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Indian Journal of Dermatology, Venereology and Leprology, Vol. 71, No. 3, May-June, 2005, pp. 179-181 Studies Clinical profile of forefoot eczema: A study of 42 cases Brar Kamal Jeet, Shenoi S.D., Balachandran C., Mehta Vandana Rai Department of Skin and STD, Kasturba Medical College, Manipal Code Number: 05057 ABSTRACT BACKGROUND : Forefoot eczema (FE) is characterized by dry fissured dermatitis of the plantar surface of the feet.AIM : To study the clinical profile of FE and the possible etiological factors. METHODS : Forty-two patients with FE were included in the study. A detailed history was recorded and examination done. Fungal scrapings and patch test with Indian Standard Series (ISS) were performed in all patients. RESULTS : The most common site affected was the plantar surface of the great toe in 16 (38.09%) patients. Hand involvement, with fissuring and soreness of the fingertips and palm, was seen in four patients (9.5%). Seven patients (16.6%) had a personal history of atopy whereas family history of atopy was present in six (14.2%). Seven patients (16.6%) reported aggravation of itching with plastic, rubber or leather footwear, and 13 (30.9%), with detergents and prolonged contact with water. Negative fungal scrapings in all patients ruled out a dermatophyte infection. Patch testing with ISS was performed in 19 patients and was positive in five. CONCLUSIONS : FE is a distinctive dermatosis of the second and third decade, predominantly in females, with a multifactorial etiology, possible factors being chronic irritation, atopy, footwear and seasonal influence. Keywords: Forefoot eczema, Atopy INTRODUCTION Forefoot eczema (FE) is a condition characterized by dry, fissured dermatitis of the plantar surface of the feet. It usually occurs in the age group of 3-15 years. Various etiological causes have been postulated for this condition, like an allergic contact dermatitis to footwear, dermatophyte infection, and maceration of the foot following use of occlusive footwear.[1] FE is a clinical diagnosis, although skin scraping to exclude fungus and patch tests to exclude footwear allergy are advised. The aimed to study the clinical profile of FE and to evaluate the possible etiological factors.METHODS Forty-two patients with FE were chosen for the study. The inclusion criteria were erythema, fissuring, scaling of the soles with or without involvement of the dorsa of the feet. Patients with well-defined plaques suggestive of psoriasis or with a history suggestive of allergic contact dermatitis were excluded. A detailed history was elicited regarding the age of onset, duration of disease, seasonal variation, presence of pain or pruritus, personal and family history of atopy, and the areas of the foot affected. The personal and family history was recorded in an equal number of age and sex-matched controls. The controls were healthy volunteers without any skin lesions.The diagnosis of FE was made primarily on clinical grounds, after excluding dermatophyte infection and allergic contact dermatitis. Dermatophyte infection was ruled out by performing a potassium hydroxide mount from the lesions in all patients, and patch testing with the Indian Standard Series (ISS) was performed in those with involvement of the dorsa of the feet and/or history of aggravation with use of socks/footwear. Statistical analysis was done using the Chi square test. RESULTS Of the 42 patients, 39 (92.8%) were females and three (7.14%) males with their age ranging from 3 years to 35 years [Table - 1]. The duration of the disease was 2 years or less in 27 patients (52.3%) [Table - 2]. Nineteen patients (45.2%) reported deterioration in clinical symptoms during the rainy or winter season and relative improvement during the summer. Twenty-six patients (61.9%) complained of pruritus while 11 (26.19%) had pain due to fissuring.The most common site to be involved initially was the plantar surface of the great toe and other toes [Figure - 1] in 16 (38.09%), followed by forefoot [Figure - 2] in 14 (33.3%), dorsa of the feet in 6 (14.2%), intertriginous area in 3 (7.14%), instep in 2 (4.7%) and heel in 1 (2.3%) [Table - 3]. The entire sole was involved in a minority of cases [Figure - 3]. Four patients (9.5%) had involvement of the hands, with fissuring and soreness of the fingertips and palm. Seven patients (16.66%) gave a personal history of atopy and six (14.2%), a family history. Of the 50 controls, 17 gave a personal history of atopy ( P >0.05 not significant by Chi square test). Seven patients (16.66%) reported aggravation of itching with the use of leather, plastic or rubber footwear and 13 (30.9%) had aggravation with detergents and prolonged contact with water. Patch testing with ISS was performed in 19 patients (45.2%) who either had involvement of dorsa of the feet and or aggravation with footwear or socks. Patch test was negative in 14 (73.6%). Three patients (15.7%) showed sensitivity to nickel and two (10.5%) showed sensitivity to gentamicin and framycetin. DISCUSSION FE is characterized by symmetrical smooth, red-glazed appearance of the skin with fissuring, loss of epidermal ridge pattern and fine scaling. It has a predilection for the distal parts of the soles and toes, particularly the great toe, sparing the intertriginous spaces.[2] After its first report in 1968, it has been described under a variety of names (e.g. juvenile plantar dermatitis,[3] forefoot dermatitis, atopic winter feet, dermatitis plantaris sicca, forefoot eczema, peridigital dermatitis, sweating sock dermatitis) depending on the author′s beliefs concerning its pathogenesis and possible association with atopy.[4]The average age of onset is between 3-15 years but it occasionally occurs in adults. In our study, the mean age of onset was in the second decade. We also observed a significant female preponderance. This could be attributed to the fact that women do more wet work than men. Though most patients complain of redness, irritation, cracking and soreness, pruritus is seldom reported; however, in our study pruritus was more common. The plantar surfaces of the great toes were the first areas to be involved. Other weight-bearing areas were subsequently affected, but there was relative sparing of the instep and interdigital web spaces. Summer aggravation has been reported in earlier studies, possibly due to increased frictional activity, with improvement during cooler months.[5] However, none of our patients had winter remission. The improvement in summer in our patients could be attributed to sweating that may have softened the skin. There was no significant association with atopy.[6] Seven patients (16.66%) complained of aggravation by footwear, but the patch test yield for footwear related antigens was low.[7] Nearly one-third of our patients had aggravation following contact with water and detergents. Most Indian women are engaged in household work involving washing clothes and utensils. As many of them squat on the ground, their feet are exposed to water and detergents. FE thus may be a manifestation of chronic low-grade irritant dermatitis. In conclusion, FE is a distinctive dermatosis of the second and third decades, predominantly in females, with a multifactorial etiology, the possible factors being chronic irritation, atopy, footwear and seasonal influence. REFERENCES
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