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Imaging Quiz Answer: A Foot Rash With a Foul Odor

CPT Timothy L. Gardner, MD; LTC Dirk M. Elston, MD



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The dark, moist environment created by athletic shoes and the accompanying friction predispose active patients to certain dermatologic conditions. Friction and maceration can cause blisters and calluses, providing a setting for microbes of various kinds to thrive. The overgrowth of skin flora can produce pitted keratolysis, which was the diagnosis for this patient (figure 2).



Pitted keratolysis is a superficial infection of the skin with the bacteria Micrococcus sedentarius, Dermatophilus congolensis, or species of Corynebacterium and Actinomyces.(1-3) (See "Pitted Keratolysis: A Common Infection of Active Feet," October 1996.) The most common site for pits to appear is on the weight-bearing surfaces of the feet (4). The palms of the hands can also be affected, but one typically sees scale collarettes rather than pits (5). The infection is most often asymptomatic, but a painful violaceous plaque-like form of pitted keratolysis has been reported (4).

The clinical appearance of the rash with foot odor is usually sufficient to make the diagnosis. Biopsies are generally not required, but are occasionally submitted by clinicians unfamiliar with the condition.

On biopsy, the causative gram-positive organisms are found in the sides and bases of the pits in the stratum corneum (figure 3) (3,6). It appears that the organisms produce proteolytic enzymes that erode the horny layer (3). The odor is believed to come from a mixture of thiols, sulfides, and thioesters (2).


Initial treatment consists of limiting the use of occlusive footwear and reducing friction and moisture. Properly fitted shoes and absorbent cotton socks should be worn. Hyperhydrosis can be a predisposing factor, and a drying agent such as 20% aluminum chloride, 2% buffered glutaraldehyde, or 40% formalin ointment can be used (7-9). Aluminum chloride is the preferred treatment. Since aluminum chloride and other drying agents possess no antibacterial properties, the pitting may remain unless a topical antibiotic is used (7).

A 1-month trial of aluminum chloride is usually adequate, but many clinicians use topical antibiotics as initial therapy because they are less irritating. Effective topical antibiotics include erythromycin, clindamycin phosphate, mupirocin, gentamicin sulfate, and tetracycline hydrochloride (4,5,10,11). Some topical antifungals with gram-positive antibacterial properties (such as miconazole nitrate and clotrimazole) can be used (5). Systemic erythromycin has also been beneficial (4).

With treatment, the odor and pitting resolve within 3 to 4 weeks without sequelae (11). In our patient, treatment consisted of the use of topical erythromycin three times daily, which cleared the lesions and odor in 3 weeks.


  1. Rubel LR: Pitted keratolysis and dermatophilus congolensis. Arch Dermatol 1972;105(4):584-586
  2. Nordstrom KM, McGinley KJ, Cappiello L, et al: Pitted keratolysis: the role of Micrococcus sendentarius. Arch Dermatol 120217;123(10):1320-1325
  3. Tilgen W: Pitted keratolysis (keratolysis plantare sulcatum): ultrastructural study. J Cutan Pathol 1979;6(1):18-30
  4. Shah AS, Kamino H, Prose NS: Painful, plaque-like, pitted keratolysis occurring in childhood. Pediatr Dermatol 1992;9(3):251-254
  5. Zaias N: Pitted and ringed keratolysis: a review and update. J Am Acad Dermatol 120212;7(6):787-791
  6. Stanton RL, Schwartz RA, Aly R: Pitted keratolysis: a clinicopathologic review. J Am Podiatry Assoc 120212;72(8):436-439
  7. Shelley WB, Shelley ED: Coexistent erythrasma, trichomycosis axillaris, and pitted keratolysis: an overlooked corynebacterial triad? J Am Acad Dermatol 120212;7(6):752-757
  8. Lamberg SI: Symptomatic pitted keratolysis. Arch Dermatol 1969;100(1):10-11
  9. Gordon HH: Pitted keratolysis: forme fruste old treatments, letter. Arch Dermatol 120211;117(10):608
  10. Vazquez-Lopez F, Perez-Oliva N: Mupirocine ointment for symptomatic pitted keratolysis, letter. Infection 1996;24(1):55
  11. Burkhart CG: Pitted keratolysis: a new form of treatment, letter. Arch Dermatol 120210;116(10):1104
Dr Gardner is a resident in the department of dermatology and Dr Elston is chief of the dermatology service, both at the Wilford Hall Medical Center at Lackland Air Force Base in Lackland, Texas. Address correspondence to Dirk M. Elston, MD, 59th Medical Wing, Dept of Dermatology/MMID, 2200 Berquist Dr, Suite 1, Lackland AFB, Texas 78236-5300; e-mail to [email protected].



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