Hiperqueratosis plantar / Plantar hyperkeratosis

RESUMEN La hiperqueratosis es un trastorno caracterizado por el engrosamiento de la capa externa de la piel, que está compuesta de queratina, una fuerte proteína protectora. Puede ser causada por fricción, conllevando la aparición de callosidades, inflamación crónica, eccema o trastornos genéticos, como la ictiosis ligada al cromosoma X. Se presentó el caso de un paciente de 47 años, que acudió al Servicio de Ortopedia por lesión escamosa a nivel de ambas regiones plantares con dificultad para la marcha. El tratamiento quirúrgico fue el empleado en este paciente para la obtención de la biopsia exerética. La evolución fue favorable en el postoperatorio mediato e inmediato, y el paciente se incorporó de forma rápida a su vida normal. Con este caso se identificaron las características clínicas de la hiperqueratosis plantar, así como el uso de la biopsia exerética como estándar de oro para el diagnóstico positivo en los tumores periféricos. Un diagnóstico adecuado por el médico inicial, la interrelación del Servicio de Ortopedia con la consulta de tumores periféricos, y el tratamiento quirúrgico seleccionado, constituyen factores determinantes en la evolución favorable de los pacientes con este diagnóstico (AU).

ABSTRACT Hyperkeratosis is a disorder characterized by thickening of the outer layer of the skin, which is composed of keratin, a strong protective protein. It can be caused by friction, leading to callosities, chronic inflammation, eczema or genetic disorders such as X chromosome-linked ichthyosis. We presented the case of a patient, aged 47 years, who attended the Orthopedic Service for scaly lesion at the level of both plantar regions with difficulties to walk. Surgical treatment was used in this patient to obtain an exeretic biopsy. The evolution was favorable in both the mediate and immediate postoperative period, and the patient quickly returned to his normal life. This case identified the clinical characteristics of plantar hyperkeratosis and the use of exeretic biopsy as a gold standard for positive diagnosis in the peripheral tumors. An adequate diagnosis by the initial physician, the interrelation of the orthopedic service with the consultation of peripheral tumors, and the chosen surgical treatment are determining factors in the favorable evolution of patients with this diagnosis (AU).

Do plantar hyperkeratoses affect balance in people older than 65 years old?

Tactile information picked up by plantar receptors provides afferent sensory information that is fundamental for controlling body balance. Plantar hyperkeratoses may alter the quality and quantity of such information, thereby modifying balance. AIM: Analyse how plantar hyperkeratosis debridement affects static body balance in subjects of 65 years of age or older. METHODS: In order to analyse the impact of hyperkeratoses on balance, 50 older people took part in this study. Pain caused by plantar hyperkeratoses was measured on a visual analogue scale. Static balance was assessed on a pressure sensitive platform. The treatment was scalpel debridement of hyperkeratoses. RESULTS: Pain decreased significantly (p=0.03). Regarding the variables analysed, significant differences were found between pre- and post-treatment values in anteroposterior length (Length, mm) (p=0.032) and anteroposterior amplitude (Amp, mm) (p=0.044) of the centre of plantar pressure with eyes open. CONCLUSIONS: Plantar hyperkeratosis debridement is capable of interfering favourably with sensory afferent inputs, thereby improving control of stability and modifying stabilometric readings in the AP component when a subject balance with eyes open.

Effect of debridement of plantar hyperkeratoses on gait in older people - An exploratory trial.

Hyperkeratoses are a common cause of foot pain due to the release of inflammatory mediators, which can have an impact on the mobility and independence of people suffering from them. However, the repercussions that hyperkeratoses have on gait parameters remain uncertain. AIM: The aim of this study is to analyze the repercussions that plantar hyperkeratosis debridement has on several kinematic and kinetic variables of gait in a group of older participants. METHODS: 98 older participants (75.1 ±â€¯6.7 years) were randomly assigned to two groups: Group A, Scalpel debridement of plantar hyperkeratoses; and Group B, Control group (Simulated debridement). Plantar hyperkeratotic pain was measured before and after treatment on a visual analog scale. Several kinematic and kinetic variables of gait were measured before and after treatment using a Win-Track pressure sensitive walkway. RESULTS: A significant difference was found in the level of pain between the treated group and the control group (p < 0.01 [8.55-18.15; 95% confidence interval]). Regarding the gait parameters, statistically significant reductions were found in peak pressures (p < 0.05; Cohen's d = 2.688) and maximum force (p < 0.04; d = 0.262). CONCLUSIONS: Data suggests that debridement of plantar hyperkeratosis may lead to a reduction in pain and appear to reduce peak maximum force and peak plantar pressure. No significant changes were observed in the kinematic variables analyzed. The duration of the benefits remain unknown.

