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DPM
Porokeratosis: How do YOU treat it?
Section:  Dermatology

The ever common presentation of focal hyperkeratosis on the plantar aspect of the foot...how do you treat it and what kind of success rate do you see?  These are painful lesions that are often sub metatarsal head, but clearly distinct from a simple shear or pressure callus.  I usually treat them with debridement and custom orthototics with offloading to the site of the lesion(s).

Here is a representative photo:

DM Poro

MEMBER COMMENTS
RE: Cantharone Plus under occusion

I've treated many of these focal nucreated lesions over the years, and was able to get a definative cure about 2/3rds of the time with a good application of the vessicant Cantharone Plus ( a mixture of the vessicants Cantharidin/Podophyllin and Salicylkic Acid) under occlusion.  Theoretically, any powerful vessicant should work, but I learned to like the controlled effect of Canthrone Plus.

 

The method I used was to debride the lesion as thoroughly as possible, even using a small currette or 69 beaver blade to scoop out as much of the keratotic plug as possible.CantharonePlus I would then apply a drop of Cantharone Plus with the wooden end of a wood stcik cotton applicator, allow it to dry, and then repeat this 1 time, for a total of 2 applications.  I would then cover the spot and the surrounding area, usually the entire forefoot, with Elastoplast.  This materials sticks like fly paper and is occlusive.  It must maintain a good occusion to work, so I would run some tape between 2 adjacent toes and wrap the Elastoplast around the dorsum of the foot. I gave then a shower protector, and an analgesicand have the patient return to the office the next day. If you've ever had a blister on the bottom of your foot, you know what it feels like. 75% of the time, they would present with a nice sterile vessicle surrounding the lession.  Most often without anesthesia, I would take a tissue nipper and remove the roof of the vessicle, and then you find out how much of the core of the lesion you weren't able to remove with debridement ! Usually, you pull out what looks like a keratin plug that was embedded into the dermis.  There is usually no bleeding with this step.  Occasionally, this step is too painful to do without anesthersia, and I would do a field block from dorsal into the area to achieve anesthesia.  I estimated that I'd get about a third of these lesions recurring over time after this treatment, but it often took years to recoccur..and 2/3rds never reoccur.

 

What is a porokeratosis ?  It's still debated, but I became convinced over time that they represented clogged up sweat ducts.  The epidermis invaginates into sweat ducts, and all epidermal cells slough over time as a continuous process.  If the duct becomes blocked, the cells pile up and compacts from weight bearing.  I believe that is what causes these lesions.

 

Cantharone Plus was last manufactured by a Canadian company called Dormer. A google search on it revealed a number of current sources.

RE:

I treat by enucleation and off-loading the lesions with straight metatarsal padding and orthotics.  On occasion, I will surgically excise these lesions with a minimal plantar metatarsal condylectomy or straight excisional biopsy if they located on the heel or anywhere else on the plantar surface of the foot.  I have found that cryotherapy and laser cauterization rarely works. 

RE:

As far as etiology, I'm convinced these lesions, whether they are actual porokeratotic lesions or straight regions of focal hyperkeratosis, are probably traumatically induced by nature. 

This is from an earlier blog post in The Foot Blog from 2006.

The histological characteristics of a ‘corn’ or punctuate keratodermal lesion is a thickened stratum corneum, hyperplastic stratum malpighii, atrophic changes to the stratum malpighii at the base of the plug.  There is focal loss of the stratum granulosum with fibrosis of the dermis and dilation of the eccrine sweat ducts. 

Porokeratosis plantaris discretum is classified in some texts as a benign skin tumor.  Since the lesion is common and found on the bottom of the foot, and is keratotic, I have included this lesion as a plantar keratoderma. Porokeratosis plantaris discretum is characterized as a translucent keratinous plug surrounded by white rim of macerative tissue believed to be the plugged rim of an eccrine sweat duct.  Variants will show a keratin plug, and others will not have an associated plug.   They measure anywhere from 1-3 mm in diameter, so they are small.  It is theorized to be a blocked eccrine sweat gland secondarily to the stimulation of intraepidermal portion of the eccrosyringium.  There is some debate whether this is true microscopically.   In 1951, Marvin Steinberg, DPM, reported on a plantar hyperkeratotic lesion and labeled it plugged duct cyst.  In 1970, Steinberg and Taub reported a previously unrecognized dermatopathological entity and called it porkeratosis plantaris discreta.  Of 649 biopsies taken between 1963 and 1969, only 13.5% were found to be interpreted as consequence of sweat pore obstruction.  However, in 1990, Yanklowitz and Harkless reported the term as a misnomer.  They could not corroborate the microscopic (using light and electron microscopy) findings.  It has been my experience that the lesions can be very deep and painful.  They also respond well to surgical excision.  They are sometimes located under a bone prominence and sometimes not associated with pressure points. 

 

 

RE:

Intractible plantar keratosis or IPK is sometimes confused with porokeratosis.  The IPK also has diffuse maceration surrounding the keratosis, but these lesions are more associated with deeper keratinisation of tissue underlying a bony prominence.  They are in general , larger than the porokeratosis sometimes measuring 20-30mm in diameter.  It is most commonly seen under the metatarsal head regions of the forefoot.  I have also observed that smokers can develop these lesions, so there may be a neural or stimulatory component to the development of these lesions.  A variability of metatarsal decompression type osteotomies have been performed to eliminate these lesions with variable success.  The IPK can be so deep, that it appears to encompass into the dermis and can bleed on deep debridement. 

I.  Non-mechanical punctuate keratosis includes various diseases and conditions such as arsenic intoxication, secondary syphilis, malignancies, autosomal dominant and recessive diseases.  There are also a few premalignant keratosis that fall into the nonmechanical keratosis such as arsenical keratosis and actinic keratosis or solar keratosis.  Although not necessarily premalignant, seborrheic keratosis can be a cutaneous sign of internal malignancy such as adenocarcinoma.  This is usually preceded by a rare sign called the sign of Leser-Trelat.  An associated erythema with a rapid increase in the number of lesions accompanied by pruritis may indicate adenocarcinoma. 

