Wednesday, March 03, 2010

An Orphan Patient

Abstract:  44 yo man with a 10 year history of a progressive and disabling dermatitis if the feet.
HPI:  This 44 yo professional was first seen 10 years ago with a dermatitis of both feet and nails.  KOH prep from toe nails was positive for hyphae and he was treated with 3 months of Lamisil p.o.  Nails and feet improved at that time.  He was next seen in 2004 with dermatitis of both feet located on plantar areas which was predominantly hyperkeratotic with areas of excoriation.  He had developed a cellulitis of the right leg which required hospitalization.  KOH from affected aeas was negative in 2004.  Treated with betamethasone diproprionate 0.05% ointment and wet compresses and was "80%" improved in two weeks.  At that time a diagnosis of "keratoderma" and possible "dyshidrosis" was considered.  The process recurred and he asked his PCP to place him on prednisone which was done and seemed to help for a while.  From 2004 - 2010 he saw a number of other dermatologists and podiatrists both locally and at a large university center where a number of other therapies were tried, including Castelanni's paint.  None worked for very long and he was seen back at my office in March 2010.  The patient is at the end of his wits with this.  It dominates his life and is the cause of pain which interferes with his ability to stand at work.

O/E:  March 1, 2010:  Symmetrical hyperkeratosis of the plantar aspects of both feet with areas of excoriation.  Nails look normal.  Palms normal.  KOH prep from plantar dermatosis is negative for hyphae and a fungal culture was plated.

Photos March 2010:

Diagnosis:  Is this keratoderma, tylosis or an unusual contact dermatitis? Could this have begun with tinea pedis nine years ago or was than an incidental finding?

Plan:  Patch testing needs to be considered to r/o occult contact.  I doubt biopsy will help.  Will start therapy with Salex Cream (6% salycilic acid) as we await fungal culture.

Questions:  Does anyone have strong feelings about a diagnosis here?  If so, what therapy should be tried? 

1. Shelley WB, Shelley ED.  The orphan patient. N Engl J Med. 1988 Mar 10;318(10):646. In this important letter to the NEJM, the Shelleys define the orphan as an individual “with a unique, inchoate, baffling and often disabling disease and yet clearly not discernable in the medical literature.”  While the patient described here is not strictly an "orphan patient" his 10 year unsuccessful quest for control or cure, puts him in that unfortunate category.  Your help will be appreciated.

2. Brian Maurer sent us an important review of "Shoe Dermatitis" by Robert Adams which appeared in California Medicine in 1972.  It is still valuable.


  1. Amit PandyaMarch 03, 2010

    It still looks like tinea to me. If KOH preps are negative, you might consider a biopsy for a PAS stain.

  2. I think biopsy is worthy to try. Sometimes unexpected things happen.
    It can be psoriasis, localized palmoplanter mycosis fungoides.

    Thank you
    Khalid Al Hawsawi
    Toronto, Canada

  3. The distribution of the dermatitis is reminiscent of “shoe dermatitis,” a contact allergic dermatitis secondary to chemicals used in the manufacture of modern footwear. Brian Maurer. (DJE attached the article I found to the Reference section)

  4. pictures show definitive borders suggestive of tinea pedis with fissures in the heel gives a psoriasiform look.would wait for the culture and then proceed with a biopsy .
    Is there any h/o atopy?

  5. I would do a KOH test to exclude dermatophyte infection. The site for the KOH is important to reduce false negative results.I usually choose interdigital web space and edge of the lesions.

    I think in this case tinea pedis is however unlikely - for such extensive lesions the nails appeared uninvolved.

    Consider hyperkeratotic eczema, plantar psoriasis or keratoderma.

    Start him on oral acetretin, moisturisers, superpotent corticosteroid ointments and perhaps propylene glycol as well. Avoid all trigger or aggravating factors. Good luck!!

  6. Tinea pedis is unlikely - with such an extensive feet involvement for so many years other body parts like groins, hands, nails are often affected.
    Keratoderma - it looks too inflammatory and late onset for keratodermas.
    Dermatitis (dyshidrosis)- unusual to get localized to feet with no hands involvement over years, distribution and morphology of lesions not classical

    Mycosis fungoides - symmetrical itchy lesions over feet are unusual

    I will keep psoriasis as possiblity, consider doing biopsy, look for signs of disease in other body parts (hidden spots) and treat accordingly.

  7. I think it is psoriasis and needs neotigison course of therapy
    khalifa sharquie

  8. I agree with the possiblity of Psoriasis. Biopsy may be fruit full.

  9. Was biopsy done? I lean toward psoriasis or spongiotic dermatitis. I really doubt tinea.


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