Dermatologic Therapy, Vol. 27, 2014, 101–104 Printed in the United States · All rights reserved
© 2013 Wiley Periodicals, Inc.
DERMATOLOGIC THERAPY ISSN 1396-0296
THERAPEUTIC HOTLINE Pitted keratolysis, erythromycin, and hyperhidrosis Guglielmo Pranteda*, Marta Carlesimo*, Giulia Pranteda†, Claudia Abruzzese*, Miriam Grimaldi‡, Sabrina De Micco*, Marta Muscianese*, & Ugo Bottoni§ *Dermatology Unit, NESMOS Department, Faculty of Medicine and Psychology “Sapienza” University Rome “S. Andrea Hospital,” Rome, Italy, †Dermatology Unit, Faculty of Medicine, Umberto I Hospital, Sapienza University, Rome, Italy, ‡Plastic Surgery Unit, Madonna delle Grazie Hospital, Matera, Italy and §Department of Health Science, University Magna Graecia, Catanzaro, Italy
ABSTRACT: Pitted keratolysis (PK) is a plantar skin disorder mainly caused by coryneform bacteria. A common treatment consists of the topical use of erythromycin. Hyperhidrosis is considered a predisposing factor for bacterial proliferation and, consequently, for the onset of PK. The aim of this study was to evaluate the relationship between PK erythromycin and hyperhidrosis. All patients with PK seen in Sant’Andrea Hospital, between January 2009 and December 2011, were collected. PK was clinically and microscopically diagnosed. All patients underwent only topical treatment with erythromycin 3% gel twice daily. At the beginning of the study and after 5 and 10 days of treatment, a clinical evaluation and a gravimetric measurement of plantar sweating were assessed. A total of 97 patients were diagnosed as PK and were included in the study. Gravimetric measurements showed that in 94 of 97 examined patients (96.90%) at the time of the diagnosis, there was a bilateral excessive sweating occurring specifically in the areas affected by PK. After 10 days of antibiotic therapy, hyperhidrosis regressed together with the clinical manifestations. According to these data, we hypothesize that hyperhidrosis is due to an eccrine sweat gland hyperfunction, probably secondary to bacterial infection. KEYWORDS: eccrine sweat glands, hyperhidrosis, pitted keratolysis
Introduction Pitted keratolysis (PK) is a common plantar skin disorder characterized by circular shallow pits in the stratum corneum (pitted aspect) or small erosions with an elongated form along the plantar furrows (Keratolysis sulcata). PK predominantly affects the pressure-bearing areas of the plantar surface of the feet, and it is rarely seen on the
Address correspondence and reprint requests to: Guglielmo Pranteda, MD, Professor, Via di Grottarossa 1035, 00189 Rome, Italy, or email: [email protected].
non–pressure-bearing areas and on the palm of the hand (1,2). An important often associated symptom that can cause social embarrassment is malodor, probably due to the production of sulfur compounds (3). PK is mainly caused by coryneform bacteria and one of the more common treatments consists of the topical use of erythromycin. Most of the authors identify hyperhidrosis as the main predisposing factor for bacterial proliferation and, consequently, the reduction of sweating as an important goal to cure PK. However, according to another pathogenic hypothesis, hyperhidrosis could be caused by bacterial infection and is not a predisposing factor to PK. To investigate this
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aspect, we analyzed the quantity of sweating in patients with PK before and after antibiotic treatment.
and values between 30 and 40 mg/minute as very high hyperhidrosis (5). Statistical analysis
Material and methods Patients All patients with PK, seen in Sant’Andrea Hospital, UOC Dermatology, NESMOS Department, between January 2009 and December 2011, were collected, and their clinical and microbiological data were analyzed. PK was clinically diagnosed according to the characteristic clinical manifestations and microscopic examination.
Microscopic examination All patients were subjected to a direct microscopic examination of the skin scrapings with potassium hydroxide (KOH) water solution, a rapid method to put in evidence the presence of typical coccoid and filamentous elements (4).
Treatment All patients underwent topical treatment with erythromycin 3% gel applied twice daily, without the concurrent use of aluminum chloride solution or other antiperspirant treatments. At the beginning of the study and after 5 and 10 days of treatment, a clinical evaluation and a gravimetric measurement of plantar sweating were assessed. A clinical follow-up of 6 months was performed for all the patients.
Gravimetric measurements of plantar sweating Subjects were required to be at rest in a normaltemperature room. Their feet were wiped before the test. A preweighed filter paper (Whatman #541, 90 mm, Maidstone, UK) was placed in each foot for 5 minutes and then the filter papers were removed and weighed again. The difference in weight was calculated in milligrams. This test was repeated three times: before the beginning of the treatment, 5 and 10 days after starting therapy. The gravimetric scores for each visit were obtained by taking the average of the readings from the right and left feet. Normal sweating was considered for values
© 2013 Wiley Periodicals, Inc.