Using a Distant Abdominal Skin Flap to Treat Digital Constriction Bands: A Case Report for Vohwinkel Syndrome.

In this study, a Vohwinkel syndrome case is presented where in 5th digit constriction bands in the right hand were reconstructed using a distant abdominal skin flap. Vohwinkel syndrome, or keratoderma hereditarium mutilans, is a rare, autosomal dominant genetic skin condition that causes palmoplantar hyperkeratosis and constricts finger and/or toe bands. In a typical manifestation, the finger and toe constriction bands lead to progressive strangulation and autoamputation, which requires immediate clinical treatment. Topical keratolytics and systemic retinoids have been used to treat hyperkeratosis but without consistent results. Only 1 effective approach for autoamputation has been accepted, reconstructive surgery.Applying a distant abdominal skin flap produced satisfying postoperative effects at the 18-month follow-up.

Abordagem cirúrgica de faixas constritivas em Síndrome de Vohwinkel / Surgical correction of constrictive bands in Vohwinkel syndrome

A Síndrome de Vohwinkel ou ceratodermia hereditária mutilante é uma ceratodermia palmoplantar rara, que se manifesta na infância e se torna mais evidente nas fases de adolescência e idade adulta. Doença de herança preferencialmente autossômica dominante, acomete mais mulheres e caucasianos. A hiperceratose palmoplantar difusa, com aparência de favo de mel; as faixas constritivas digitais conhecidas como pseudoainhum, e as placas ceratósicas em forma de estrela-do-mar no dorso de mãos e pés, podendo acometer cotovelos e joelhos, são os achados clínicos característicos da Síndrome. O presente trabalho trata de um relato de caso de uma paciente com Síndrome de Vohwinkel e a terapêutica cirúrgica realizada nas faixas constritivas.

Vohwinkel syndrome, also known as hereditary mutilating keratoderma, is a rare palmoplantar keratoderma that manifests in childhood and becomes more evident in adolescence and adulthood. This preferential autosomal dominant disease affects more women and Caucasians. Its clinical features are diffuse palmoplantar keratoderma with the appearance of honeycomblike constricting rings in the fingers and toes known as pseudo-ainhum, and starfish-shaped keratotic plaques on the dorsal aspect of the hands and feet that can affect the elbows and knees. The present report describes a case report of a patient with Vohwinkel syndrome and surgical correction of the constrictive bands.

Palmoplantar keratoderma: treatment with CO2 laser case report and review of the literature.

Palmoplantar keratoderma is a heterogeneous group of disorders affecting keratinization on the palms and soles of the feet. The benign lesions cause pain and limit function. Treatment of palmoplantar keratoderma remains problematic and restricted to symptomatic therapy; no cure exists. Medical treatments and surgical excision are currently the mainstay of therapy; however, these treatments have limited success, significant morbidity, and recurrence is common. We present a case report of successful treatment with CO2 laser therapy and a review of the literature.

[Original treatment of constitutional painful callosities by surgical excision, collagen/elastin matrix (MatriDerm(®)) and split thickness skin graft secured by negative wound therapy]. / Traitement original des callosités plantaires douloureuses constitutionnelles par exérèse, matrice de collagène et d'élastine (MatriDerm(®)) et greffe de peau mince en un temps, associée à une thérapie par pression négative.

Constitutional painful callosities is an unusual pathology, integrated in the frame of "palmoplantar keratodermia" (PPK). Lesions are located at areas of support of the sole. These lesions are painful and disable the normal walking. Treatments are suspensive and painkillers. We report our experience of a single surgical treatment: surgical excision, split thickness skin graft applied on a dermal substitute and secured by negative wound therapy. A 28-year-old patient, affected by this disease, has a desire of pregnancy but her treatment is highly teratogen. A year post-op, wounds were healed. The walk was possible with a relief of the pain, without any ulcerations. The surgical treatment by excision and graft or flaps was previously reported for PPK. The use of dermal substitute was never described for this indication. Dermal substitute compensate the thickness of the soft tissue defect and give an accurate quality of elasticity in this localisation .The negative wound therapy enhances the quality and shortens the length of graft taking, and the adhesion of the dermal substitute on his bed.

Excision and grafting of palmoplantar keratoderma.

