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#Allergy and Immunology #Dermatology
Juvenile plantar dermatosis (JPD), also known as “wet and dry foot syndrome”, is a skin disorder of the feet that commonly affects children from ages 3 to 14. JPD is frequently seen in children with eczema, but it is not a requirement for diagnosis. Forefoot eczema (FE) synonymous with JPD is a condition characterized by dry, fissured dermatitis of the plantar surface of the feet. Herein we describe a 5-year-old boy with recurrent episodes of itchy dry lesions with cracking over the forefoot.
Forefoot eczema in adults and children is a skin condition that generally presents in adults of all ages and boys between 3-14 years of age, but it may also occur in females. When it occurs in children the prognosis is one of gradual improvement.1 Children’s eczema, also known as ‘juvenile plantar eczema’ has a tendency to be more severe during the summer months. Juvenile plantar dermatosis (JPD) typically presents as an erythematous rash of the weight-bearing plantar aspects of the feet; the distal one-third of the plantar surface of the feet and toes tend to be involved more frequently. The proximal two-thirds of the plantar surface are not involved. Areas of involvement generally appear smooth and shiny with a high incidence of painful fissuring and cracking.1-5
A 5-year-old boy presented to our OPD with complaints of itching and scaling on the dorsum of both feet since 10 months. Patient gave history of developing itching on the dorsum of both feet which was associated with formation of red raised lesions at the same site. Later patient also noticed discharge of watery fluid from the area. There was history of aggravation of symptoms on wearing his school shoes and also during winters.
The lesions subsided on using some local medications, details not known. No history of similar lesions in his elder sibling. History of wheezing and episodes of common cold on and off since he was 2 years of age but now the episodes have subsided. On local examination there were hyperkeratotic plaques with scales seen over dorsum of the forefoot and fissuring with scaling over the plantar aspect of toes (Fig. 1). The patient was treated with topical mometasone BD for 2 weeks and a urea containing moisturizer for regular use on both feet along with antihistamines tablet Levocetirizine 5 mg for itching. There were no other skin lesions and any signs of atopy. The lesions cleared completely and the patient was advised to continue moisturizers and cotton socks upon wearing his school shoes.
JPD typically presents as an erythematous rash of the weight-bearing plantar aspects of the feet; the distal one-third of the plantar surface of the feet and toes tends to be involved more frequently. The proximal two-thirds of the plantar surface are not involved.
Areas of involvement generally appear smooth and shiny with a high incidence of painful fissuring and cracking. In some cases, the skin of the affected areas desquamates.1-4
The most common site to be involved initially was the plantar surface of the great toe and other toes followed by forefoot, dorsa of the feet, intertriginous area, instep and heel. The entire sole can be involved in a minority of cases. Few patients can have involvement of the hands, with fissuring and soreness of the fingertips and palm.1 Forefoot eczema (FE) is also known as ‘juvenile plantar dermatitis’, ‘forefoot dermatitis’, ‘atopic winter feet’, ‘dermatitis plantaris sicca’, ‘peridigital dermatitis’, ‘sweating sock dermatitis’.5
The desquamation of the skin can mimic keratolysis exfoliativa, but this typically presents initially as pinsize white dots that coalesce. Furthermore, keratolysis exfoliativa tends to affect the palms of the hands more often than the feet and is often asymptomatic.3 The differential diagnosis of JPD also includes tinea pedis. However, tinea pedis typically involves the fourth and fifth toe web spaces, whereas JPD generally spares the toe webs. Although tinea pedis rarely affects small children, clinicians should not assume based on a patient’s younger age that a questionable presentation is JPD rather than tinea pedis. A potassium hydroxide (KOH) preparation can confirm or rule out tinea.6,7
The exact etiology and pathogenesis of JPD are not well-understood. JPD is often seen in ‘atopic’ children, i.e., those who have atopic dermatitis (eczema), asthma or hay fever.1,2 Their skin seems generally more sensitive than others. The problem is related to friction. Friction is greater when the foot moves up and down in a shoe, especially when the foot is sweaty.3
The foot gets wetter in synthetic shoes (e.g., nylon or vinyl), and moves more in open sandals. There is tendency to be more severe during the summer months when heat and humidity cause the feet to perspire and sweat. The many synthetic materials and chemicals used in the manufacturing process for shoes and socks are a contributing factor in the occurrence of foot eczema. Sweat retention and covering of the feet by woolen or polyester socks aggravates this condition, whereas cotton allows the skin to breathe. Keeping the foot for a long time in a shoe or sock without aeration is an important triggering factor. Changing to leather footwear and wearing cotton socks may help relieve the problem. It is also important that the footwear fits well and the sole of the foot is not sliding against the insole of the shoe. Walking barefooted on woolen or polyester carpets may contribute to juvenile plantar eczema as this may lead to static electric charges that may play a role in skin dryness and irritation of juvenile plantar eczema. It is sometimes difficult to tell JPD apart from atopic dermatitis, contact dermatitis, psoriasis, keratolysis exfoliativa, or a fungal infection. To aid diagnosis, tests such as scrapings and patch tests may be recommended.7-9
The treatment guidelines for juvenile plantar dermatosis are: Reduce friction: Wear well-fitting shoes, preferably leather, with two pairs of cotton socks. Lubricate the dry skin: Greasy moisturizers can be very helpful, including white soft paraffin, particularly applied after a bath and before bed. Dimethicone barrier creams are easier to use during the day, applied every four hours. Have a rest day: Schedule quiet times with little or no walking to allow the fissures to heal. Cover the cracks: Fissures heal faster when occluded. Plasters are usually satisfactory. Spray or liquid bandage or nail glue can be applied to the fissure and will relieve the pain. Take care not to stick the toes together. Topical steroids: Topical steroid ointments are often prescribed, but rarely prove more effective than simple emollients. The more potent products are worth a trial for a couple of weeks. If helpful, they should then be reserved for a flareup, particularly if the affected skin is red or itchy.1-5
- Brar KJ, Shenoi SD, Balachandran C, et al. Clinical profile of forefoot eczema: A study of 42 cases. Indian J Dermatol Venereol Leprol 2005;71:179-81.
- Svensson A. Prognosis and atopic background of juvenile plantar dermatosis and gluteofemoral eczema. Acta Derm Venereol 1988;68(4):336-40.
- Gibbs NF. Juvenile plantar dermatosis: Can sweat cause foot rash and peeling? Postgraduate Medicine 2004;115(6):73.
- Kalia S, Adams SP. Dermacase. Juvenile plantar dermatosis. Can Fam Physician 2005;51: 1203-13.
- van Diggelen MW, van Dijk E, Hausman R. The enigma of juvenile plantar dermatosis. Am J Dermatopathol 1986;8(4):336-40.
- Broberg A, Faergemann J. Scaly lesions on the feet in children- tinea or eczema? Acta Paediatr Scand 1990;79:349-51.
- Ashton RE, Griffiths WA. Juvenile plantar dermatitisatopy or footwear? Clin Exp Dermatol 1986;11:529-34.
- Moorthy TT, Rajan VS. Juvenile plantar dermatosis in Singapore. Int J Dermatol 1984;23:476-9.
- Stables GI, Forsyth A, Lever RS. Patch testing in children. Contact Dermatitis 1996;34:341-4.