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SELF ASSESSMENT QUIZ SAQ Scaly Fissured Soles SELF ASSESSMENT QUIZ SAQ Scaly fissured soles AK Douieb,1 MD, Bayoumi Eassa,2 MD 1Consultant, Department of Dermatology, HPLM, Larache, Morocco 2Department of Dermatology, Venereology & Andrology, Faculty of medicine, Al-Azhar University, Cairo, Egypt CLINICAL FINDINGS no other cutaneous lesions and any signs of atopy. A 7-year-old boy presented to our OPD with The lesions cleared completely and recured again pruritus and scaling on the dorsum of both feet one week after stoppage of the therapy. since 4 years. There was history of aggravation of symptoms during winters. The lesions subsided What is the clinical diagnosis? on using some topical medications, there was • Keratolysis exfoliativa no history of similar lesions in his family. There • Eczema was personal history of bronchial asthma since • Psoriasis birth, and it was under remission for one year. • Fugal infection Cutaneous examination showed hyperkeratotic scaly plaques and fissuring over the plantar aspect Microscopic examination of sections from a of feet (Fig. 1). Scraping from the scales for fungus skin biopsy showed hyperkeratosis and focal was negative on KOH examination. A punch parakeratosis. There was epidermal acanthosis with 4mm skin biopsy was taken from right foot and paranuclear vacuolization in few keratinocytes. the patient was treated with topical mometasone, The dermis showed perivascular and peri tacrolimus and a urea containing moisturizer for eccrine duct (at their point of entry to epidermis) regular use on both feet along with antihistamines inflammatory infiltrate formed lymphohistiocytic. tablet Levocetirizine 5 mg for itching. There were PAS stain was negative for fungi (Fig. 2, 3). Fig. 2 Hyperkeratosis, parakeratosis, acanthosis with elongated and fused rete ridges. Paranuclear vacuolization Fig. 1 Scaly fissured plantar surface of the forefoot and in few keratinocytes. Perivascular and peri-eccrine heels. lymphohistiocytic infiltrate. Correspondence: Dr. AK Douieb, Consultant, Department of Dermatology, HPLM, Larache, Morocco, Email: [email protected] The Gulf Journal of Dermatology and Venereology Volume 28, No.1, April 2021 61 SAQ Self Assessment Quiz the feet, intertriginous area, instep and heel. In few cases the entire sole can be affected. Some cases the hand can be involved, with fissuring and soreness of the fingertips and palm.1 Forefoot eczema (FE) is also known as ‘juvenile plantar dermatitis’, ‘forefoot dermatitis’, ‘atopic winter feet’, ‘dermatitis plantarissicca’, ‘peridigital dermatitis’, ‘sweating socks dermatitis’.5 The scaling of the skin can resemble keratolysis exfoliativa, but this typically presents initially as pin size white dots that coalesce. Furthermore, Fig. 3 The inflammatory infiltrate mainly around eccrine keratolysis exfoliativa tends to affect the palms of ducts at their entry to epidermis. the hands more often than the feet and is often DIAGNOSIS asymptomatic.3 Juvenile plantar Dermatosis The differential diagnosis of JPD also includes tinea pedis. However, tinea pedis typically involves DISCUSSION the fourth and fifth toe web spaces, whereas JPD Juvenile plantar dermatosis (JPD) is a generally spares the toe webs. Although tinea dermatological condition that generally occurs in pedis rarely affects small children, clinicians adults of all ages and boys between 3-14 years of should not assume based on a patient’s younger age. Also, it is more common in females. When it age that a questionable presentation is JPD rather occurs in children the prognosis is one of gradual than tinea pedis. A potassium hydroxide (KOH) improvement.1 Children’s eczema, also known preparation can confirm or rule out tinea.6,7 as ‘juvenile plantar eczema’ has a tendency to be The exact etiology and pathogenesis of JPD are more severe during the summer months. not well-understood. JPD is often seen in ‘atopic’ The typical clinical features of Juvenile plantar children, i.e., those who have atopic dermatitis dermatosis (JPD) include erythematous rash of (eczema), asthma or hay fever.1,2 Our patient the weight-bearing plantar aspects of the feet, and gave us a past history of bronchial asthma. The the distal one-third of the plantar surface of the skin of patient with JPD seems generally more feet and toes tend to be involved more frequently. sensitive than others. The condition is related to The proximal two-thirds of the plantar surface friction. Friction is greater when the foot moves are not involved. Areas of involvement generally up and down in a shoe, especially when the foot appear smooth and shiny with a high incidence of is sweaty.3 painful fissuring and cracking.1-5 It is a better to avoid synthetic shoes. As the foot The affected regions commonly presented as became wetter in synthetic shoes (e.g., nylon or smooth and shiny with a high incidence of painful vinyl), during the summer months the condition fissuring and cracking. In some pateints, the skin is liable to be more severe, because heat and of the affected regions desquamates.1-4 The plantar humidity cause the feet to perspire and