Palmoplantar keratodermas may present to the clinician with an extremely broad series of clinical findings. Management has also taken on a wide variety of medical and surgical modalities. The literature seems to provide evidence that optimum management consists of surgical excision with skin grafting. It is believed that this will eliminate all of the underlying tissue and associated skin appendages, which are believed to be the source of this abnormal skin entity. We present a case of a patient in which tangential excision with delayed split-thickness skin grafting was performed after initial application of an acellular dermal matrix (Integra). Unfortunately, there was nearly immediate recurrence of this disease, and we, therefore, suggest a more aggressive approach to the initial excision.

Keratoderma hereditarium mutilans (Vohwinkel syndrome).

Keratoderma hereditarium mutilans, or Vohwinkel syndrome, is a very rare genetic skin condition which causes palmoplantar hyperkeratosis and constricting rings of the fingers and toes. Approximately 50 cases have been reported in the literature with only three having been managed surgically. All three had a high rate of recurrence and unfavourable results in the long term. We report two more cases managed surgically with a follow up of 5 and 8 years respectively. Our experience suggests that the use of full thickness grafts to line the released contractures does not work in the long term as the grafts become raised and painful, requiring multiple revisions. Surgical correction was easy to achieve but difficult to maintain and achieved poor outcomes in general. We therefore feel that the indication for surgical treatment should be a neurovascular compromise.

Results of distal metatarsal osteotomy using absorbable pin fixation.

BACKGROUND: Metatarsalgia with plantar hyperkeratosis can be a difficult problem to treat. Many different techniques have been reported with the Weil osteotomy very popular currently. Despite good results complications include metatarsophalangeal stiffness, hyperextension of the toe, prehensile deficit and a reduction in strength. We evaluated our results with a distal diaphyseal osteotomy. MATERIALS AND METHODS: From 1999 to 2005, we performed 66 distal midshaft subtraction osteotomies in 62 patients suffering from metatarsal overload without metatarsophalangeal subluxation. Fixation was obtained with an absorbable pin. Some patients underwent simultaneous corrective surgery for hallux valgus, hallux rigidus or lesser toe deformities. There was an average of 18 months followup. RESULTS: The mean preoperative Maryland score was 52; the mean postoperative score was 86. Seventy-two percent of the patients were very satisfied and 28% felt their condition improved with only occasional pain (VAS 2 to 4). The only complications reported was a loss of correction due to breakage of the pins in three patients (two sustained trauma and the third began walking prematurely without a postoperative shoe). CONCLUSION: The good clinical results obtained and the low incidence of complications have encouraged us to use this technique to treat symptomatic metatarsal overload. Surgical accuracy, adherence to the postoperative regimen and, where necessary, adequate correction of the first ray were important factors for success.

[Surgical treatment of keratosis palmaris in Mal de Meleda]. / Peut-on traiter chirurgicalement le Mal de Meleda (kératodermie palmoplantaire diffuse de Siemens) ?

BACKGROUND: Mal de Meleda (MDM, OMIM #248300) is a rare congenital palmoplantar keratosis. Deep fissures cause pain and limit extension of the metacarpo-phalangeal joints. We report the case of a patient operated on both hands with a 29-year interval between each hand. OBSERVATIONS: A 53-year-old patient with MDM demonstrated severe keratosis of the left hand. The same surgeon operated on the right hand. Both hands were operated using the same technique. Skin of the palm, the palmar side of the index, and the first phalangeal of third, fourth and fifth fingers were excised with a sharp rugine. The hand was immediately covered by a full thickness-skin graft (FTSG) harvested on groin. CONCLUSIONS: The excision of all keratosis on the palm can lead to complete cure of MDM symptoms. FTSG is essential, especially on the fingers, in order to minimize secondary retraction. At the palm, FTSG offers better mechanical resistance then a split-thickness skin graft. A large groin graft, with closure of the donor site in a Y fashion, can cover the entire hand. Long term follow-up (29 years) demonstrates no recurrence of keratosis on surgically treated areas.

Palmoplantar keratoderma and skin grafting: postsurgical long-term follow-up of two cases with Olmsted syndrome.

Olmsted syndrome is a rare congenital mutilating palmoplantar keratoderma associated with periorificial keratotic plaques. Treatment options include topical keratolytics, systemic retinoids, and debulking procedures. Full-thickness excision of hyperkeratotic plaques followed by skin grafting has been reported in the medical literature, although long-term results have not been evaluated. We present two cases of Olmsted syndrome with severe palmoplantar keratoderma treated with excision and skin grafting, along with long-term clinical results 11 years (patient 1) and 6 years (patient 2) following the initial surgery.