Managing Infections and Odor

Living with Bothnian type palmoplantar keratoderma (PPKB) involves more than just managing thickened skin. Because of the constant moisture from hyperhidrosis and the “trapping” effect of thickened skin, your hands and feet are highly susceptible to secondary infections. Recognizing the signs of these infections and understanding how to prevent them is key to managing odor and physical discomfort ^[1][2].

Pitted Keratolysis: The ‘Punched-Out’ Pits

One of the most common complications of PPKB is pitted keratolysis. This is a bacterial infection caused by microorganisms like Corynebacterium species ^[2][3]. These bacteria thrive in the warm, moist environment created by your hyperhidrosis and the thick layers of keratin ^[4].

• How it Happens: These bacteria produce enzymes called proteinases that literally digest the keratin in your skin ^[2][5]. This digestion creates the characteristic tiny, circular, “punched-out” pits on the soles of the feet, especially in weight-bearing areas ^[2].
• The Cause of Odor: As the bacteria break down the skin proteins, they release sulfur-containing compounds ^[2]. This is what causes the distinct, often strong, “rotten egg” or vinegar-like odor associated with the condition ^[2].

Fungal Comorbidities

The same moist environment that invites bacteria also makes you more likely to develop fungal infections.

• Tinea Pedis (Athlete’s Foot): This is a fungal infection of the skin that can cause itching, scaling, and redness, particularly between the toes ^[6][7].
• Onychomycosis: This is a fungal infection of the nails, which can cause them to become thickened, yellowed, or brittle ^[6][8].
  In patients with PPKB, these infections can be harder to treat because the fungus can hide deep within the thickened layers of skin ^[7].

Treatment and Prevention Strategies

Managing these complications requires a two-pronged approach: killing the microbes and keeping the skin dry.

1. Medical Treatments (When to see a doctor)

If you notice persistent odor, increasing pain, or that the “punched-out” pits are spreading despite good moisture management, it is time to see a dermatologist for prescription treatments:

• Topical Antibiotics: First-line treatments for pitted keratolysis include clindamycin, erythromycin (1% gel or solution), or mupirocin (2% ointment) ^[2][9]. These are usually applied twice daily for 2 to 4 weeks ^[10][9].
• Topical Antifungals: For fungal infections, medications like luliconazole or efinaconazole may be used ^[7][8].

2. Moisture Management

Since moisture is the root cause, keeping your skin dry is the best way to prevent infections from returning:

• Moisture-Wicking Socks: Avoid 100% cotton socks, which trap moisture against the skin. Instead, choose specialized “wicking” fabrics made of merino wool, bamboo blends, or specific athletic synthetics designed to pull sweat away from the foot ^[11][12].
• Open Footwear: Whenever possible, wear sandals or open-toed shoes to allow air circulation. If you must wear closed shoes, rotate between two pairs so each pair can dry completely for 24 hours between uses.
• Absorbent Powders: Using antifungal or absorbent powders inside your socks and shoes can help reduce overall dampness throughout the day.
• Frequent Sock Changes: Changing your socks 2 or 3 times a day can significantly reduce the time your skin spends in a “macerated” (soggy) state.

By combining these strategies with your daily skin softening routine, you can minimize the risk of painful infections and maintain better skin health ^[1][2].

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