PITTED KERATOLYSIS IN PHYSICALLY ACTIVE INDIVIDUALS: RISK FACTORS, DIAGNOSIS, TREATMENT AND PREVENTION OF RECURRENCE - A NARRATIVE REVIEW

Abstract

Introduction: Pitted keratolysis is a superficial bacterial infection of the plantar stratum corneum, caused primarily by Kytococcus sedentarius and species of the genus Corynebacterium. Although this condition is well documented in general dermatology, it represents a growing and often misdiagnosed clinical problem in populations with high levels of physical activity, including athletes, military recruits and occupational groups exposed to prolonged foot occlusion.

Objective: The objective of this narrative review is to comprehensively systematize current clinical knowledge regarding risk factors, diagnostic pathways, targeted antimicrobial therapy and long-term strategies for preventing recurrences of pitted keratolysis in physically active individuals.

Materials and Methods: The literature review was conducted by searching the electronic databases PubMed/MEDLINE and Google Scholar for studies published between 2011 and 2026. After rigorous selection, 50 key scientific publications including clinical studies, case series, and diagnostic and therapeutic reviews, were included in the qualitative analysis.

Results: The evidence gathered shows that plantar hyperhidrosis, prolonged occlusion in synthetic footwear or cotton socks and repeated microtrauma to the foot create a moist environment with an elevated pH, which stimulates the synthesis of bacterial proteases as well as the formation of crater-like epidermal defects, accompanied by the development of bromhidrosis associated with the production of volatile sulfur compounds. Among physically active individuals, where men account for over 80-90% of patients, pitted keratolysis is often mistaken for athlete’s foot (Tinea pedis) or plantar warts (Verrucae plantares). Modern diagnostic tools, particularly dermoscopy (which reveals smooth lesions with preserved papillary lines) and examination under a Wood’s lamp (showing coral-red fluorescence of porphyrins), significantly improve diagnostic accuracy. First-line treatment consists of topical antibiotics: 1% clindamycin, 2% erythromycin or 2% mupirocin, applied in non-greasy, fast-evaporating formulations. However, it has been shown that antibiotic therapy alone does not protect against reinfection without concurrent treatment of hyperhidrosis (aluminum chloride solutions, botulinum toxin injections) and the adoption of behavioral and hygiene practices for particularly vulnerable areas.

Conclusions: Effective treatment of pitted keratolysis in physically active individuals requires an integrated clinical algorithm. Long-term therapeutic success relies on combining targeted topical antibacterials with aggressive sweat reduction and footwear modification to eliminate environmental triggers.