DERMATOLOGIC THERAPY ISSN 1396-0296
THERAPEUTIC HOTLINE Pitted keratolysis, erythromycin, and hyperhidrosis Guglielmo Pranteda*, Marta Carlesimo*, Giulia Pranteda†, Claudia Abruzzese*, Miriam Grimaldi‡, Sabrina De Micco*, Marta Muscianese*, & Ugo Bottoni§ *Dermatology Unit, NESMOS Department, Faculty of Medicine and Psychology “Sapienza” University Rome “S. Andrea Hospital,” Rome, Italy, †Dermatology Unit, Faculty of Medicine, Umberto I Hospital, Sapienza University, Rome, Italy, ‡Plastic Surgery Unit, Madonna delle Grazie Hospital, Matera, Italy and §Department of Health Science, University Magna Graecia, Catanzaro, Italy
ABSTRACT: Pitted keratolysis (PK) is a plantar skin disorder mainly caused by coryneform bacteria. A common treatment consists of the topical use of erythromycin. Hyperhidrosis is considered a predisposing factor for bacterial proliferation and, consequently, for the onset of PK. The aim of this study was to evaluate the relationship between PK erythromycin and hyperhidrosis. All patients with PK seen in Sant’Andrea Hospital, between January 2009 and December 2011, were collected. PK was clinically and microscopically diagnosed. All patients underwent only topical treatment with erythromycin 3% gel twice daily. At the beginning of the study and after 5 and 10 days of treatment, a clinical evaluation and a gravimetric measurement of plantar sweating were assessed. A total of 97 patients were diagnosed as PK and were included in the study. Gravimetric measurements showed that in 94 of 97 examined patients (96.90%) at the time of the diagnosis, there was a bilateral excessive sweating occurring specifically in the areas affected by PK. After 10 days of antibiotic therapy, hyperhidrosis regressed together with the clinical manifestations. According to these data, we hypothesize that hyperhidrosis is due to an eccrine sweat gland hyperfunction, probably secondary to bacterial infection. KEYWORDS: eccrine sweat glands, hyperhidrosis, pitted keratolysis
Introduction Pitted keratolysis (PK) is a common plantar skin disorder characterized by circular shallow pits in the stratum corneum (pitted aspect) or small erosions with an elongated form along the plantar furrows (Keratolysis sulcata). PK predominantly affects the pressure-bearing areas of the plantar surface of the feet, and it is rarely seen on the
Address correspondence and reprint requests to: Guglielmo Pranteda, MD, Professor, Via di Grottarossa 1035, 00189 Rome, Italy, or email: [email protected].
non–pressure-bearing areas and on the palm of the hand (1,2). An important often associated symptom that can cause social embarrassment is malodor, probably due to the production of sulfur compounds (3). PK is mainly caused by coryneform bacteria and one of the more common treatments consists of the topical use of erythromycin. Most of the authors identify hyperhidrosis as the main predisposing factor for bacterial proliferation and, consequently, the reduction of sweating as an important goal to cure PK. However, according to another pathogenic hypothesis, hyperhidrosis could be caused by bacterial infection and is not a predisposing factor to PK. To investigate this
101
Pranteda et al.
aspect, we analyzed the quantity of sweating in patients with PK before and after antibiotic treatment.
and values between 30 and 40 mg/minute as very high hyperhidrosis (5). Statistical analysis
Material and methods Patients All patients with PK, seen in Sant’Andrea Hospital, UOC Dermatology, NESMOS Department, between January 2009 and December 2011, were collected, and their clinical and microbiological data were analyzed. PK was clinically diagnosed according to the characteristic clinical manifestations and microscopic examination.
Microscopic examination All patients were subjected to a direct microscopic examination of the skin scrapings with potassium hydroxide (KOH) water solution, a rapid method to put in evidence the presence of typical coccoid and filamentous elements (4).
Treatment All patients underwent topical treatment with erythromycin 3% gel applied twice daily, without the concurrent use of aluminum chloride solution or other antiperspirant treatments. At the beginning of the study and after 5 and 10 days of treatment, a clinical evaluation and a gravimetric measurement of plantar sweating were assessed. A clinical follow-up of 6 months was performed for all the patients.
Gravimetric measurements of plantar sweating Subjects were required to be at rest in a normaltemperature room. Their feet were wiped before the test. A preweighed filter paper (Whatman #541, 90 mm, Maidstone, UK) was placed in each foot for 5 minutes and then the filter papers were removed and weighed again. The difference in weight was calculated in milligrams. This test was repeated three times: before the beginning of the treatment, 5 and 10 days after starting therapy. The gravimetric scores for each visit were obtained by taking the average of the readings from the right and left feet. Normal sweating was considered for values