Keratosis punctata of Hallopeau is a plantar keratosis named after a French dermatologist, Francious Henri Hallopeau.  It is an autosomal dominant trait.  There are several dermatologic syndromes used to describe different type of lesions and presentations that can range from nodular to bullous in nature.  The keratosis punctata variety is an autosomal dominant disorder.  The lesions are epidermal and can present in three different forms; truncated, macular or verrucoid.  The lesions usually begin to develop between the ages of 15 and 30 years and continue to last throughout life.  Since this is also a palmoplantar keratoderma (PPK), the lesions involve the palm and feet symmetrically, bilaterally with groups of small, black-like punctuate lesions. 

Karretosis Follicularis or Dariers-White disease  is a non-mechanical, autosomal dominant disease of late childhood.  The lesions can appear a multiple papules on the heels that are cobblestone-like in appearance.  Sometimes the lesions can manifest itself on the skin behind the ears.  Pinpoint papules occur in relation to and in between corresponding hair follicles. 

RE:

Osteopoikilosis is a rare autosomal dominant disorder that affects bone.  Also called ‘spotty bones’ , it is commonly characterized by ovoid regions of periarticular sclerosing, usually affecting the hip, shoulder and knee joints.  Cutaneous, punctuate keratosis to the soles of the feet affect about 25% of this population.  It is associated with dermatofibrosis lenticularis disseminate, scleroderma, dwarfism and cleft palate. 

Richner-Hanhart’s Syndrome is an inborn disease of Tyrosinemia .  It is an autosomal recessive trait caused by hepatic tyrosine aminotransferase deficiency seen in infants in the first few months of life.  It will cause hepatomegaly and liver cirrhosis if left untreated.  The syndrome is characterized by palmoplantar keratosis, lacrimation, corneal sensitivity, mental retardation and self mutilation. 

Basal Cell Nevus Syndrome or Gorlin’s Syndrome is an autosomal dominant trait that can cause punctuate palmoplantar keratomas (PPK).  The disease was first described by Gorlin in 1960 characterized by multiple nevoid basal cell carcinomas.  It is a very rare disease with the diagnosis confirmed by calcification of the falx cerebri, odontogenic cysts of the jaw and nevoid basal cell cutaneous nevi. 

Arsenical keratosis is associated with arsenic intoxication and is rarely seen in the United States.  Arsenic is used in industrial and agricultural compounds.  It is still seen in regions of the world such as Mexico and Taiwan, where arsenic levels can be detected in drinking water.  Arsenic is naturally found in rock, which can leach into drinking aquifers.  In 1888, Hutchinson reported an increase in cases of squamous cell carcinoma insitu or Bowen’s disease  in patients ingesting arsenical medications. The lesions usually presents as small, yellow-brown like round and even wart-like along the soles of the feet.  The lesions may also coalesce to form plaques. 

Actinic keratosis or Solar keratosis is a premaglinant, scaling, ill-marginated, red to pink hyperkeratotic papule of the epidermis.  It is more common in light-complected individuals.  Actinic keratosis is more pronounced on sun exposed areas such as the top of the foot rather than on the sole of the foot.  The lesions are well defined, raised and usually appear as a red to pink plaque.  Sometimes, as the lesions dry, yellow to brown crusting may form over the lesions.  The lesions are also pruritic, so associated excoriations may be seen. 

Seborrheic keratosis is autosomal dominant in inheritance.  It is characterized by a classic dark, well marginated hyperkeratosis of the epidermis containing horn cysts.  It is usually a skin condition seen in the elderly population and most often appears as a ‘paste-like’ papule or plaque.  The condition can also be associated with malignant adenocarcinoma.  A rapid increase in the number or these lesions with associated pruritis is diagnostic for the sign of Leser-Trelat.  A variant of seborrheic keratosis is Stucco keratosis.  These lesions are lighter in color, often a light yellow to white lesion commonly seen in the elderly around the ankles or on top of the foot.  The lesion is loosely adherent to the outer epidermis and is crust-like.  The classic diagnosis of this lesion is the ability to ‘pick’ off the lesion directly from the skin with your finger nail. 

RE:

II.  Mechanical punctuate keratosis 

These lesions are typically hyperplastic to the epidermis.  The epidermal rete ridges arrange themselves in a haphazard pattern called pseudoepitheliomatous.  There is significant increase in the stratum corneum and is caused by reactive stresses to the skin.  The two most common types of mechanical punctuate keratosis is associated with epidermal inclusion cyst and/or foreign body implantation. 

The epidermal inclusion cyst is certainly the most common cyst of the foot.  It is basically caused by traumatic inoculation of epidermal cells into the dermis.  The characteristic appearance of this cyst is a dome shaped, firm nodule.  If a central core is found, sometimes caseated, cheesy keratinatious material can be expressed from the lesion. 

Foreign body implantation is a variant of the epidermal inclusion cyst.  Here on debridement, we see a macerated region just under the keratoma that appears very similar to a porokeratosis plantaris discreta.  However, on closer inspection, a small foreign body is seen.  When the cyst is inspected, many times a central foreign body can be found in the cyst.  Here we see a small foreign body implantation of a metal shaving removed from an inclusion keratoma.  On initial clinical inspection, the lesion looks like a typical punctuate keratoma to the bottom of the foot.  However, on sharp debridement, the small metal shaving is identified as foreign body material inducing punctuate hyperkeratosis.

 

RE: Porokeratosis: How do YOU treat it?

During residency, John, Jolly tried a rotational advancement to excise one and move the potential area of recurrence to another site. We thought that that might take care of the problem. But instead the lesion reoccured along the incision line, giving credence to the idea that they occur in areas of trauma to the skin. Mind you that we relocated the incision to areas of low stress (no tension on the skin, no metatarsal head directly above the skin, etc.)

