Coexistent erythrasma, trichomycosis and pitted keratolysis: An overlooked corynebacterial triad? Walter B, Shelley, M.D. , Ph.D. , and E. Dorinda Shelley, M.D. Peoria, IL

axillaris,

The simultaneous presence of erythrasma, trichomycosis axillaris, and pitted keratolysis is reported in two patients. The common bond is the presence of strains of aerobic corynebacteria, which have dermatologic but not microbiologic specificity. The possibility is raised that this triad of diseases may exist more often than previously realized. (I AM ACAD DERMATOL 7:752-757, 1982.)

The delight in making a definitive diagnosis often blunts the cl inician 's interest in looking for additional disease. This is especially true in a problem-oriented dermatologic practice when the patient shrugs off everything else as normal. Still, a careful general examinat ion of the skin may be, at the very least, intellectually rewarding. We pre- sent two examples in which the primary problem was erythrasma, with its diagnostically satisfying coral red fluorescence. Only after a closer, wider look did we see two additional related problems, unsuspected by both us and the patients.

CASE REPORTS Case 1

This 34-year-old male truck driver complained of a scaling, burning, dark rash of the axillary and crural areas. It began in the groin 13 years before while he was in Vietnam, and for the preceding 2 years it had in- volved both axillae. Examination revealed sharply mar- ginated, scaly, reddish-brown plaques on both axillae, inguinal areas, and on the lateral aspect of the scrotum (Figs. 1 and 2). Under Wood's light examination, all of these areas showed a vivid coral red fluorescence.

From the Department of Dermatology, Peoria School of Medicine, University of Illinois.

Accepted for publication March 25, 1982.

Reprint requests to: Dr. Walter B. Shelley, Peoria School of Medicine, One lllini Dr., P.O. Box 1649, Peoria, IL 61656.

752

On closer inspection, some of the axfllary hairs showed a grayish irregular thickening (Fig. 2, inset). Under Wood's light examination, nearly every hair in the axilla showed a faint gray-white fluorescence. The hairs of the pubis, sternum, forearm, and scalp were normal and did not fluoresce. Examination of the fluorescent hairs under the microscope showed beading concretions along ahnost the entire shaft (Fig. 3). Gram's stain revealed the concretions to be gram- positive pleomorphic rods, and on culture they had the characteristics of aerobic coryneform bacteria.

The feet were hyperhidrotic and malodorous. Wood's light examination was negative. The stratum corneum of the central soles was pitted (Fig. 4), and there was a dramatic topographic sculpturing of the plantar surfaces of the toes (Fig. 5). Stratum corneum biopsies were secured using the Gillette Super Blue Blade technic. Specimens were then mounted on viewing stubs painted with a silver conductive paint for scanning electron microscopy. After a 200-,~ coating of gold, imaging was accomplished with a JEOL JSM 35 scan- ning electron microscope (25 kv, specimen tilt, 30°). This showed the pits to be relatively deep, and bacteria were seen at higher magnification (Figs. 6 to 8).

A diagnosis of coexistent erythrasma, trichomycosis axillaris, and pitted keratolysis was made. Erythromy- tin base was prescribed in an oral dose of 250 mg four times daily, and a solution of 20% aluminum chloride (Drysol) was applied nightly to the soles. Nothing was used topically in the axillary or inguinal area.

Three weeks later, the scaling and burning of the groin and axillae had completely disappeared. Only a

0190-9622/82/120752+06500.60/0 © 1982 Am Acad Dermatol

Volume 7 Number 6 December, 1982 Erythrasma, trichomycosis, and keratolysis 753

Fig. 1. Sharply marginated scaling plaques of crural area.

trace of coral red fluorescence remained at the outer margin of the plaques. The plantar hyperhidrosis and odor were significantly reduced, but the pits remained. The concretions and faint fluorescence of the axillary hairs remained unchanged.

