Skin Conditions that Mimic Tinea Pedis



Skin Conditions that Mimic Tinea Pedis
Skin Conditions that Mimic Tinea Pedis
Marti Jill Rothe, M.D.
Associate Professor of Dermatology
UConn Health Center
Conditions that Mimic Tinea Pedis
• Allergic Contact Dermatitis
• Dyshidrosis/Pompholyx
• Palmoplantar Psoriasis
All of these conditions can be complicated by secondary tinea pedis and unguium
Allergic Contact Dermatitis
• A warm, moist environment and occlusion within the shoe potentiates development of dermatitis
• Areas of foot in contact with the culprit allergen are usually affected but spreading of the skin reaction beyond the areas of contact is common
• Usually contact dermatitis spares toe webs, flexural creases of the toes, and instep
• Usually contact dermatitis is symmetrical but may affect one foot to a greater degree
• Id reactions with vesicles on hands, papulovesicles
on trunk and extremities, nummular plaques on trunk and extremities may be evident
Allergic Contact Dermatitis to Shoes
Allergic contact dermatitis to shoes
spares the toe webs and plantar arch but
affects the other aspects of the plantar
foot and often the dorsal foot under the
tongue of the shoe.
Allergic Contact Dermatitis with Id Reaction
Allergic Contact Dermatitis with Id Reaction
Most Common Sources of Culprit Allergens
Socks and stockings
Vehicles, preservatives, fragrances in topical medications and moisturizers
• Metals
Allergic Contact Dermatitis:
Patch Testing
Allergic Contact Dermatitis:
Patch Testing
Most Common Culprit Allergens
Para‐tertiary butylphenol formaldehyde resin:
– Additive in rubber glues
– Found as component of neoprene adhesives used to attach shoe linings and insoles
Allergic Contact Dermatitis to Shoe Glue
Oztas et al: Contact Dermatitis 2007;56:294‐5
Most Common Culprit Allergens
Rubber allergens:
– Carba mix, thiuram mix, MBT, mercapto mix, mixed dialkyl thioureas, black rubber mix
– May be present in outer sole, insoles, tongues, outer upper toe in athletic shoes
– May migrate to other parts of shoe when shoe becomes wet
Allergic Contact Dermatitis to Rubber
Nederost: Dermatologic Clinics 2009;27:281‐7
Purpuric Dermatitis to Black Rubber Mix
• Purpuric allergic contact dermatitis is rare
• Most commonly implicated allergens: rubber chemicals
and textile dyes • Less common allergens: chromium, epoxy resins, and formaldehyde resins
• Irritant purpuric contact dermatitis has been reported secondary to topical EMLA cream, benzoyl peroxide, and sap of Agave americana
Verma et al: Contact Dermatitis 2007;56:362‐4
Most Common Culprit Allergens
– Tanning agent for leather
– Newer manufacturing processes give better fixation of chromium and make it less likely for chromium to be leached from shoes due to perspiration
Allergic Contact Dermatitis to Textile Dye in Socks
Opie et al: Contact Dermatitis 2004;297‐303
Allergic Contact Dermatitis to Medicaments
Patient had positive patch test reactions to lanolin, econazole nitrate, and iodopropynyl butyl carbamate
Consider Patch Testing to the Patient’s Shoes
• Use very thin samples to avoid pressure effects
• Soak samples in water for 15 minutes before application
• Leave in place for 4‐5 days rather than the usual 2 days
Allergic Contact Dermatitis: Is it from dimethylfumarate?
My patient reported developing rash on foot shortly after he
began wearing new sandals manufactured in China.
Dimethylfumarate is present in a powder used in sachets which are placed in sofas and shoe boxes to protect from mold. The chemical evaporates and impregnates the products.
There have been numerous reports of allergic contact dermatitis secondary to dimethylfumarate in products imported from China.
Management of Shoe Dermatitis
Wet dressings
Topical corticosteroids, pimecrolimus, tacrolimus
Oral corticosteroids, oral antibiotics
Discard old socks worn in culprit shoes
Treat hyperhidrosis: zeasorb powder, aluminum chloride, Drionic unit, botulinum toxin, tea foot baths
• Patch testing and allergen avoidance
DRIONIC for Hyperhidrosis
Online price $140
Tea Foot Baths to Reduce Hyperhidrosis
• Boil 6 to 8 tea bags in 1 quart of water for 10 minutes
• Place in basin and allow to cool to lukewarm temperature
• Soak feet for 30 minutes once to twice daily
• After 1 to 2 weeks can reduce frequency
• Stains skin and toenails
Management of Shoe Dermatitis
American Contact Dermatitis Society
• Web site for members provides listings of companies that make hypoallergenic shoes including vegetable tanned leather shoes, wooden clogs, plastic shoes
• L.L.Bean has shoes with sheepskin insoles stitched to leather sole
• “Jellies” sandals are made of rubber‐free plastic
• Birkenstock sandals are made of cork and latex
Dyshidrosis or Pompholyx?