RE: Porokeratosis: How do YOU treat it?

FYI, Dr. Gary Dockery, who has written several dermatology chapters and textbooks, uses the injection of diluted dehydrated alcohol, directly underneath the skin lesion... the same kind of alcohol solution that is commonly used in the chemical neurectomy and neuroma treatment.

When I was in training in Cleveland, I have seen cantharone used as a vessicant, for many skin lesions, anything from IPKs to plantar warts... and I think they worked pretty good, while some of the patients complained of severe pain once in a while, especially if you are treating large or multiple areas. Another vote for cantharone from me.

RE: Porokeratosis: How do YOU treat it?

I largely use cantharone, as was the practice in my training program, although I have seen people use sclerosing alcohol injections for the management of these types of skin lesions, as Kazu mentions, and it seems effective.

RE: Porokeratosis: How do YOU treat it?

I used to wonder what all the excitment was about until I developed a porokeratosis on my own foot.  It felt like a needle in my foot.   I have frozen them with liquid nitrogen, and also used Cantharon.,  I now use debridement with urea 40% ointment in the void after  and Plastizote inserts,  I claim only fair sucess with this method, 

RE: Porokeratosis: How do YOU treat it?

I have excellent results with debridement of the core and immediate freezing with liquid nitrogen. I have them follow up in one month for one more treatment and many of them are gone at that point.

RE: Porokeratosis: How do YOU treat it?

Thanks, Dr.Winters.  I think all vessicants, if sufficiently powerful, work well in this situation...liquid nitrogen certainly being one of them. The application needs to be titrated based on the location of the lesion.  My experience has been that porokeratoses tend to appear under the weight bearing areas of the forefoot, and to a lesser extent, the heel. Pressure seems to be part of the etiology...facilitating the clogging up of the sweat duct.  The skin in these locations is among the thickest on the body, so a fairly potent vessicant application is required.

RE: Porokeratosis: How do YOU treat it?

Since everyone has exhausted most treatment options, I'll just put in my 2 cents....

Canthone w/ occlusive dressing...if recalcitrant, I am now using the CryoProbe after enucleation and then applying Canthrone.

 For the most severe recalcitrant cases, I treat them like a verruca plantaris, CO2 laser excision and curretage, Effudex ointment with occlusion x 2 weeks.  Seems to work.

Eric 

Re: Porokeratosis: How do YOU treat it?

Where does everyone order Cantharone from?  I am trying to have my hospital pharmacy order it so I can have it in my clinic for use, but they claim it is not FDA approved and is only available from Canada....

Re: Porokeratosis: How do YOU treat it?

Cantharone Plus was last manufactured by a Canadian company called Dormer. A google search on it revealed a number of current sources.

Alan

Re: Porokeratosis: How do YOU treat it?

Did anyone else notice that this thread has over 2600 views?

Unless it's just Alan Sherman clicking on it over and over?  :) 

Re: Porokeratosis: How do YOU treat it?

I actually enjoyed this thread very much. It is interesting how we treat the same skin lesion in so many different ways.

I did my residency in Cleveland OH, Salt Lake City UT, and now practice in Los Angeles CA. I can tell you from my personal experience that how we practice (ie. osteotomy fixation method) differ completely from region to region.

For example, in Cleveland, I've seen percutaneous k-wire fixation for almost every hammer toe correction. In Salt Lake City, hammertoes were almost never fixated. In Los Angeles, many people fixate Austin with percutaneous k-wire, which I have never seen in Cleveland.

I think it's pretty cool to have this forum where we can exchange ideas so easily. 

Re: Porokeratosis: How do YOU treat it?

I usually debride this down to core and apply phenol.  I repeat this every 2 to 3 months.  For the true mascerated porokeratotic lesion, it seems to work well.  There are many ways to skin the cat so to speak.  The objective is to either remodel or ablate the dermal subcutaneous region where the histologic defect occurs and have new dermis replace the defective tissue.  Dr. Kline, nice review of the differential lesions.  That should have been an ezine.  Does anyone have issues with recurrence when these are excised?

Re: Porokeratosis: How do YOU treat it?

The fact that there are 2600+ viewings of this string makes an important point: there is no one completely effective treatment for all patients yet.

I have read many good ideas here. But I am not competely convinced that we are all talking about the same lesion though (as Dr. Kline indicates in his excellent educational contribution).

George, I would bet you dollars to doughnts that yes, if we are being perfectly honest and not just bragging that "in my hands.....", these do recur. If we think we have cured our patients for good because the patients don't return, they may be seeing the podiatrist across town for the same condition/different treatment! 

This is a difficult condition that we truly don't understand the etiology of yet.  Once we do, they we can develop a true treatment and possible cure.

Re: Porokeratosis: How do YOU treat it?

Well, first off, the etiology of the Intractable plantar keratosis is different from the Porokeratosis plantaris discretum lesion and the treatment should follow that difference. For the true Porokeratosis plantaris discretum lesion, I have done the treatment shown to us by Harvey Lemont at the Temple School (so many years ago): numb up the area under the lesion so that you can work without a chance of the patient jerking the foot and causing a calamity. Excholeate around the rim of the lesion to raise a section and then grab it with a hemostat. Continue to excholeate the obvious, whitish colored core of the lesion to the base. The depth of this may be shocking in some cases, but success is completely dependant upon working to the base. Once at the base of the lesion, it will pluck out and leave a small diameter, somewhat deep non-bleeding evacuated site. It will be non-bleeding if you use epinephrine in your block, by the way. I use two cotton tipped sticks of phenol for 30 seconds each, constantly rotating the stick in the site. After two sticks to cauterize the site, with attendant color changes, I flush with EtOH on a cotton tipped stick, place a little topical antibiotic on it with a Band-Aid. I place no restrictions upon the patient as far as weightbearing or activity and the site is usually minimally tender once the block has worn off. I’ve averaged around an 85% success rate with one treatment, following this protocol. Thanks, Dr. Lemont!