Case 2

This 27-year-old male construction worker com- plained of a dermatitis of his axillae of many months' duration. Examination revealed a reddish-brown scal- ing area in each axilla. The axillary hairs appeared normal, but under Wood's light examination the axillae showed bright coral red fluorescence, and the axillary hairs all showed a faint yellow fluorescence. The pubic hairs and inguinal areas were uninvolved. Examination of axillary hairs under the microscope disclosed that they each had a sleeve of material along the shaft. Gram's stain showed the sleeve to be composed of gram-positive pleomorphic bacteria, which on culture were aerobic and could be classified as corynebacteria. Inspection of the soles showed asymptomatic pitting of both. Wood's light examination of the toewebs was negative.

A diagnosis of coexistent erythrasma, trichomycosis axillaris, and pitted keratolysis was made. One week of erythromycin base (250 mgm four times daily), coupled with clotrimazole (Lotfimin solution) topically in the axillae, completely cleared the Wood's light evi- dence of erythrasma and trichomycosis. Treatment for the keratolysis was declined by the patient.

DISCUSSION

The surface of the human skin swarms, even as the surface of the planet Earth, with myriads of invisible bacteria. Over half of these are gram- positive pleomorphic aerobic rods." Although they

Fig. 2. Scaling, pigmented plaque of axilla. Inset shows concretions on hair shaft apparent only on closer in- spection.

belong to the genus Corynebacterium, they have blithely procreated in a bewildering variety of mongrel strains that virtually defy taxonomy by species? Only one member of the genus, Coryne- bacterium diphtheriae, the famous pathogen and first of the genus to be recognized, is an exception to this. All the rest, with a wondrous primitive capability of adapting to a variable environment, wander through the literature as either nameless diphtheroids or, as the microbiologist would label them, coryneform (club-shaped) bacteria. Dozens of species have been named only to be proved taxonomically unsound. 4 These include C. minu- tissimum and C. tenuis as the causal organisms for erythrasma and trichomycosis axillaris, respec- tively.

Many of the names have proved only to indicate the source of the isolate, e.g., C. pilosum, C. renale, C. vaginale, C. bovis, and C. aquaticum. Others, such as C. haemolyticum and C. pyo-

'7S4 Shelley and Shelley Journal of the

American Academy of Dermatology

Fig. 3. Axillary hair under magnification shows irregular coating of colonies of aerobic gram-positive pleomorphic bacteria.

Fig. S. Keratolysis plantare sulcatum variant of pitted keratolysis. Sculptured pattern of loss of stratum corneum from plantar surface of toes.

Fig. 4. Pitting of the sole.

genes, have been named for their pathogenic ca- pabilities. ~ None have strictly species-definable biochemical, morphologic or cultural characteris- tics, in contrast to most other bacteria. For exam- ple, one attempt to classify 158 isolates on the basis of 110 biochemical and cultural characteris- tics failed to reveal identifiable species. I~ In lieu of speciation, the authors proposed grouping into foul" "phena . " The organisms of each phenon (lI, III, IV, V) had a characteristic DNA base compo-

sition. More recently, a group of fifty-two strains causing nosocomial infections in immune-sup- pressed patients could at best be given the label of group J. K. 7 Even computer analysis of 134 strains with ninety-seven biochemical tests demonstrated only two major groupings based on glucose oxi- dation, s In another study based on metabolic end products detected by gas-liquid chromatography, three groups of corynebacteria were revealed. 9 The labile character of the organisms is demon- strated by the fact that the presence of Tween 80 is essential for the growth of certain lipophilic cory- nebacteria isolates, but this requirement may dis- appear after several subcultures. TM

Hence, the common base for the triad of dis- eases remains simply coryneform bacteria. In erythrasma the pathogen always has the capacity to grow in the stratum corneum in such abundance as to exhibit a coral red fluorescence and to induce a mild inflammatory scaling. 11 In trichomycosis,

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Erythrasma, trichomycosis, and keratolysis 755

Fig. 6. Pitted keratolysis. Opening of pit on sole, as seen on electron scanning microscopy. (Original magnification, x 100.)

