Presentation

• This is cracking and peeling of the weight-bearing areas of the soles of children.^[1][2]
• It occurs in boys more often than girls and is most common between the ages of 3 and 14^[3] with an average age of 8. Onset in adulthood is not uncommon.^[1]
• It is worst in the summer.
• The sole becomes shiny and glazed. Usually the heel is unaffected but it may be involved and occasionally the palms are affected too. The web spaces between the toes are spared. It is the weight-bearing surface of the sole that is most involved.
• The skin becomes scaly.
• Painful fissures develop. They are usually under the toes and on the ball of the foot. They may take many weeks to heal.

Aetiology

It is thought that friction and sweating are important and the consensus of opinion is very much that socks and shoes made of synthetic materials are to blame. The condition was first described in the 1970s.^[4]

Risk factors

There is a predisposition in atopic children.

Diagnosis

The age of the child and the shiny fissured skin is typical.

Differential diagnosis

• Atopic eczema.
• Contact dermatitis.
• Psoriasis.
• Exfoliative keratolysis.
• Fungal infection - usually easily distinguished, as tinea pedis generally does not cause cracking or peeling of the weight-bearing areas; instead it may cause fine scaling over the instep, or maceration between the toes.

Investigations

Skin scapings for mycology and patch testing for contact dermatitis may be indicated.

Primary care management

The evidence base for management is very poor and all is at the level of expert opinion with no RCTs.^[5]

• Advise well-fitting leather shoes and cotton socks rather than synthetic materials (two pairs of cotton socks worn simultaneously may help to reduce friction).^[2]
• Days with little or no walking to allow the fissures to heal. Fissures may heal faster when occluded. Sticky plasters are usually adequate but a 'liquid bandage' or nail glue can be applied to the fissure and will relieve the pain.
• Greasy moisturisers such as soft paraffin (Vaseline®), can be helpful. Apply after a bath and before bed. Barrier creams are easier to use during the day. They are applied every four hours.
• Topical steroid creams may be beneficial in inflammatory episodes but should be used for only a short time.^[6] Antifungal agents are of no value.

Prognosis

The condition tends to improve in cooler weather but may recur the following summer. From the age of about 8 it tends to improve and usually disappears after puberty.^[7]

When to refer

Referral is not usually required.