Re: Porokeratosis: How do YOU treat it?

which medicine take for porokeratosis,thanks

Re: Porokeratosis: How do YOU treat it?

Wow, John! Over 44,000 views on this subject!

What would your grandfather think of this?

I am giving a talk about this at the Midwest Conference in March. I must admit that I am taking a bit of a different stance than your dear grandfather, Marvin, the Father of Podiatry. We have modalities that he did not have at his disposal then or he might have had a different take on it I would imagine.

Yanklowitz and Harkless, Markinson, Bakotic and Dockery now say that the "plugged sweat gland" does not actually exist and the porokeratosis plantaris discreta should not be a recognized entity. I say that perhaps we should give ourselves a break and allow ourselves permission to call the hard, conical shaped lesion on the plantar foot a "poro" even though it is not a plugged sweat gland.

A rose by any other name is still a rose......

I still run across gentlemen (always men...) who were your grandfather's students and they will argue me into the ground about this. Loyal to the end. I could show them the electron microscopes. I think that is a wonderful thing. Loyalty to a mentor's word!  

Evidence based medicine doesn't hold a candle to loyalty to a mentor.

Re: Porokeratosis: How do YOU treat it?

After debriding the lesion(s) with a #64 blade and removing the keratin plug or core of tissue.  I run a diamond tipped high speed rotary burr inside the lesion and spray it with alcohol if the patient complains that it gets too hot.  This aids in further removal of the hyperkeratotic rim that even the most skilled hand can not remove.  I too have great results with Cantharone.  My experience with excision is that they can and do occasionally come back, sometimes with a vengeance.  Seems to me that the company that produces Cantharone has changed the secret formula over the recent years.  Sometimes I receive a red bottle with the pungent gummy substance and this is the BEST.  Lately, I have seen it in a green bottle and it seems thin and runny and is even hard to dry.  There are several different companies selling this:  Cantharone, Canthacur, Cantharidine, Canthacur PS, etc.... I like Cantharone plus available form  http://www.dormer.ca/Phy_Pages/Wart_Removers.aspx  Works GREAT on warts too.  A good compounding pharmacist can make this stuff as well.  For example, we have saved THOUSANDS on Celestone Soluspan 10ml vials by having a local compounding phamacist make the drug for our clinic.

 

Re: Porokeratosis: How do YOU treat it?
Quote:

The ever common presentation of focal hyperkeratosis on the plantar aspect of the foot...how do you treat it and what kind of success rate do you see? These are painful lesions that are often sub metatarsal head, but clearly distinct from a simple shear or pressure callus. I usually treat them with debridement and custom orthototics with offloading to the site of the lesion(s).

Here is a representative photo:

DM Poro


I completed your grandfathers Residency in 1970, I observed at his practice for many years, I sat in his living room evenings in awe and I owe my personal and professional strength and passion to him.
I taught Injection Therapy A La Steinberg for eight years at NYCPM and continue to lecture on his work when requested. I think I could serve as an existing loyalist of his bloodline on this thread.


He started ETOH injections, he fathered the podiatric microbiology academia that Dr's Bakotic, Markinson and Dockery now lead, he fathered our first Residency Program, he held 17 patents, sat in front of Congress when we needed an expert to get us included in laws, he hated cortisone, he had perfect pitch, he fathered LLoyd and grandfathered you, I would wager him against almost any MD in a debate on almost any medical subject, he was a Renaissance Man
But,
there are two sad parts to this story. he rarely published and he added what he called AMA Pads and LA Pads to the arch and forefoot of almost all of his patients (we cut them out) that have been almost completely overlooked as part of his legacy.


I think he didn't publish because he was clinical and not a researcher, he was experiential and not experimental, he regarded compassion, rapport and other human and social scientific skills almost as highly as his huge natural science accumen when being a Physician. Taking the time to publish would have kept him from his patients, his students and his passion for mankind and his destiny.


I think that he didn't give much import to his pads when he taught and lectured because his mantra was that he was not an arch maker, not a corn and toenail cutter, he was a Doctor! and that was a more important thing for him to mentor into our profession than, dare I say it, Biomechanics.

I have continued to cut, experiment and expand on Dr. Steinbergs pads for 40 years and in addition to following many of his dictums, today, I own my own dyes and have my pads packaged as kits and I market them into podiatry as Foot Centering Pads and like Dr. S, I apply them on almost every initial visit in practice.

It led me to Functional Foot Typing, The Foot Centering Theory of Biomechanics and a host of other social and human diagnoses and treatments that the EBM purists are eliminating from medicine as they strategically eliminate compassion, rapport and its social and human components.


There has been one small entry on this thread about using met pads and orthotics for treating Dr. Marvin Steinberg's lesion, whatever you want to call it, after 44,000 reads.


I ask two questions.

Have any of you seen more than a handful of Steinberg Lesions that was not accompanied by biomechanical pathology or weightbearing components?
Do you have any notion of what happens to these lesions progression when their etiological component of foot type-specific biomechanical pathology is treated or eliminated as there is scant EBM on the subject, only the experience of those DPM's who have chosen to practice biomechanics?


I finish with what I recall as a fact for Lloyd or John to verify.
Dr. Steinberg's wife, Ruth, wrote me on personal stationary that read.
Mrs. Dr. Marvin Steinberg.
That was a part of what made Dr. Steinberg and your mother and grandmother respectfully so special and difficult to replicate.


John, I think that Marvin and Ruth are holding hands and smiling as this thread unfolds.

Dr Sha

Re: Porokeratosis: How do YOU treat it?

These are those puctate lesions 1-2mm diameter, usually in a nonweightbearing area of the foot.

When I was first in practice, I tried currettage, the same as for warts.  Can't say I had one success, and 100% failure.  So I tried the cantharadine was was amazed at how good it worked.