Fig. 7. Pitted keratolysis. View into pit. (Original magnification, × 2,000.)

the pathogen has the remarkable property of adherence to the hair, so that grossly visible col- onies arise which do not wash off. ~2 In pitted keratolysis, the coryneform bacteria have the pro- teolytic enzymatic capacity to digest keratin, leav- ing "footprints" of their otherwise invisible presence. ~a

Thus, no matter what strains of corynebacteria produce these three visible diseases, each by med- ical definition has to have the unique consistent metabolic capability to become evident. Grouping is possible on the basis of the organisms' interac- tion with the varied substrates of intertriginous skin, hair, and plantar stratum corneum. Thus, by

756 Shelley and Shelley Journal of the

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Fig. 8. Pitted keratolysis. View of wall of pit showing bacteria. (× 3,000.)

their disease "ye shall know them." As physi- cians, we are perceiving "C. erythrasmae," "C. pilosum," "C. keratolyticum," despite their ab- sence of identity when isolated and cultured in the laboratory of the microbiologist.

The coexistence of these three corynebacterial diseases in our patients is remarkable. It has not been noted previously, although the coexistence of erythrasma and tinea cruris, as well as pedis, has been reported.~4 The superficial external nature of the three diseases makes it unlikely that our pa- tients were suffering from an immune deficit. More likely, favorable environmental factors had a determinant role. Axillary hyperhidrosis favors a tremendous overgrowth of coryneform bacteria, resulting in gross colonies on the hair shafts. Simi- larly, plantar hyperhidrosis could promote the growth of coryneform bacteria to the extent that their keratolytic action would cause potholes in the thick stratum corneum. Hyperhidrosis of inter- triginous folds, coupled with the failure to use deodorant sprays, antiseptic foot powders, and antibacterial soaps, likewise favors the over- growth of the fluorescing corynebacteria causing erythrasma.

It should be emphasized that erythrasma was the only condition of concern to both the patient and,

in turn, the clinician. The other two of this trio of diseases were discovered by inspection. The hair ensheathment was not arresting in appearance, es- pecially since attention was focused on the drama- tic background of erythrasma. Indeed, the specific diagnostic use of the Wood's light only served to distract. The faint fluorescence of the axillary hairs was pale and insignificant against the bril- liant coral red of the erythrasma.

In the search for the corynebacterial triad, we emphasize that the Wood's light is a useful diag- nostic tool for trichomycosis axillaris, although at times ignored, la It is essential that a lamp of ade- quate size be turned on long enough to attain full intensity and that the clinician take a minute or two for his own dark adaptation. Control observa- tions for questionable fluorescence can be made on hairs elsewhere. As for pitted keratolysis, it is enough to remember to ask the patient to remove his shoes and socks. Recall when examining the toewebs for red fluorescence that erythrasma may involve the perianal area, as well as other inter- triginous zones. 1~ It may also present in a puzzling disciform version. 17 At times, interdiction of washing for a few days may be essential for a valid Wood's light examination.

Treatment of this triad is remarkably effective.

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Erythrasma, trichomycosis, and keratolysis 757

Erythrasma responds to a variety o f topical mea- sures ranging f rom old Whitf ield 's ointment to the new miconazole cream, but mos t clinicians elimi- nate the corynebacter ia with a 5-day course of erythromycin orally. ~1 Noteworthy is the fact that miconazole is active against gram-posi t ive bac- teria as well as fungi. TM The corynebacteria of t r ichomycosis , as well as pitted keratolysis, are so cl indamycin-sensi t ive that topical applications of c l indamycin readily induce a c u r e ? ",'2° In the

case o f t r ichomycosis , shaving when acceptable gives an instant cure and certainly is the perfect prophylaxis. The nightly use of 20% aluminum chloride in anhydrous ethyl alcohol is our own preference for treating t r ichomycosis axillaris and pitted keratolysis , or erythrasma of the toewebs. Not only is it bactericidal but also it eliminates the hyperhidrosis which favors recurrence of the problem. '-'~

General ly, patients with corynebacterial in- fections ,are less scrupulous in cleansing their skin than others are. The two individuals reported here

were no exception to this rule. Accordingly, as a prophylactic measure they were instructed to bathe carefully daily using an antibacterial soap. This should reduce, both by mechanical and chemical means, the corynebacterial surface flora to numbers below the pathogenic range. Interestingly, despite the fact that recent studies show aerobic coryne- bacteria are responsible for axillary odor, .)., these patients did not have an unusual malodor at the time of their clinical visits. Possibly species dif- ferences in the corynebacter ia or the use of a pre- visit deodorant accounts for this.

