There are many causes of hyperkeratosis on the soles of the feet – commonly things like psoriasis, eczema and tinea pedis. In this blog I would like to focus on another, less discussed condition, which primarily affects middle aged women – Keratoderma Climactericum (figure 1).
As I often say, hyperkeratosis of the soles is a symptom - not a diagnosis and when patients present with it, a careful history and examination is required to highlight diagnostic pointers towards the correct diagnosis.
Clinical Presentation of Keratoderma Climactericum
The typical history of keratoderma climactericum (KC) is of a gradual onset of hyperkeratosis affecting both feet. The condition normally affects women within 10 years of the onset of the menopause.
Typically, it manifests as small islands of dryness across the soles evolving into thicker hyperkeratotic plaques which than coalesce to form larger lesions of hard skin. Itching is not an unusual feature. In time, intra-lesional skin may become erythematous, atrophic and painful fissures causing difficulty with walking (Figure 2). As the condition progresses, it may appear on the palms as well (although this tends to milder in presentation).
Keratoderma climactericum is diagnosed on clinical grounds - suspicion should be raised in any female patient around menopausal age with erythema and a new hyperkeratosis of the soles (and occasionally the palms).
Biopsy of lesions is not conclusive and only shows non-specific changes of hyperkeratosis (thickening of the stratum granulosum). In such cases it is important to consider other, more common, diagnoses such as tinea pedis, psoriasis and dermatitis. Non-response to topical antifungals within two weeks can rule out dermatophyte infection. Eczema normally presents with a history of the disease and lesions elsewhere in flexural areas. A spontaneous development of hyperkeratosis exclusively on the feet with formation of fissures is an unusual presentation of eczema. Psoriasis, likewise, will have lesions evident on the elbows, knees and scalp. A spontaneous development of hyperkeratosis exclusively on the feet with formation of fissures is an unusual presentation of eczema. Palmo-plantar pustulosis is more often observed in smokers
History of Keratoderma Climactericum
KC was first discussed by Haxthausen in paper published in the British Journal of Dermatology in 1934 [1]. The term “climacteric” is used to describe the time just preceding menopause characterised by declining ovarian function. Haxthausen first described the condition in a group of 10 menopausal women. Debate has since speculated how diminishing oestrogen levels can lead to hyperkeratosis of the soles and palms of the sufferer. Research has demonstrated the presence of oestrogen receptors in the skin, particularly in the lower limb, although their exact function remains unclear [2]. Shuster [3] suggested that lower oestrogen levels can decrease collagen in the skin. Other changes of the skin during the menopause have been reviewed by Wines & Willsteed [4] and I will look at this topic in a future blog.
Treatment of Keratoderma Climactericum
There is no consensus on the management of Keratoderma Climactericum. The literature suggests a number of treatment approaches including emollients, salicylic acid, topical steroids and oral retinoids [5-7]. My personal approach in a number of cases has been the use of topical steroids with a response normally seen in a fortnight. In a previously published case [8], I used a steroid impregnated tape applied to the fissuring which showed improvement within two weeks of use. This was used in conjunction with daily urea-based emollients.
Occasionally, patients may fail to respond to these treatments. A case report of KC refractory to steroids demonstrated the successful use of a topical oestrogen cream (0.635% conjugated oestrogen applied twice daily) in improving the skin condition of a patient with KC affecting the palms and soles [9]. Oral oestrogen has also shown to be effective.
Conclusion
KC is an unusual cause of hyperkeratosis of the soles and palms. Women in middle age who develop a gradual, progressive of plantar skin changes should be considered to have KC, whilst considering ruling out more common conditions such as eczema, psoriasis and tinea pedis.
References
1. Haxthausen H: Keratoderma climactericum. Br J Dermatol 1934, 46:161-167.
2. Ciocca DR, Roig LM: Estrogen receptors in human nontarget tissues: biological and clinical implications. Endocr Rev 1995, 16:35-62.
3. Shuster S, Black MM, McVitie E: The influence of age and sex on skin thickness, skin collagen and density. Br J Dermatol 1975, 93:639-643.
4. Wines N, Willsteed E: Menopause and the skin. Australas J Dermatol 2001, 42:149-148; quiz 159.
5. Kline A: Haxthausens's disease or keratoderma climactericum: a case report. Podiatry Internet Journal 2007, 2:2.
6. Deschamps P, Leroy D, Pedailles S, Mandard JC: Keratoderma climactericum (Haxthausen's disease): clinical signs, laboratory findings and etretinate treatment in 10 patients. Dermatologica 1986, 172:258-262.
7. Robinson H: Keratoderma climactericum: a case study. J Brit Pod Med 1997, 52:178-190.
8. Bristow I, Turner A: Case Report: The management of heel fissures using a steroid impregnated tape (Haelan) in a patient with keratoderma Climactericum. Podiatry Now 2008, 11:22-23.
9. Norman TE, Obed O, Chen A, Worswick SD: Palmoplantar keratoderma climactericum successfully treated with topical oestrogen. JEADV Clinical Practice 2023, 3:309-312.