Problem is that fedreal employee podiatrists cannot get canthardine.  So as a way of treating I use sal acid pads (40%), give very detailed instructions to patient to place pad 1/4" square of pad directly on top of the lesion at bedtime.  In morning, remove pad and scrub with soft handbrush or equivalent.  Don't reapply until bedtime again.

I see the patient q30 days and mechanically debride.  Have had many successes, and most have markedly improved in 6-12 months.  Still hoping that U.S. gov allows us to get canthadin in the future.

Re: Porokeratosis: How do YOU treat it?

Dr. Shavelson,
I do wish that someone like yourself would write a history of podiatry, including these stories of Dr. Marvin Steinberg. I've enjoyed speaking with you about them. I can't get that picture of his students packed in the office bathroom, waiting for the bell that would summon them into the treatment room to meet the patient!

How wonderful! He was such a gentleman and professional. And then the idea of retiring to the salon that evening to continue to reap his wisdom. It sounds so old-world like and wonderful. It would have been an honor to meet him.

I'm sure that he, too, would have liked to have had the advances of electron microscopy and to be able to know more about the Steinberg's lesion. He strikes me as the "life-long learner" and someone who would have had no trouble adjusting to the fact that with improved technology we now know more about that piece of tissue!

Thank you again for those great stories and memories!

Re: Re: Porokeratosis: How do YOU treat it?
Quote:

Dr. Shavelson,
I do wish that someone like yourself would write a history of podiatry, including these stories of Dr. Marvin Steinberg. I've enjoyed speaking with you about them. I can't get that picture of his students packed in the office bathroom, waiting for the bell that would summon them into the treatment room to meet the patient!

How wonderful! He was such a gentleman and professional. And then the idea of retiring to the salon that evening to continue to reap his wisdom. It sounds so old-world like and wonderful. It would have been an honor to meet him.

I'm sure that he, too, would have liked to have had the advances of electron microscopy and to be able to know more about the Steinberg's lesion. He strikes me as the "life-long learner" and someone who would have had no trouble adjusting to the fact that with improved technology we now know more about that piece of tissue!

Thank you again for those great stories and memories!

Dr Satterfield:

I adore your concept of a "life long learner".

 

Would a life long learner have the time to divert in order be a life long proover?

 

Would he/she have the scientific stomach and human strength to deny a treatment for a certain malady that was helping lets say, 90% of his patients, for years, to half of the subjects that he was studying (the control group).  Could this really be a physician doing that?

 

I recall the famous landmark british study (haven't read it recently) that took 10,000 diabetics into two 5000 patient groups after trying to remove varients between the groups and then they exercised one group and denied the other.

 

It was a ten year study that revealed that pedal, ocular, renal and cardiac disease was rather dramatically reduced in the exercised group (what a propodiatry study!).

 

They halted the study after eight years (again not sure of the exact details) because they couldn't in good conscience continue denying the control group of healthy exercise.

 

This probably remains one of the two most important studies in diabetes (the other is a similar study using glucose control) to this day and for me, my physician, clinical, integrative, biomechanical heart cries for the 5000 patients in the control group and their bloodlines and what those scientists did to them.

 

I am a life long learner and Present is on my list of safe places for stimulation, education, sharing and expansion as my

evidence based practice continues to evolve.

 

Does our future have a place for life long learners or only life long proovers?

 

My reaction to "show me the evidence" is show me the next student or the next patient and I hope my work gains enough respect that some scientist will research it.  Dr. Steinberg taught me that.and sad for podiatry and medicine, his never reached that level in the scientific community.

 

Dr Sha

 

 

 

 

Re: Porokeratosis: How do YOU treat it?

 I didn't see my routine listed; I encourage 40% urea and a pumice stone, and have more consistently had about a years relief rather than an out and out cure via simple punch biopsy.

Re: Porokeratosis: How do YOU treat it?

I must query the participants to this thread as to whether, in addition to whatever the hands on care you are rendering to your patients, which I believe is fundamental to beginning to gain conrol over these little devils, you are using some form of biomechanical care in addition, when they are weightbearing (under a met head).?

 

Dr Sha

Re: Porokeratosis: How do YOU treat it?

Hello Everyone:   First time I am posting on this so hope it comes out.  As far as tx of porokeratosis I just pare them down with a #64 blade (or,  if covered with a lot of diffuse hk tissue a 15 blade , & f/u c. a 64).  If there is a true biomechanical fault it is addressed, otherwise I simply have the pt. get a pair of OTC arches (Spenco Cushion Arches work very well) and off-load the area with a wide-based accommodation.  I used to do blunt dissection (as in verruca tx) but in most cases this was "overkill" and didn't seem to work as well as the more simpler txs.  As an aside, I have had  referrals for these listed as "poroma" (which is a whole different ball game).             These are very common problems and it's very interesting to read the different txs.  On this topic I notice that there was about a year-and- a-half break before activity picked up again reflecting such concern over a rather "mundane" (certainly NOT to the patient) topic.           BTW, two questions?   I think the term "seed corn" is simply a synonym for porokeratosis.  Correct?   And 2nd:  Why do some of the topics have little "fires" on them and others don't?  Is that an icon for "activity"?    Vinny DiPaolo

Re: Porokeratosis: How do YOU treat it?

Vinny,

 

As one of the regular bloggers, WELCOME!

 

I believe Dr. Sherman can answer most of your questions regarding the "fires".

 

I haven't chimed in yet on porokeratoses, so I guess now is as good as time as any.

 

I really believe that most porokeratoses are really biomechanical abnormalities, and basically, if OTC or custom orthoses don't work, then addressing them surgically is the only option.  Padding is more band-aid, and if there is a structural problem that truly causes the abnormal pressure, then fixing the problem is the only solution.

 

Eric

Re: Porokeratosis: How do YOU treat it?

I think the one reason why, until Dr. Steinberg defined the porokeratosis as a histopathological lesion and suggested treatments for the lesion he defined, this painful, often disabling entity was treated as a corn with palliative and band aid care.

 

I would consider surgical elevation of a metatarsal head for treating a corn or callus as overkill bordering on malpractice.

