Pitted Keratolysis

Overview

What is pitted keratolysis?

Pitted keratolysis is a bacterial skin infection that causes a foul odor and itchiness. It most often affects the skin on your feet. You’re most at risk of developing pitted keratolysis if you have sweaty feet and wear shoes with limited airflow.

Who does pitted keratolysis affect?

Pitted keratolysis can affect anyone who has feet but it’s most common among men and people assigned male at birth (AMAB).

You might be more at risk of developing pitted keratolysis if you:

  • Wear shoes and/or socks that are too tight (occlusive) and have limited airflow.
  • Sweat excessively (hyperhidrosis).
  • Live in a warm or tropical climate.
  • Work or participate in activities where you’re outdoors and on your feet for most of the day.

How common is pitted keratolysis?

Pitted keratolysis is common among people who work in certain occupations where you spend most of your day on your feet or among people who participate in strenuous physical activities, including:

  • Military personnel.
  • Athletes.
  • Farmers.
  • Industrial workers.

Symptoms and Causes

What are the symptoms of pitted keratolysis?

Symptoms of pitted keratolysis include:

  • Smelly feet (bromhidrosis).
  • White patch of skin or a patch that’s lighter than your natural skin tone.
  • Pits or tiny indentations in the patch of skin that look like small holes.
  • Pits can cluster together to form a sore (lesion) that looks like a crater.
  • Itchy sensation on your affected skin.

You might notice your symptoms become more apparent when your skin is wet.

Where do symptoms of pitted keratolysis affect my body?

Symptoms of pitted keratolysis affect your feet, specifically the web spaces between your toes and the ball, heel and soles of your foot. Although rare, it can also affect the palm of your hand.

What causes pitted keratolysis?

A bacterial infection causes pitted keratolysis. The most common types of bacteria that can cause infection include:

  • Actinomyces.
  • Corynebacteria.
  • Dermatophilus congolensis.
  • Kytococcus sedentarius.
  • Streptomyces.

These types of bacteria grow and thrive in warm and moist conditions, which is why it commonly affects your feet if you’re wearing tight socks and shoes with minimal airflow.

Your skin “pits” or forms small indentations because the bacteria (protease enzyme) destroys layers of your skin cells that continuously shed dead skin cells (stratum corneum or the horny layer).

The odor caused by the infection occurs because the bacteria release a stinky sulfur compound.

Is pitted keratolysis contagious?

No, pitted keratolysis isn’t contagious and can’t spread from person to person.

Diagnosis and Tests

How is pitted keratolysis diagnosed?

Your healthcare provider will diagnose pitted keratolysis after reviewing your complete medical history and performing a physical exam to learn more about your symptoms. They might ask questions about the type of shoes and socks you wear, especially around the time you noticed your symptoms.

Tests aren’t always necessary, as pitted keratolysis has a distinct appearance on your skin, but your healthcare provider might offer tests to rule out similar conditions, which could include:

  • Culture test: Your healthcare provider will rub a swab over your skin or scrape a small amount of your affected skin off to collect some of the bacteria to identify it.
  • Skin biopsy: Your healthcare provider will remove a small sample of your skin tissue to examine it under a microscope.

Management and Treatment

How is pitted keratolysis treated?

Treatment for pitted keratolysis focuses on removing the bacterial infection from your body. Your healthcare provider will prescribe topical antibiotics that you rub on your skin like a lotion. Antibiotics could include:

Antiseptics like benzoyl peroxide gel or cream can help clear the infection from your feet.

If you have a condition that causes excessive sweating, like hyperhidrosis, your healthcare provider will offer additional treatment for your sweating to prevent pitted keratolysis from returning in the future.

The condition rarely goes away on its own without treatment from your healthcare provider.

Are there side effects of the treatment?

There are possible side effects of taking antibiotics, which could include:

Before starting any treatment, talk to your healthcare provider about side effects and discuss the current medications you take to avoid drug interactions.

Can I use at-home remedies to treat pitted keratolysis?

It’s dangerous to apply at-home remedies to your skin without approval from your healthcare provider. If you regularly use essential oils, like tea tree oil, ask your healthcare provider before using it on your affected skin. Don’t apply bleach or apple cider vinegar to your skin to make the odor from pitted keratolysis go away.

You can soak your feet in a diluted mixture of hydrogen peroxide and water to clean your feet. The peroxide solution should be no more than one part hydrogen peroxide to three parts warm water. Use this soak for a few minutes. After the soak, you can use a pumice stone to remove dry skin from your feet.