Lofgren and Warshaw Dermatitis 2006;17:165‐181
• Dyshidrosis: chronic recurrent eruption of 1‐2 mm vesicles on palms, soles, and/or lateral aspects of fingers
• Pompholyx: rare explosive onset of large bullae on hands
Causes of Dyshidrosis
Lofgren and Warshaw Dermatitis 2006;17:165‐181
Guillet et al Arch Dermatol 2007;143:1504‐1508
Intravenous immunoglobulin therapy
Allergens as a Cause of Dyshidrosis
Guillet et al Arch Dermatol 2007;143:1504‐1508
• 120 pts with dyshidrosis
seen during a 3 year period
• 70% had hand involvement only, 10% foot involvement only, 20% both hand and foot
• 81 of 120 pts with dyshidrosis had allergic contact dermatitis
• Hygiene product most common cause of allergy usually related to fragrance and Balsam of Peru
• Metal was the second most common cause of allergy with positive reactions to nickel, chromium, cobalt
– only 2 of 30 metal positive pts flared with oral nickel and cobalt challenge
Dietary Treatment of Dyshidrosis
Beer Beets Cabbage
Cloves Cocoa, chocolate, coffe, tea
Liver Nuts
Whole grain flour
All canned foods or foods cooked with Ni‐containing pots, utensils
Lettuce Lentils
Cocoa, chocolate, coffee, tea
Sunflower and sesame seeds, nuts
Herring, shrimp, oysters
Whole wheat flour, bran, oatmeal
Therapeutic Ladder for Dyshidrosis
• Dry skin care
• Avoidance of irritants and allergens
• Wear dry cotton socks and white cotton gloves under vinyl • Antihistamines
• Soaks of dilute vinegar, aluminum acetate, potassium permanganate
• Topical steroids, pimecrolimus, tacrolimus
Treatment for hyperhidrosis
Oral steroids
Systemic tx:
– Azathioprine
– Mycophenolate mofetil
– Cyclosporine
Low nickel, low cobalt diet
Hand and Foot Psoriasis
• Affects 1/3 of patients with psoriasis
• Many patients have only acral psoriasis without psoriasis elsewhere
• Often associated with psoriatic arthritis
• Patients have diminished quality of life related to physical limitations and pain
• Often treatment resistant
• May mimic frictional hand eczema, contact dermatitis, dyshidrosis, tinea
Tinea in Pt with Psoriasis
Variants of Palmoplantar Psoriasis
Variants of Palmoplantar Psoriasis
Hyperkeratotic with Fissures
Variants of Palmoplantar Psoriasis
Palmoplantar pustulosis
Acrodermatitis Continua
Jo et al:
J Dermatology 2006;33:787‐91
Palmoplantar Pustulosis
• Associated with autoimmune • Sterile pusutles and thyroid disease, celiac disease, erythematous plaques on tobacco use, type2 DM
palms and soles
• Women affected 3 times more • Exacerbated by stress, metal allergies, focal infection commonly than men
(tonsillitis), manual trauma
• Usually begins in 5th and 6th
• May be associated with decades
SAPHO syndrome (synovitis, • Approximately 20% of pts have acne, pustulosis, hyperostosis, psoriasis affecting other sites
osteitis) especially affecting • Does not share gene locus anterior chest wall
strongly associated with • May develop as paradoxical psoriasis vulgaris and guttate
reaction to anti‐TNF therapy
• Some experts consider PPP to be a different entity than pustular psoriasis
Generalized Pustular Psoriasis
Therapeutic Ladder for Palmoplantar Psoriasis
• Topical therapy
– Tar soaks
– Ultrapotent topical steroid cream qAM and ointment qhs
– Cover ointments with wet cotton gloves or socks and then wrap with plastic for 2 hours then follow with emollient cream – Vitamin D analogs
– Tazarotene qhs and topical steroid qAM
– Urea, Salicylic acid lotion
• Phototherapy
– NB‐UVB Hand and Foot
– Excimer laser
– Topical PUVA
• Systemic therapy
• Miscellaneous tx’s reported for PPP
– Colchicine
– Itraconazole
– Tetracycline
Excimer Laser
308 nm Excimer Therapy Han et al: Photodermatology, Photoimmunology, & Photomedicine 2008;24:231‐6
25 treatments once weekly
308 nm Excimer Therapy
Nistico et al: JEADV 2006:20; 523‐526
44 of 54 pts with palmoplantar psoriasis had 75% improvement after an average of 10 treatments for palms and 13 for soles with benefit maintained at 16 week followup