 

Does';t that make the poro more?

 

I wonder if any of our derm oriented bloggers can suggest where the poro has a more inflammatory or pressure producing or nerve irritating histopatholgy than a corn.

 

Perhaps we need to redefine this lesion as having biomechanical etiology and a microscopic focus of pressure laden material that causes underlying inflammation and or superficial nerve pain reaction that can be disabling, necessitating care beyond routine.

 

No patient of mine in 40 years with a painful porokeratosis could tolerate the pain without functional sequelae and compensation and I think as foot care specialists, we know that to be more than enough to reclassify this entity in a different class than callus and corn.

 

Dr Sha 

 

 

Re: Porokeratosis: How do YOU treat it?

When the usual, what you said, fails- I go with Doc Dockery's tx protocol.  When the patient's had enough, they go for it.  Sclerosing 4% sterile alcohol in 0.5% Marcaine (draw 2ml off the bottle, then put 2ml s/a in).  Very tiny needles, right?  Less pressure.  He says can use Marc w/ epi to help keep it in the area longer, or at least he used to I believe; more effective that way.  You can pull it up on PodiatryToday.com, or even PMNews.com I think.  Been in there a few times now- in both his foot books, which beat any generic derm book by far. Happy trails to you & your pt.

Re: RE: Porokeratosis: How do YOU treat it?
Quote:

I used to wonder what all the excitment was about until I developed a porokeratosis on my own foot.  It felt like a needle in my foot.   I have frozen them with liquid nitrogen, and also used Cantharon.,  I now use debridement with urea 40% ointment in the void after  and Plastizote inserts,  I claim only fair sucess with this method, 



I am getting another one, and I do not like it at all! The onset of 5/5 sharp pain was sudden at a plantar site formerly only 1/5 dull pain.  On close re-inspection the previous skin lines in boundary of a callus have a small white pinpoint plug with pain on direct and lateral pressure.  It looks like nothing, but hurts like the dickens. And that spells, ' Porokeratosis!'

Re: Porokeratosis: How do YOU treat it?

Well,, I'll put in my 2 cents since I don't see MY favorite treatment. This is an old timer, handed down to me from someone who in turn had it handed to them from someone who had graduated chiropody college in 1934.

1. pare the lesion as best as one can.

2. felt aperture pad around said lesion.

3. have in each hand a cotton swab. one swab dipped in 100% phenol solution [phenol crystals ensure maximum concentration and consistency from patient to patient], the other in nitric acid. Do NOT let them touch yet [extreme exothermic reaction].

4. bring both swabs to the lesion. warn the patient before that it will hurt and get hot. when they touch there will be an audible 'pfft' and puff of smoke. the patient WILL curse you for the pain and heat. most of the time. beware the kicking leg.

5. apply salicylic acid compound to the whole in the felt. depending on the patient and lesion this can be anywhere from 12 to 50% salicylic acid. [we had ours custom compounded I think with bees wax and other 'stuff' I don't recall. I think there was a yellowish colored analgesic ointment included].

6. cover with elastikon or elastoplast.

7. the patient leaves this on for 1 week. I have seen it stay on 2 weeks when benzoin is used. they get it wet every day in the shower which helps release the salicylic acid slowly.

8. when they return the lesion is easily exchocliated or pared down.

this takes 1 or 2 treatments. the patient is either 'cured' or they go find someone who uses a less painful method. Actually my patients came back regularly even when they new this treatment was coming because it worked and kept them working. the exothermic reaction is quite dramatic. your patient knows that they have been treated.

dave gottlieb, dpm  views expressed are solely my own and do not reflect anyone or any thing else's.

 

Re: Re: Porokeratosis: How do YOU treat it?
Quote:

Well,, I'll put in my 2 cents since I don't see MY favorite treatment. This is an old timer, handed down to me from someone who in turn had it handed to them from someone who had graduated chiropody college in 1934.

1. pare the lesion as best as one can.

2. felt aperture pad around said lesion.

3. have in each hand a cotton swab. one swab dipped in 100% phenol solution [phenol crystals ensure maximum concentration and consistency from patient to patient], the other in nitric acid. Do NOT let them touch yet [extreme exothermic reaction].

4. bring both swabs to the lesion. warn the patient before that it will hurt and get hot. when they touch there will be an audible 'pfft' and puff of smoke. the patient WILL curse you for the pain and heat. most of the time. beware the kicking leg.

5. apply salicylic acid compound to the whole in the felt. depending on the patient and lesion this can be anywhere from 12 to 50% salicylic acid. [we had ours custom compounded I think with bees wax and other 'stuff' I don't recall. I think there was a yellowish colored analgesic ointment included].

6. cover with elastikon or elastoplast.

7. the patient leaves this on for 1 week. I have seen it stay on 2 weeks when benzoin is used. they get it wet every day in the shower which helps release the salicylic acid slowly.

8. when they return the lesion is easily exchocliated or pared down.

this takes 1 or 2 treatments. the patient is either 'cured' or they go find someone who uses a less painful method. Actually my patients came back regularly even when they new this treatment was coming because it worked and kept them working. the exothermic reaction is quite dramatic. your patient knows that they have been treated.

dave gottlieb, dpm  views expressed are solely my own and do not reflect anyone or any thing else's.

 

 


I lost my nerve at 4. mid-sentence, but I was sitting as I read your note.  If I had been standing on the lesion I would say yes.   Is your treatment is now different?

Re: Porokeratosis: How do YOU treat it?

'Is your treatment now different?"

Honestly, I haven't seen a porokeratoma in a long time. When I do I use a modified version of my old fav. I let the lesion sit with a soapy wet gauze for a good long while. This softens is and seems to have an analgesic effect. Then I enucleate lesion, apply a felt aperture pad and put chunks of silver nitrate on it, cover that with a wee bit of gauze and some tape.

I tell the patient to leave this on as long as it will stay [usually any where from a few days to a week] then take it off. Expect a black circle to be there. Let that fall off on it's on. Come back only if still a problem after that.