Next t ime you see any one of these corynebac- terial infections, look for the other two. They can come in threes.

Marcia Miller, Ph.D., performed the bacteriologic studies, and Robert Caughey assisted in the electron microscopic investigations.

REFERENCES

1. Shelley WB, Wood MG: The stratum corneum biopsy for instant visualization of fungi. J AM ACAD I)ERMATOL 2:56-58, 1980.

2. Pitcher DG, Jackman PJH: The current status of aerobic cutaneous coryneforrn bacteria, in Maibach HI, Aly R, editors: Skin microbiology relevance to clinical infec- tion. New York, 1981, Springer-Verlag, pp. 19-28.

3, Pitcher DG: Aerobic cutaneous coryneforms: Recent taxonomic findings. Br J Dermatol 98:363-370, 1978.

4. Rogosa M, Cummins CS, Lelliott RA, Keddie RM: Coryneform group of bacteria, in Buchanan RE, Gib- bons NE, editors: Bergey's manual of determinative bac- teriology, ed. 8. Baltimore, 1974, The Williams & Wil- kins Co., pp. 599-632.

5. Ceilley RI: Foot ulceration and vertebral osteomyelitis with Corynebacterium haemolyticum. Arch Dcrrnatol 113:646-647, 1977.

6. Bousfield I J: A taxonomic study of some corynebaeteria. J Gen Microbiol 71:444-455, 1972.

7. Young VM, Meyers WI, Moody MR, Schimpff SC: The emergence of corynefbrm bacteria as a cause of noso- comial infections in compromised hosts. Am J Med 70: 646-650, 1981.

8, Pitcher DG, Noble WC: Aerobic diphtheroids of human skin, in Bousfield I J, Calleley AG, editors: Special pub- lications of the Society for General Microbiology. I. Coryneform bacteria. New York, t978, Academic Press, Inc., pp. 265-287.

9. Hine IE, Hill LR, Lapage SP: Identification of medically important Corynebacterium spp by means of metabolic end-products detected by gas-liquid chromatography. J Appl Bacteriol 45:v-vi, 1978,

10. Smith RF: Characterization of human cutaneous lipo- philic diphtheroids. J Gen Microbiol 55:433-443, 1969.

11. Sarkany 1, Taplin D, Blank H: Erythrasma--common bacterial infection of the skin. JAMA 177:130-132, 1961.

12. Crissey JT, Rebell GC, Laskas JJ: Studies on the causa- tive organism of trichomycosis axillaris. J Invest Der- matol 19:187-197, 1953.

13. Tilgen W: Pitted keratolysis (keratolysis plantare sul- catum). Ultrastructural study. J Cutan Pathol 6: 18-30, 1979.

14. Schlappner OL, Rosenblum CA, Rowden G, Phillips TM: Concomitant erythrasma and dermatophytosis of the groin. Br J Dermatol 100: 147-151, 1979.

15. Jillson OF: Wood's light: An incredibly important diag- nostic tool. Cutis 28:620-626, 1981.

16. Bowyer A, McColl I: Erythrasma and pruritus ani. Acta Dermatol 51:444-447, 1981.

17. Engber PB, Mandel EH: Generalized disciform ery- thrasma. Int J Dermatol 18:633-635, 1979.

18. Pitcher DG, Noble WC, Seville RH: Treatment of ery- thrasma with miconazole. Clin Exp Dcrmatol 4:453-456, 1979.

19. White SW, Smith J: Trichomycosis pubis. Arch Der- matol 115:444-445, 1979.

20. Burkhart CG: Pitted keratolysis: A new form of treat- ment. Arch Dermatol 116:1104, 1980. (Letler to Editor.)

21. Shelley WB, Hurley HJ: Studies on topical antiperspirant control of axillary hyperhidrosis. Acta Derm Venereol 55:241-260, 1975.

22. Leyden JJ, McGinley KJ, Holzle E, Labows JN, Klig- man AM: The microbiology of the human axilla and its relationship to axillary odor. J Invest Dermatol 7'7:413- 416, 1981.

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