Traditional Systemic Psoriasis Therapies
Gold standard tx for skin and Risk for hepatotoxicity, bone joints; low cost:$1,000/year for 25 marrow suppression, multiple mg qwk plus labs
drug interactions; caution with renal impairment; frequent lab monitoring and periodic liver bx; abortifacient
Cys A (Neoral)
Rapid improvement of labile psoriasis; can help joints
Risk for immunosuppression, htn,
nephrotoxicity, hyperlipidemia, multiple drug interactions,hypertrichosis; frequent laboratory monitoring; high cost: $6,000‐7,800/year for 300 mg qd plus labs
Acitretin (Soriatane)
Rapid improvement of pustular
psoriasis; high efficacy for palmoplantar disease; no immunosuppression
Risk for hyperlipidemia, hepatotoxicity, dry skin and mucous membranes, alopecia;
teratogen; periodic laboratory monitoring; no benefit for joints; high cost: $9,000/year for 25 mg qd plus labs
Biologics for Psoriasis Drug
Infliximab (Remicade)
High efficacy for skin and joints;
infrequent tx (wk 0,2,6,then q6-8
wks); wt based dosing; rapid clearing
by 2nd or 3rd tx; infrequent lab
IV infusion at infusion center; risk for
infusion rks;greatest risk for
immunosuppression; hepatotoxicity ;
exclusion criteria:MS,CHF; $2030,000/year
Adalimumab (Humira)
High efficacy for skin and joints; qowk
SC injection; rapid significant
response by wk 4;infrequent lab
Risk for immunosuppression;
exclusion criteria: MS,
Etanercept (Enbrel)
High efficacy for skin and joints; once
or twice weekly SC injection;
improvement within 1-3 mos; recent
successful trial for children and
adolescents with psoriasis;infrequent
lab monitoring
Risk for immunosuppression;
exclusion criteria:MS, CHF; some
pts require continued twice wkly
Ustekinumab (Stelara)
High efficacy for skin; rapid clearing
by wk 12; in trial for joint disease;
infrequent SC tx (wk 0, 4, then q12
wks);no restriction for MS pts; wt
based dosing
SC injection by nurse at physician’s
office or at pt’s home; Risk for
immunosuppression; $23-46,000/year
Efalizumab for Palmoplantar Psoriasis
Wozel et al: Acta Dermatovenerol Alp Panonica Adriat 2008 3:133‐6
Efalizumab (Raptiva) Pulled From Market
• Monoclonal antibody against CD11a
• Prevents T‐lymphocyte activation, migration, and reactivation
• 2003: approved for treatment of moderate to severe plaque psoriasis
• Found niche in treating hand and foot psoriasis with one study showing 33% of efalizumab treated patients achieving Physician Global Assessment of clear/nearly clear
• 2008 USA: 2 cases of progressive multifocal leukoencephalopathy
(> 70 y/o) led to death; efalizumab as monotherapy for > 3 years
• Feb 2009: 3rd case identified in Germany (47 y/o); efalizumab as monotherapy for > 3 years
• 4th pt with progressive neurologic symptoms died of unknown cause
• April 8, 2009 Genentech announced phased voluntary withdrawal of efalizumab from US market
Successful treatment with infliximab
DiLernia and Guareschi: Dermatol Online J 2010;16:8
Leonardi et al: Arch Dermatol
Published on line Dec 2010
49 pts treated with adalimumab and
23 pts treated with placebo for 16 weeks
At 16 weeks, 31% (15 of 49) of adalimumab
pts and 4% (1 of 23) of placebo pts achieved a Physician’s Global Assessment of clear/almost clear
TNF‐α Inhibitor Induced Psoriasis
• More than 120 cases described in the literature
• Strong predilection for development of palmoplantar pustulosis
• Most pts were receiving treatment for an indication other than psoriasis (rheumatoid arthritis, ankylosing
spondylitis, inflammatory bowel disease)
• Most pts were able to continue treatment with the anti‐TNF and add topical therapy for the psoriasis; some pts switched to an alternative anti‐TNF with good results
Dyshidrosiform Immunobullous
Disease Kim et al. Dyshidrosiform Bullous Pemphigoid: Acta Derm Venereol 2004;84:253‐4
CTCL of Palms and Soles
Responsive to topical PUVA
Spieth et al: Dermatology 2002;
Pt with CTCL, Shoe Dermatitis, and Id Reaction 

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