How soon after treatment will I feel better?

After you start taking an antibiotic, it will begin working within your body to rid it of bacteria. It could take between two to three days before you start to feel better. If you take an antibiotic and don’t see an improvement in your symptoms after a week, talk to your healthcare provider.

Prevention

How can I prevent pitted keratolysis?

You can reduce your risk of pitted keratolysis by:

  • Wearing shoes with good airflow; avoid rubber boots.
  • Wearing dry shoes each day.
  • Choosing socks and shoes that fit your feet and aren’t too tight.
  • Washing your feet and hands with soap and water when you remove your shoes and socks.
  • Changing your shoes and socks when they get wet.

Outlook / Prognosis

What can I expect if I have pitted keratolysis?

Pitted keratolysis causes your feet to smell bad. After a long day on your feet, you might notice a foul odor coming from your feet, shoes and socks. If you have pitted keratolysis, that odor will still be present after you wash your feet and change your socks and shoes. If you notice an odor, along with tiny indentations in the skin on the bottom of your foot, visit your healthcare provider. Antibiotics effectively treat the condition to make the odor go away.

If you work in an environment where you’re on your feet all day, choose shoes with good ventilation to improve how much air reaches your feet. For example, rubber boots don’t offer sufficient airflow.

Your socks can play a role in how much air gets to your feet too. The best material to improve airflow to your feet through your socks is cotton. Synthetic materials or blended materials in socks can restrict airflow to your feet.

Living With

When should I see my healthcare provider?

Visit your healthcare provider if your symptoms don’t improve after taking antibiotics for one week. Visit the emergency room if you have symptoms of an allergic reaction from taking antibiotics, including:

  • Severe itchiness.
  • Swelling skin.
  • A rash or hives.
  • Difficulty breathing.

What questions should I ask my doctor?

  • What type of shoes do you recommend I wear?
  • How can I prevent this condition from returning in the future?
  • Are there side effects of the treatment?
  • How often should I apply topical antibiotics to my skin?
  • Do the antibiotics interfere with any of the medications I currently take?

Frequently Asked Questions

How does trypophobia affect a pitted keratolysis diagnosis?

If you have a fear of patterns with a lot of holes (trypophobia), a pitted keratolysis diagnosis can be a trigger for your fear. Visit your healthcare provider if you experience anxiety related to your phobia, as well as symptoms of pitted keratolysis. Your healthcare provider will offer treatment to make the bacteria that cause pits in your feet go away, which will ease your fear.

What is the difference between pitted keratolysis and athlete’s foot?

Pitted keratolysis and athlete’s foot are both conditions that affect your feet. Pitted keratolysis occurs as a result of a bacterial infection that causes smelly and itchy feet. Athlete’s foot is a contagious fungal infection that causes an itchy rash on your feet.

A note from Cleveland Clinic

Pitted keratolysis is a bacterial infection that can cause your feet to smell bad. If you still have an odor coming from your feet after you wash your feet at the end of the day, it’s a sign that you have pitted keratolysis. Visit your healthcare provider if you have symptoms so they can offer treatment to remove the infection from your body. Prevent the bacteria from returning by changing your shoes and socks when they get wet and wearing shoes with good airflow.

Last reviewed by a Cleveland Clinic medical professional on 06/17/2022.

References

  • American Osteopathic College of Dermatology. Pitted Keratolysis. (https://www.aocd.org/page/PittedKeratolysis) Accessed 6/17/2022.
  • DermNet New Zealand Trust. Pitted Keratolysis. (https://dermnetnz.org/topics/pitted-keratolysis) Accessed 6/17/2022.
  • Meshkov LS, Nijhawan RI, Weinberg JM. Bacterial Infections. (https://accessmedicine-mhmedical-com.ccmain.ohionet.org/content.aspx?bookid=2585&sectionid=211767935) Kelly A, Taylor SC, Lim HW, et al., eds. Taylor and Kelly's Dermatology for Skin of Color, 2e. New York, NY: McGraw Hill; 2016. Accessed 6/17/2022.
  • Miller LS. Superficial Cutaneous Infections and Pyodermas. (https://accessmedicine-mhmedical-com.ccmain.ohionet.org/content.aspx?bookid=2570&sectionid=210430286) Kang S, Amagai M, & Bruckner AL, et al., eds. Fitzpatrick's Dermatology, 9e. New York, NY: McGraw Hill; 2019. Accessed 6/17/2022.

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