other possible allergic causes of AD.


1. Krafchik, B.R. Atopic Dermatitis eMedicine [online], 2008.
2. American Academy of Dermatology [online], 2008.
3. Iden, D.L. Facts about Pediatric Atopic Dermatitis, correspondence, 2008.

Address correspondence to: Dr. Al Kline, DPM, 3130 South Alameda, Corpus Christi, Texas 78404. E-mail: al@kline.net

Adjunct Clinical Faculty, Barry University School of Podiatric Medicine. Private practice, Chief of Podiatry, Doctors Regional Medical Center. Corpus Christi, Texas, 78411.

© The Foot & Ankle Journal, 2008

Photo Quiz: Pediatric itching of the lower extremities

Al Kline, DPM1

The Foot & Ankle Journal 1 (5): 7

ISSN 1941-6806
doi: 10.3827/faoj.2008.0105.0007

Case History

An 8 year old male and his 11 year old brother presented to the office with a long history of severe scaling, rash and itching of both ankles. There are itchy, red patches along the back of the knees. (Figs. 1,2)


Figure 1   Areas of scaling, rash and lichenification along the posterior and anterior ankle. (a,b)  The flexural regions of the knees are also affected. (c) (11 year old boy)


Figure 2   Rash, skin dryness and scaling along the posterior leg (a).  Anterior leg scaling with eczematous features (b).  (8 year old boy)

The child’s parents relate to the brothers having the scaling on and off since the children were about 4 or 5 years old. Flare-ups would often be exacerbated during the summer and winter months. In the summer, the children would often swim in the family pool and develop severe regions of itching to both extremities. It was particularly severe in areas of skin folds, particularly to the anterior ankle and back of the knees. In the winter months, the skin would not stay hydrated enough, and the skin would typically get very itchy and secondarily infected from scratching. This would leave the skin with crusts and lichenified regions of skin after scratching.

The children would often have areas of skin that would not tan or pigment after these flare-ups. (Fig. 3)


Figure 3   Regions of post inflammatory hypopigmentation to the arms.    (8 year old boy)

Question: Based on the patient’s clinical history, which of the following is the correct diagnosis?

A. Eczema
B. Winter’s itch
C. Pediatric Atopic Dermatitis
D. Food allergy
E. Hypersensitivity skin reaction
F. All of the above


Address correspondence to: Dr. Al Kline, DPM, 3130 South Alameda, Corpus Christi, Texas 78404. E-mail: al@kline.net

1Adjunct Clinical Faculty, Barry University School of Podiatric Medicine. Private practice, Chief of Podiatry, Doctors Regional Medical Center. Corpus Christi, Texas, 78411.

© The Foot & Ankle Journal, 2008

Answer: Photo Quiz #2

ANSWER:   Epidermal Inclusion Cyst (EIC)


An epidermal inclusion cyst or EIC is a benign soft tissue cyst derived from implanted epidermal cells into the dermis. A more general term is epidermoid cyst. The classic epidermal inclusion cyst is due to traumatic implantation of epidermal cells with a characteristic pore or punctum. The pore is usually attached and communicates with the cyst forming a cheesy, caseating material that can sometimes be expressed on deep palpation. This material is the result of inflammation in part mediated by the horny material contained in epidermoid cysts which contain polymorphonucleocytes. [1]

In this case, there was no central pore, which made the diagnosis more difficult. It appears that repetitive tissue trauma and inflammation played an important role in the formation of this cyst. The patient was quit active and involved in many sports that caused repetitive forefoot injury. Other causes of the cyst may include occlusion of the pilosebaceous unit, eccrine duct occlusion, HPV infection or surgical implantation of epidermis. It can also be caused by sequestration of epidermal rests in embryonic life. [1]

The histologic findings in all epidermoid cysts are consistent of a keratin-containing cyst concentrically laminated with condensed keratin lined by stratified squamous epithelium.

The choices for this photo quiz included subcutaneous epithelioma, adventitial bursa, ganglion cyst, sebaceous cyst, giant cell tumor, schwannoma and histiocytoma.

Adventitial bursae, ganglion cyst, and shwannoma could be immediately ruled out. These structures do not contain epidermis or keratin histologically. The giant cell tumor can also be ruled out. A giant cell tumor is a tumor of bone caused by the proliferation of multinucleated giant cells. [2]

Epitheliomas are by definition confined to the epidermis. A common epiethioma is basal cell carcinoma. A ‘subcutaneous’ epithelioma is a rare lesion that usually ulcerates or calcifies within the subcutaneous tissue. A histiocytoma is a common benign skin tumor in young dogs. [3]


1. Becker, Kenneth: Epidermal Inclusion Cyst; emedicine [online].
2. Lesley-Ann Goh, MBBS, FRCR: Giant Cell Tumor; emedicine [online].
3. Histiocytoma, Marvista Animal Medical Center, [online].

Photo Quiz: An unusual swelling of the foot

Al Kline, DPM

Case History

A 13 year old female presents with a two year history of a “lump” to the bottom of the right forefoot.  The patient reports pain, discomfort when walking and exercising with no history of trauma. The patient plays sports and enjoys running and basketball. She is involved in multiple track events including the discus and shot-put. There is increasing pain and swelling to the plantar forefoot region.

The patient has no drug allergies and does not take medication. The physical examination is normal. There is no history of past surgery or medical condition. Foot mechanics reveal mild pronation, but no apparent biomechanical faults. Vascular and neurological status is normal. There is a well, circumscribed firm soft tissue mass that is painful to palpation just under the third metatarsal head region. Radiographs reveal no bone abnormalities of the foot. (Fig. 1)


Figure 1 Swelling seen in the region of the plantar third metatarsal head region.  The swelling is firm and painful to palpation.

A multiplanar, multiecho pre and post contrast MRI of the forefoot is provided for review (15 cc gadolinium). The MRI revealed a 8 x 14 x 28mm, well circumscribed cystic focus plantar to the third MTP joint. No significant contrast enhancement is identified. The adjacent third MTP joint is preserved. The remaining metatarsal phalangeal joints are unremarkable. The visualized extensor and flexor tendons are intact.

The patient was taken to surgery. A large, firm ‘cocoon-like’ mass was removed. (Fig. 2) The tissue was submitted in formalin. Cut sections showed solid gray-white surfaces with a 1 to 2 mm rim of gray-pink tissue around the periphery. No distinct areas of cystic change are seen and multiple representative sections are submitted in one cassette. No malignancy is present. Slides were submitted. (Fig. 3)


Figure 2 A firm soft tissue mass was removed.  The mass appeared to be located in the subcutaneous layer along the plantar surface of the third metatarsal head.


Figure 3 Sections showed keratin-containing features with focal histiocytic reaction in the adjacent stroma.

Question: Based on the patient’s history, physical exam, radiological tests, surgical findings and pathology report, which one of the following is the correct diagnosis?

A. Subcutaneous epithelioma
B. Adventitial bursa
C. Ganglion cyst
D. Epidermal inclusion cyst
E. Sebaceous cyst
F. Giant Cell Tumor
G. Schwannoma
H. Histiocytoma