I once had a wart on my heel and used cantharin on it. It was so painful I quickly took it off and vowed never to put my patient through that [the phenol and nitric not withstanding].

Dave Gottlieb, DPM views expressed are solely my own and do not reflect those of my employer.

Re: Porokeratosis: How do YOU treat it?

Is this poro on your newly operated foot or the older one?

Under which met or IP Joint?

Whats your foot type?

Do you have an LLD?

Dennis

Re: Re: Porokeratosis: How do YOU treat it?
Quote:

Is this poro on your newly operated foot or the older one?

Under which met or IP Joint?

Whats your foot type?

Do you have an LLD?

Dennis



The porokeratosis or porokeratoma  is on the most recently operated foot. The lesion is at the plantar lateral aspect of the intermediate phalange head of the 3 rd toe which is in slight varus. I do not have a LLD structurally.  As to the 'foot type',  I have 'Everyman's" foot.  The STJ is pronated in stance although on lateral xray the calcaneal inclination angle is not decreased.  I have little faith in lateral xray angle standardization.

Re: Porokeratosis: How do YOU treat it?

Dr. Bates - sorry for your pain. HOwever, I would like to learn from it. Can you please share with us - what you felt after using each of the particular treatments you have already exposed yourself too? Which were more tolerable? which more painful? which possibly would you never do to a patient after a possible painful experience you had etc....or not bad reactions and you would try any of them....? (thanks in advance.)

Re: Porokeratosis: How do YOU treat it?

Re: Porokeratosis: How do YOU treat it?

This is NOT my patient.  This is a pic sent to me by a Physicist, Mr. Don Ashburn , who says he has developed a nonsurgical treatment for porokeratosis.  He says this requires 2 visits 3 days apart.  He says it is pain-free and requires no anesthesia.  He says the DPM  he tested this with has  become a 'surgeon ' and is no longer much interested in skin lesions.  Mr. Ashburn also says a podiatry supply company lost interest in marketing this because it takes 2 visits and also because they believe podiatrists will not be interested in this because it will reduce their patient's periodic CNC visits.  Amazing!

Re: Re: Porokeratosis: How do YOU treat it?
Quote:

This is NOT my patient.  This is a pic sent to me by a Physicist, Mr. Don Ashburn , who says he has developed a nonsurgical treatment for porokeratosis.  He says this requires 2 visits 3 days apart.  He says it is pain-free and requires no anesthesia.  He says the DPM  he tested this with has  become a 'surgeon ' and is no longer much interested in skin lesions.  Mr. Ashburn also says a podiatry supply company lost interest in marketing this because it takes 2 visits and also because they believe podiatrists will not be interested in this because it will reduce their patient's periodic CNC visits.  Amazing!



Mr. Ashburn and I have NO financial relationship at all.   I tried to buy some of this material for Disciples Clinic several months ago, but for some reason Mr. Ashburn was unable to ship.  I believe that Mr. Asburn is in error if he believes a palliative periodic treatment for reduction of keratosis is a Medicare covered service in a patient with NO medical problems.  IT IS NOT is my educated statement. Non covered will be very profitable if removing all keratin without scaring is possible.

Re: Porokeratosis: How do YOU treat it?

The lesion shown in the photo looks very much like the post-procedure appearance after treatment with a vessicant and is consistent with a successful procedure. You can see where the keratin plug came out.   It does look a bit undertreated, though..I'd be happy with a little more vessication, more of an inflamation halo, although I didn't see the lesion pre-treatment and arent' sure how long since the treatment. The vessicle is intra-dermal and can, by itself, completing separate the plug from the skin. If I undertreated, under anesthesia, I'd circumscribe the exisitng connection with a 64 blade, completing the removal. See the 2nd Comment above for a description of using Canthrone Plus under occlusion as a vessicant.  There are a variety of vessicants - acids, bases, electrocautery.  Once you learn to apply one in a controlled and replicatable manner, the rest is just style points.  I used to love seeing these patients at 5-7 days, removing the elastoplast, anesthesizing the foot and most often, successfully pulling out the large keratin plug.  I've seen enough of these in long term patients to know that my rate of long term sucess was about 75%.  25% had immediate recurrances..in as long as it took to grow back. 2nd treatments were more, not less, successful.  And many patients experienced little enough discomfort to have me do it again, if needed. Occurring exclusively in weight bearing areas, I'd do a block from dorsal in the forefoot.  Heel poros are rarer, and yes, David, they require more vessicant due to the thick heel skin and yes, that vesicle does often hurt more - I think the thick skin causes the fluid to be under more pressure. Dwight's friend must have a vessicant of his own...hard to know from a guy's description if it's better or worse, unless he's tried a variety.  I like the "magician" nature of your carbolic/nitric acid technique, David.  I only remember puffs of smoke in my office from my hyfercator. But then, I sound nostalgic...  

 

Re: Re: Porokeratosis: How do YOU treat it?
Quote:

The lesion shown in the photo looks very much like the post-procedure appearance after treatment with a vessicant and is consistent with a successful procedure. You can see where the keratin plug came out.   It does look a bit undertreated, though..I'd be happy with a little more vessication, more of an inflamation halo, although I didn't see the lesion pre-treatment and arent' sure how long since the treatment. The vessicle is intra-dermal and can, by itself, completing separate the plug from the skin. If I undertreated, under anesthesia, I'd circumscribe the exisitng connection with a 64 blade, completing the removal. See the 2nd Comment above for a description of using Canthrone Plus under occlusion as a vessicant.  There are a variety of vessicants - acids, bases, electrocautery.  Once you learn to apply one in a controlled and replicatable manner, the rest is just style points.  I used to love seeing these patients at 5-7 days, removing the elastoplast, anesthesizing the foot and most often, successfully pulling out the large keratin plug.  I've seen enough of these in long term patients to know that my rate of long term sucess was about 75%.  25% had immediate recurrances..in as long as it took to grow back. 2nd treatments were more, not less, successful.  And many patients experienced little enough discomfort to have me do it again, if needed. Occurring exclusively in weight bearing areas, I'd do a block from dorsal in the forefoot.  Heel poros are rarer, and yes, David, they require more vessicant due to the thick heel skin and yes, that vesicle does often hurt more - I think the thick skin causes the fluid to be under more pressure. Dwight's friend must have a vessicant of his own...hard to know from a guy's description if it's better or worse, unless he's tried a variety.  I like the "magician" nature of your carbolic/nitric acid technique, David.  I only remember puffs of smoke in my office from my hyfercator. But then, I sound nostalgic...  

