Juvenile plantar dermatosis

Published on 19/03/2015 by admin

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Juvenile plantar dermatosis

Stephen K. Jones

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Juvenile plantar dermatosis (JPD) is a specific condition comprising symmetrical erythema (with a polished ‘billiard ball’ appearance), scaling and fissuring, primarily of the pressure areas of the foot. Vesiculation is never found. The commonest sites involved are the plantar aspects of the great toe, forefoot, heel, and rarely the fingertips and palms. The instep and interdigital skin are rarely affected. The condition occurs almost exclusively in children, and clears around puberty.

Management strategy

JPD usually presents between 4 and 7 years of age. Most series suggest that it is a ‘disease of school years,’ with clearing in most by puberty. It is uncommon in adults. Spontaneous resolution occurs in the majority of patients.

The main etiologic factor is thought to be the occlusive effect of ‘trainer’ sports shoes and man-made fibers in hosiery, resulting in hyperhidrosis. This, some suggest, washes away surface lipids, which are already reduced because of the relative lack of sebaceous glands on the plantar surface of the foot. This hyperhidrosis is, therefore, followed by rapid dehydration of the skin on removal of footwear. It is proposed that this maceration/dehydration renders the skin susceptible to trauma (e.g., from sport). Avoidance of vigorous exercise may therefore be helpful in these patients.

The role of atopy is debated. Some series have found an increased incidence of atopy in patients/families and, indeed, this condition was first referred to as ‘atopic winter feet.’ It has been argued that the atopic diathesis predisposes the skin of the foot to the traumatic effects of sport and vigorous activity, and the effects of alternating hyperhidrosis and dehydration. Other series, however, have found no increased incidence of atopy.

Investigations are unlikely to be helpful but positive patch tests have been found in between 10% and 29% of cases. Even when these are to footwear-related allergens, however, there is debate as to whether allergen avoidance affects clinical outcome. Increased numbers of bacteria have been suggested to cause inflammation of the sweat ducts and thereby inhibit sweat secretion, but this has not been a consistent finding.

Changing to non-occlusive footwear along with cotton socks or ‘open’ footwear has been proposed as a therapeutic maneuver. Emollients, both to reduce fissuring and to reduce the dehydration occurring on removing occlusive footwear, are reported to be helpful. Topical corticosteroids may be beneficial if there is an inflammatory component. Occlusive bandages containing zinc ointment, ichthammol, or tar may help if hyperkeratosis and fissuring are a prominent feature. All the above often only help temporarily, and regular rotation of emollients may be required.

It is the impression of most dermatologists that this condition has become less common in recent years, possibly related to changes in teenage ‘fashion’ and footwear materials.

Second-line therapies

image Change to non-occlusive footwear C
image Sport avoidance C
image Emollients C
image Topical corticosteroids C
image Rotation of topical agents C
image Topical tacrolimus C

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Juvenile plantar dermatosis

Stephen K. Jones

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Juvenile plantar dermatosis (JPD) is a specific condition comprising symmetrical erythema (with a polished ‘billiard ball’ appearance), scaling and fissuring, primarily of the pressure areas of the foot. Vesiculation is never found. The commonest sites involved are the plantar aspects of the great toe, forefoot, heel, and rarely the fingertips and palms. The instep and interdigital skin are rarely affected. The condition occurs almost exclusively in children, and clears around puberty.

Management strategy

JPD usually presents between 4 and 7 years of age. Most series suggest that it is a ‘disease of school years,’ with clearing in most by puberty. It is uncommon in adults. Spontaneous resolution occurs in the majority of patients.

The main etiologic factor is thought to be the occlusive effect of ‘trainer’ sports shoes and man-made fibers in hosiery, resulting in hyperhidrosis. This, some suggest, washes away surface lipids, which are already reduced because of the relative lack of sebaceous glands on the plantar surface of the foot. This hyperhidrosis is, therefore, followed by rapid dehydration of the skin on removal of footwear. It is proposed that this maceration/dehydration renders the skin susceptible to trauma (e.g., from sport). Avoidance of vigorous exercise may therefore be helpful in these patients.

The role of atopy is debated. Some series have found an increased incidence of atopy in patients/families and, indeed, this condition was first referred to as ‘atopic winter feet.’ It has been argued that the atopic diathesis predisposes the skin of the foot to the traumatic effects of sport and vigorous activity, and the effects of alternating hyperhidrosis and dehydration. Other series, however, have found no increased incidence of atopy.

Investigations are unlikely to be helpful but positive patch tests have been found in between 10% and 29% of cases. Even when these are to footwear-related allergens, however, there is debate as to whether allergen avoidance affects clinical outcome. Increased numbers of bacteria have been suggested to cause inflammation of the sweat ducts and thereby inhibit sweat secretion, but this has not been a consistent finding.

Changing to non-occlusive footwear along with cotton socks or ‘open’ footwear has been proposed as a therapeutic maneuver. Emollients, both to reduce fissuring and to reduce the dehydration occurring on removing occlusive footwear, are reported to be helpful. Topical corticosteroids may be beneficial if there is an inflammatory component. Occlusive bandages containing zinc ointment, ichthammol, or tar may help if hyperkeratosis and fissuring are a prominent feature. All the above often only help temporarily, and regular rotation of emollients may be required.

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