HYPERKERATOSIS PLANTARIS
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I have a 44yowf, single midwife who presents with hyperkeratotic,
cracking, itching feet for many years.  She called it psoriasis and
fungus infection.  Various psoriatic, fungal, plus Retin - A meds have
not helped over the years.  She also has fissures on her left hand/palm
occasionally and lichenification on her left elbow.  Biopsy on the left
elbow was positive for spongiotic psoriasiform dermatitis.  She calls
today in tears, can't sleep, has been wearing socks all the time, using
Lac Hydrin-12% and baggie occlusion overnight.  NOTHING HELPS!  I hope
YOU can help with some suggestions> and thanks!

Maida L. Burrow, M.D.
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Lac Hydrin sounds like lactic acid, or is it urea? We use urea 10%
in steroid-free intervals to remove hyperkeratoses, when the acute 
dermatitis is gone. In episodes of itching and  rhagades, the eczema is 
active and requires usually class III steroids externally as an ointment  
for a certain time (twice daily). If the patient is able to come here 
several times a week, we apply local PUVA (bathing feet and/or hands in 
8-Methoxy-psoralene solution,  a  photosensitizer, then UVA radiation). 
Especially recommended for patients with steroid-phobia.  

Dr. Hans Juergen Kammler
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Topical PUVA with a hand-foot unit is an excellent idea.  Etretinate 
might also be a consideration if she has had a tubal ligation or 
hysterectomy.  Could use with PUVA (re-PUVA) for even more rapid results.

Dan Mitchell, MD
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Retinoids can be very helpful for palmoplantar psoriasis.

Rhett Drugge
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If they were my feet I would use the aromatic retinoids as well, but I
would do two weeks worth of itraconazole or terbinafine first (risking the
liver and the taste buds). My father, an old school ENT doc, used to say in
response to the young purists "where there is a virus, there is a bacteria
not far behind"-I think the same can be said of fissured skin-bacteria,
yeast , or fungus-depending on the location.     

Diane Thaler
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Once topical therapy has failed, PUVA therapy would be my first choice 
and I would use oral psoralen, especially if topical PUVA failed.  
Etretinate would be my next choice (in the US), followed by 
methotrexate.  

Steve Feldman, MD, PhD
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Not enough information is given about this case.  I assume it is KOH and
culture negative.  The intense pruritus implies a strong inflammatory
component, and your description  decribes  an LSC-like appearance rather 
than psoriasis, so why not cool it down with a course of prednisone?  There 
are risks with that of course, but Retinoids are a bigger step in my 
opinion.
 Actually, I would first try "sandwiching" T-Derm tar oil with the
LacHydrin: That has worked a lot better for me in hyperkeratotic disorders
+/- inflammation  than keratolytics alone.   

John Uhlemann
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Keep in mind pustular flares if the feet are psoriasis and you use
prednisone. I haven't seen a painful, pustules in waves psoriatic since my
residency, but the memory is enough to make me shy away from empiric
prednisone if psoiasis is in the differential.      

Diane Thaler
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Have you biopsied those feet to rule out M. F.?

Gene Sienkiewicz, M. D.
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