Dr Keith Hopcroft continues our series of fascinating but often unrecognised conditions
‘You’ve got to do something about his smelly feet, doctor.’ This is usually the battle cry of a woman dragging her reluctant male other half for an appointment – and, typically, precipitates a script for an anti-fungal plus some simple hygiene advice. On this occasion, though, it was a mother and her teenage boy. He had spent a long weekend at a music festival, so his feet had been encased in trainers even longer than usual – and opportunities to freshen up had been minimal. His feet were, indeed, pretty pungent, so I kept the examination to a minimum. This revealed a soggy bilateral rash on the weight-bearing areas of each sole. He was otherwise well and – apart from the smell – the rash was causing no symptoms.
A cursory glance is usually all you need to make this diagnosis – provided you’ve heard of it, and seen it before. He had pitted keratolysis, a bacterial infection of the feet that is usually caused by corynebacterium.
This problem commonly affects those whose feet naturally tend to sweat a lot – or do so because they are encased in non-aerating shoes. So soldiers, athletes and trainer-loving adolescents are high-risk groups. The result is macerated skin over the pressure areas with the characteristic pits in the skin – plus the unpleasant odour. Rarely, patients complain of mild discomfort. Even more unusually, the infection can spread to the palms.
Topical antibiotics are the first-line treatment. In resistant or severe cases, oral treatment – typically erythromycin – is required. To prevent recurrence, the patient should observe basic hygiene rules and wear footwear that allows the feet to ‘breathe’. True hyperhidrosis should also be treated – usually with aluminium chloride hexahydrate solution.
Issues for the GP
It’s tempting to assume that this type of presentation will simply represent sweaty, fungal-infected feet. In which case, resolution may be delayed because of the inappropriate use of antifungals.
The smell may tempt you to avoid any examination – resist this, because the briefest glance will provide the diagnosis and potentially alter your management.
Dr Keith Hopcroft is a GP in Essex
Pitted keratolysis Pitted keratolysis The Primary Care Dermatology Society The Primary Care Dermatology Society
The PCDS was formed in 1994 by a group of GP skin specialists who recognised the need for a forum for GPs in the UK and Ireland to exchange views on primary care dermatology, hone skills and develop clinical research.
The society also provides a voice and support forum for GPSIs in dermatology.
Our key objectives are:
• To provide an innovative forum for GPs and GPSIs with
a common interest in dermatology to exchange views and
ideas, encourage research, improve patient management and promote education both for the GP and the healthcare team.
• To encourage an interest in and provide an arena to promote and establish a clearer understanding of dermatology in primary care.
• To create wider awareness and appreciation of the benefits of shared care and to encourage strong links with specialist groups such as the British Association of Dermatologists (BAD)
The Society holds a series of educational meetings around the country from dermoscopy to surgical training to general dermatological subjects, all delivered by both GPs and consultant dermatologists.