 



What would be the typical total fee to a cash paying patient for the two visits as described by Dr. Sherman?

I also used to use debridement as well as Can that one (or the like) with great success. I'd often also employ the use of an orthotic with dispersionary padding.

Recently, my wife was emailed a recipe for a naturopathic home remedy for dry skin. It's easy and cheap to make and does a good job of exfoliating. I find that it does a decent job decreasing the accumulation of calussed skin as well as dry skin.

Here's the recipe, I would like to give a disclaimer that I am NOT a pharmacist nor do I guarantee the efficacy of this book nor am I responsible for any adverse effects which may be caused. Consult a pharmacist or a dermatologist regarding your personal condition or regarding the application of this to other patients before doing so.

This is the exact content of the email:

"Ideal to help with those crusty feet!! Get it right ladies!! Summer is approaching..

Listerine: the BEST way to get your feet ready for summer. Sounds crazy but it works! Mix 1/4c Listerine (any kind but I like the blue), 1/4c vinegar and 1/2c of warm water. Soak feet for 10 minutes. Exfoliate with pumice stone or methods of your choice."
Re: Re: Porokeratosis: How do YOU treat it?
Quote:

Dr. Bates - sorry for your pain. HOwever, I would like to learn from it. Can you please share with us - what you felt after using each of the particular treatments you have already exposed yourself too? Which were more tolerable? which more painful? which possibly would you never do to a patient after a possible painful experience you had etc....or not bad reactions and you would try any of them....? (thanks in advance.)



My own two porokeratosis lesions were at separate sites and and long separated in time.  Both were on a distal toe which was relativley easy to off load and debride so I got fast relief.  But the first episode almost got me shot---Literally!   

Re: Porokeratosis: How do YOU treat it?

I dosed my own foot today. The lesion on my 4th left toe does NOT have a white halo in the center as a porokeratosis, but is a linear plantar pinch callus as the toe is in varus and rubbing exostosis of toe 3. I took a pic pre tx and had planned to take pics during application, but I had not enough hands. The printed instructions are not adequate as I discovered during the process. I will post again in 48 hours.

Re: Re: Porokeratosis: How do YOU treat it?
Quote:

I dosed my own foot today. The lesion on my 4th left toe does NOT have a white halo in the center as a porokeratosis, but is a linear plantar pinch callus as the toe is in varus and rubbing exostosis of toe 3. I took a pic pre tx and had planned to take pics during application, but I had not enough hands. The printed instructions are not adequate as I discovered during the process. I will post again in 48 hours.

The initial treatment failed because of technical error by the novice operator.  The patient was not harmed.  I will treat again when clinical conditions are optimal.  My expanded midriff did  not allow me to see well the plantar of my foot.

Re: Porokeratosis: How do YOU treat it?

http://www.youtube.com/watch?feature=player_embedded&v=C5qcU7uTkLE                The light is poor as is the aseptic technique.  But great result for porokeratosis especially considering no needles or anesthesia necessary! 

Re: Porokeratosis: How do YOU treat it?

Yeah, no gloves. I'm telling :)

Re: Re: Re: Porokeratosis: How do YOU treat it?
Quote:

Quote:

I dosed my own foot today. The lesion on my 4th left toe does NOT have a white halo in the center as a porokeratosis, but is a linear plantar pinch callus as the toe is in varus and rubbing exostosis of toe 3. I took a pic pre tx and had planned to take pics during application, but I had not enough hands. The printed instructions are not adequate as I discovered during the process. I will post again in 48 hours.

The initial treatment failed because of technical error by the novice operator.  The patient was not harmed.  I will treat again when clinical conditions are optimal.  My expanded midriff did  not allow me to see well the plantar of my foot.


I prefer to refer to that in the following manner:  "your arms aren't quite as long as they were when you were younger"

Re: Porokeratosis: How do YOU treat it?

AKA Dunlap's Disease.

Re: Re: Porokeratosis: How do YOU treat it?
Quote:

http://www.youtube.com/watch?feature=player_embedded&v=C5qcU7uTkLE                The light is poor as is the aseptic technique.  But great result for porokeratosis especially considering no needles or anesthesia necessary! 


http://transdermsolutions.com/

Re: Re: Re: Porokeratosis: How do YOU treat it?
Quote:

Quote:

http://www.youtube.com/watch?feature=player_embedded&v=C5qcU7uTkLE                The light is poor as is the aseptic technique.  But great result for porokeratosis especially considering no needles or anesthesia necessary! 


http://transdermsolutions.com/

I am not the operator. I am right handed, my watch is a Casio not a Rolex, and I wear gloves! But the results on the Left foot are amazing. And, no needles!!

Re: Re: Re: Re: Porokeratosis: How do YOU treat it?
Quote:

Quote:

Quote:

http://www.youtube.com/watch?feature=player_embedded&v=C5qcU7uTkLE                The light is poor as is the aseptic technique.  But great result for porokeratosis especially considering no needles or anesthesia necessary! 


http://transdermsolutions.com/

I am not the operator. I am right handed, my watch is a Casio not a Rolex, and I wear gloves! But the results on the Left foot are amazing. And, no needles!!

We shall soon see.  One of the DPMs in Plastic Surgery at UTSW in Dallas is including this in his long term on going study of porokeratosis.