Tuesday, January 08, 2008

Unusual Keratoderma

Susan Walsh, DPM
Foot Care Specialists of Boston Medical Center

Jag Bhawan, MD
Boston University School of Medicine
Boston, MA

Abstract: 44 year man with congenital keratoderma left foot

Hx: The patient was born with this problem. He has never seen a podiatrist or dermatologist. No other skin problems. He tries to keep callus under control by regular soaks of foot and using razor.
Past Medical History
2004- 3v CABG surgery

Reasons for presentation:
-Patient & wife inquiring about options such as skin graft, or laser
-Should be biopsied?
-started on CARMOL 20 20 % CREAM (UREA) apply to feet bid x one week then daily every day


  1. Linear epidermal nevus is a possibility, as is a mosaic form of palmoplantar keratoderma. Ichthyosis hystrix may present like this as well. I would biopsy the arch where there will be minimal pressure just to be sure, it could affect treatment options. I like the idea of topical keratolytics and maybe try tazarotene as well. Probably not symptomatic enough to warrant grafts or isotretinoin.

  2. i will keep clinical possibilities of Liner verrucous epiderma nevus or porokeratotic eccrine dermal duct nevus. Skin biopsy will help to confirm the diagnosis. Topical coal tar, salicylic acid shall help. Surgical ablation may have some practical problems over this site, though it would not make this condition worse except for if it turns out to be linear psoriasis.

  3. Bhushan KumarJanuary 09, 2008

    My diagnosis is ILVEN [Inflammatory Linear Verrucous Epidermal Nevus]

  4. This is an interesting case presentation. Every day we see things we never saw before -- and for many of us, this patient is an example. My first impression is that this man has a forme fruste of a keratoderma in that it is congenital by history. I am not sure if ILVEN is congenital. I will check eMedicine.com. Considering the location on the foot, I would stay away from surgical modalities. He may be left with a painful scar. I would consider Salex Cream as an initial therapy. I would also do a biopsy because it's important to nail down the diagnosis if possible. Based on a pathological diagnosis moe specific therapy could be offered.

  5. This is from the eMedicine chapter on "Epidermal Nevus Syndrome"
    * ILVEN is a linear, persistent, pruritic plaque, usually first noted on a limb in early childhood. ILVEN is characterized by tiny, discrete, erythematous, slightly warty papules, which tend to coalesce in a linear formation.
    * Altman and Mehregan3 delineated 6 characteristic features: early age at onset, predominance in females (with a female-to-male ratio of 4:1), frequent involvement of the left leg, pruritus, marked refractoriness to therapy, and a distinctive psoriasiform and inflammatory histologic appearance.
    * The lesions may be observed at birth, but most appear during infancy and childhood. In the study by Altman and Mehregan,3 one half of patients were noted to have lesions by age 6 months with three quarters of the 25 patients developing lesions by age 5 years. Several patients were noted to develop lesions at an older age (eg, 1 patient developed a lesion at 49 y). The left side of the body, particularly on the left lower extremity, was more often involved.
    * ILVEN may occur with musculoskeletal abnormalities in a few children, prompting the classification of ILVEN as part of ENS. One infant had ILVEN with congenital dislocation of the ipsilateral hip and Fallot tetralogy of the heart. Another infant had congenital ILVEN with congenital bony anomalies of the ipsilateral extremities. Nevus depigmentosus and ILVEN may occur together, as may ILVEN and melanodontia."

  6. Dr. P. Li LoongJanuary 10, 2008

    Dr Philip Li Loong wrote

    consider a linear verrucous epidermal nevus. ref: Terrinoni A J Invest Dermatol(2000) 114:1136-1140" a mutation in the V1 domain of K16 is responsible for the unilateral palmoplantar verrucous nevus.a biopsy may be helpful. a nevus will not likely respond to oral etretinate like a true keratoderma

  7. Doug Johnson from Honolulu wrote:
    "I'd use acetretin 10-25mg/day and 10 salicylic acid in petrolatum.
    Could be hypertrophic psoriasis
    if acquired."

  8. my diagnosis will be Linear Verrucous Epidermal Naevus. Of course. a biopsy is helpful to establish the diagnosis. Carbon Dioxide laser ablasion in layers should be helpfu. Several sittings, giving enough recovery time in between, should be a good option than an over-enthusiaistic ablasion. But recurrence will be an impending problem. Otherwise strong keratolytics, as suggested by Dr Dogra.

  9. Im a 27 yr old mom of 2 with the same birthmark on my foot. I was told it was a demacrated epidermal nevus. If anyone has anymore info on this it would be appreciated.

  10. I was born with the almost exact same mark on my left foot. it developed on my foot when i was about 2. i am 38 years of age and would like to know more about this as i have went to local doctors and it was diagnosed as hyperkeratosis. The interesting thing is i am am left handed and it starts on my inner left arm about 5 inches, then about 4-5 inches on my left chest area, then a slight line on me inner thigh, then another 5-6 inch line on my inner left leg and then a large area on my heal straight to my middle toe. It's almost like a trail that starts from my arm and ends at my foot, all on the left!

    My email is iltoro427@aol.com

    Please contact me with some info and new strategies.



    New York


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