sweat. surface of the great toe is the most common site The synthetic and chemical substances used in the to be involved followed by forefoot, dorsa of manufacturing process for shoes and socks are The Gulf Journal of Dermatology and Venereology Volume 28, No.1, April 2021 62 AK Douieb et, al. SAQ the main provocating reasons in the occurrence over extended periods of time (either through of foot eczema. Sweat retention and covering of hyperhidrosis or occlusion of the foot via footwear the feet by woolen or polyester socks aggravates made of none breathable synthetic materials), high this condition, whereas cotton permits the skin to levels of surface moisture develop.10 However, it breathe. is well-established that exposure to water does The use of a shoe or socks without aeration for not induce skin hydration. In fact, persistent water a long time are an important triggering factor. exposure is shown to disrupt epidermal barrier Wearing leather footwear and cotton socks may function.11,12 Furthermore, there is recent evidence help relieve the problem. It is also important that that transepidermal water loss increases as the the footwear fits well and the sole of the foot is temperature increases,13 a finding that may be not sliding against the insole of the shoe. Walking relevant because none breathable footwear may barefooted on woolen or polyester carpets may be associated with higher foot temperatures. As contribute to juvenile plantar eczema as this may the disrupted epidermal barrier permits excessive lead to static electric charges that may play a role evaporation of subcutaneous moisture beyond in skin dryness and irritation of juvenile plantar normal evaporation of moisture on the surface eczema. of the skin surface water loss, a cycle of further It is sometimes difficult to differentiate JPD from degradation and dysfunction is instigated. With atopic dermatitis, contact dermatitis, psoriasis, the lack of hydration, desiccated corneocytes keratolysis exfoliativa, or a fungal infection. on the epidermal layer shrink. It is likely that in Keratolysis exfoliativa has a similar appearance the presence of depleted lipids and epidermal to juvenile plantar dermatosis, but usually affects proteins, corneocyte adhesion is diminished, and the hands. Contact dermatitis (irritant, allergic) fissures develop.11-12 usually has a history of using new footwear, and The management interventions for juvenile plantar dermatitis affects the dorsal aspect of the feet. dermatosis are: Decrease friction; Wear well- Patch testing may be considered for identifying fitting shoes, preferably leather, with two pairs specific contact allergens. Dyshidrotic eczema of cotton socks; Lubricate the dry skin. Greasy presents with multiple tiny deep-seated vesicles moisturizers can be very helpful, including white on the palms, lateral fingers, and soles. Plantar soft paraffin, particularly applied after a bath psoriasis is usually associated other psoriatic and before bed. Dimethicone barrier creams are lesions on the scalp, trunk, and extremities, and easier to use during the day, applied every four typical features of nail dystrophy (i.e. pitting, hours. Have a rest day: Schedule quiet times onycholysis, etc.). Family history of psoriasis, with little or no walking to allow the fissures to nail dystrophy, and psoriatic arthritis may be heal. Cover the cracks: Fissures heal faster when positive. Tinea pedis presents with scaling and/ occluded. Plasters are usually satisfactory. Spray or maceration of the instep and interdigital spaces or liquid bandage or nail glue can be applied to the as well as onychomycosis. Potassium hydroxide fissure to relieve the pain. Take care not to stick test to visualize microscopic fungal elements or the toes together. Topical steroids: Topical steroid fungal cultures may be performed. Notably, tinea ointments are often prescribed, but rarely prove pedis is uncommon in children.7-9 more effective than simple emollients. The more In JPD, when the foot is exposed to moisture potent products are worth a trial for a couple of The Gulf Journal of Dermatology and Venereology Volume 28, No.1, April 2021 63 SAQ Self Assessment Quiz weeks. If helpful, they should then be reserved for 4. Kalia S, Adams SP. Dermacase. Juvenile plantar a flare up, particularly if the affected skin is red dermatosis. Can Fam Physician 2005; 51:1203-13. or itchy.1-5 This condition typically resolves by 5. Van Diggelen MW, van Dijk E, Hausman R. The enigma of juvenile plantar dermatosis. Am J Dermatopathol puberty and rarely occurs in adults. Follow-up can 1986; 8 (4):336-40. 5 be performed on an as-needed basis. 6. Broberg A, Faergemann J. Scaly lesions on the feet in Our patient was treated with topical emollient children- tinea or eczema? Acta Paediatr Sc and 1990; ointment, topical steroid and topical tacrolimus 79:349-51. with good and satisfactory result. Upon clearance 7. Ashton RE, Griffiths WA. Juvenile plantar of the lesions completely, he was advised to dermatitisatopy or footwear? Clin Exp Dermatol 1986; continue foot care with dimethicone barrier cream, 11:529-34.
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