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.