CLINICAL HISTORY:

Signs and symptoms:  The patient states that she awoke two days ago with 1-2 slightly raised erythematous nodules on her right foot, that were very tender to walk on. By that afternoon, she had 4-6 lesions on the plantar and lateral sides of both feet. They had become increasingly tender and now prevent ambulation. She denies fever, chills or other constitutional symptoms. She denies exposure to cold, new medications, any recent illness or trauma although she did have a prolonged ballet recital the day before.

Previous Treatment:  None

Other information: 

PHYSICAL EXAM:

Well appearing 12 year old girl with exquisitely tender erythematous dermal to subcutaneous nodules on the plantar and lateral aspects of both feet. The rest of her complete cutaneous exam is without other lesions. Pertinent negatives include lack of: adenopathy, oral or genital lesions or dermatographism.

LABORATORY TESTS:

CBC
WBC ?14.2 x 109/L, other indices WNL

DERMATOHISTOPATHOLOGY:

Pathology Figure #1. There is a prominent peri-eccrine neutrophilic infiltrate; lymphocytes and a rare eosinophil are also seen. The infiltrate extends to the surrounding tissue but frank abscess formation is not seen. The dermal ductal portion of the eccrine gland is not involved. There is no evidence of syringosquamous metaplasia. There is a mild deep dermal perivascular infiltrate of neutrophils, lymphocytes and histiocytes. There is no evidence of leukocytoclastic vasculitis. Fungal and bacterial stains are negative.

(Pathology Figure #1 - pathology pictures are being referenced in the bibliography.)

Pathology Figure#2. Immunostaining demonstrates the eccrine glands within the infiltrate.

(Pathology Figure #2- pathology pictures are being referenced in the bibliography.)

DIFFERENTIAL DIAGNOSIS:

1.   Plantar urticaria
2.   Atypical erythema nodosum
3.   Idiopathic recurrent palmoplantar hidradenitis
4.   Chilblains
5.  

SCROLL DOWN FOR ANSWER AND DISCUSSION.

CORRECT DIAGNOSIS:

Idiopathic Recurrent Palmoplantar Hidradenitis

DISCUSSION:

Idiopathic Recurrent Palmoplantar Hidradenitis (IRPH), first described in 1988 by Metzker and Brodsky, has also been described as Idiopathic Palmoplantar Hidradenitis, Palmoplantar Hidradenitis and Palmoplantar Eccrine Hidradenitis. It begins abruptly with a few, small tender plantar and occasionally palmer erythematous nodules. These progress in size (up to 3 cm) and number (up to 15) to and become increasingly painful, often becoming disabling. Approximately 50 cases have been described in the literature; however, there is a great deal of discrepancy over both the clinical and histological characteristics of the dermatoses that have been included under the rubric of IRPH.

IRPH most commonly presents in children and young adults and is self-limited. Authors have proposed a myriad of precipitating factors including hyperhidrosis, trauma, physical activity, exposure to wet footwear, and oropharyngeal streptococcal infection. One author suggested a bi-modal seasonal predilection for the spring and autumn. Most patients are without other symptoms although low-grade fever has been reported. The underlying pathology is poorly understood.

The primary histopathologic finding in IRPH consists of a nodular neutrophilic infiltrate localized to the eccrine coils with slight extension to the periglandular tissue. The infiltrate occasionally forms well-circumscribed focal abscesses. In the mid to deep dermis there may be a mild perivascular infiltrate of neutrophils, lymphocytes and few histiocytes. Extravasated erythrocytes may be present. There has been no evidence of leukocytoclastic vasculitis, eccrine syringosquamous metaplasia or microorganisms; including bacteria and fungi. The straight dermal eccrine ducts, acrosyringia and epidermis are typically spared.

The clinical differential diagnosis includes Sweet’s syndrome, traumatic plantar urticaria, atypical erythema nodosum, atypical erythema multiforme, Behcet’s disease and chilblains.

TREATMENT:

IRPH runs a benign self-limited course although recurrences have been reported. Many treatments have been reported, including systemic antibiotics, systemic steroids, nonsteroidal anti-inflammatory drugs (NSAIDS), and potassium iodide solution. Most authors agree that bed rest and symptomatic treatment with NSAIDS is adequate as the lesions typically resolve over approximately one to two weeks.

Actual treatment for this patient:

We treated our patient expectantly with bed rest and NSAIDS and her lesions began to resolve in five days and completely resolved over the following week. She has not had a recurrence.

REFERENCES:

1. Rabinowitz LG, et al. Recurrent Palmoplantar Hidradenitis in Children. Arch of Derm 1995; 131(7): 817-20

2. Simon M, et al. Idiopathic Recurrent Palmoplantar Hidradenitis in Children: Report of 22 Cases. Arch of Derm1998;134(1):76-79

3. Landau M, et al. Palmoplantar Eccrine Hidradenitis: Three New Cases and Review. Ped Derm 1998;15(2):97-102

4. Naimer SA et al. Plantar hidradenitis in children induced by exposure to wet footwear. Ped Emerg Care 2000;16(3):182-183

Additional Comment:

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