Plantar Skin Research Articles

Neurophysiological techniques to detect early small‐fiber dysfunction in transthyretin amyloid polyneuropathy

Transthyretin familial amyloid polyneuropathy (TTR-FAP) is characterized by early selective involvement of small nerve fibers. Initial clinical diagnosis is complicated by psychosocial factors. We evaluated diagnostic accuracy of sural sensory nerve action potentials, plantar sympathetic skin response (SSR), and cortical laser-evoked potentials (LEP) to dorsal foot stimulation in the early diagnosis of TTR-FAP. Sixty-three subjects with TTR-FAP (Val30Met) mutation were split into 2 groups (asymptomatic carriers and early-symptomatic patients) and compared with 33 healthy controls. The diagnostic accuracy of plantar SSR amplitude and LEP N2 latency was similar; all had very high specificity (94 to 97%) but low sensitivity (22 to 32%) in distinguishing controls from carriers and early-symptomatic patients. No control had abnormal results on both tests. Plantar SSR and LEPs have similar diagnostic performance in detecting small-fiber dysfunction in early TTR-FAP; we propose that both tests should be used to investigate this population. Muscle Nerve 49: 181-186, 2014.

Comparative Study of High-Resolution Multifrequency Ultrasound of the Plantar Skin in Patients with Various Types of Hereditary Palmoplantar Keratoderma

Background: High-variable-frequency ultrasound is used as an imaging tool for various cutaneous disorders. We utilized this tool in pachyonychia congenita (PC) patients, who typically present with plantar hyperkeratosis and often severely debilitating pain, compared to patients with epidermolytic palmoplantar keratoderma (EPPK) and mal de Meleda (MDM). Objective: To ascertain the feasibility of ultrasound technology for the diagnosis of PC. Methods: The study included a total of 16 patients, 7 with PC, 5 with EPPK and 4 with MDM, who underwent ultrasound examination of the plantar skin with high-resolution multifrequency ultrasound equipment. Results: Ultrasound scans performed over the proximal and distal plantar foot calluses in PC patients demonstrated hyperechoic dots and lines within the epidermis compatible with hyperkeratosis, engorged varicose veins in the dermis and an anechoic layer interposed between the epidermis and the dermis, corresponding to blister fluid below the calluses. In contrast to PC patients, patients with MDM and EPPK demonstrated no blisters. Conclusion: PC patients, as opposed to a group of patients with MDM and EPPK, displayed subepidermal blistering beneath their calluses. This finding may help in the diagnosis of PC and in partially explaining plantar pain as part of PC symptomatology.

Dorsal Dimelia of the Fourth Toe in a Patient With Incontinentia Pigmenti

Development of a second nail plate on either the plantar or palmar surface of a digit, known as a double nail, is an extremely rare malformation. When dorsalization of the plantar skin is also present, the condition is referred to as dorsal dimelia. Additional findings associated with dorsal dimelia may include loss of flexion creases with absent flexion at the interphalangeal joints and tapering of the distal phalanx seen on radiography. We report herein a case of an affected toe in a patient with incontinentia pigmenti (IP).

Pitted keratolysis, erythromycin, and hyperhidrosis

Pitted keratolysis (PK) is a plantar skin disorder mainly caused by coryneform bacteria. A common treatment consists of the topical use of erythromycin. Hyperhidrosis is considered a predisposing factor for bacterial proliferation and, consequently, for the onset of PK. The aim of this study was to evaluate the relationship between PK erythromycin and hyperhidrosis. All patients with PK seen in Sant'Andrea Hospital, between January 2009 and December 2011, were collected. PK was clinically and microscopically diagnosed. All patients underwent only topical treatment with erythromycin 3% gel twice daily. At the beginning of the study and after 5 and 10 days of treatment, a clinical evaluation and a gravimetric measurement of plantar sweating were assessed. A total of 97 patients were diagnosed as PK and were included in the study. Gravimetric measurements showed that in 94 of 97 examined patients (96.90%) at the time of the diagnosis, there was a bilateral excessive sweating occurring specifically in the areas affected by PK. After 10 days of antibiotic therapy, hyperhidrosis regressed together with the clinical manifestations. According to these data, we hypothesize that hyperhidrosis is due to an eccrine sweat gland hyperfunction, probably secondary to bacterial infection.

Reading Man Flap: Application to Plantar Defects

The plantar surface of the foot has highly specialized, densely adherent, glabrous skin, making functional replacement difficult. Glabrous skin defects should be replaced with similar skin to restore function and aesthetics. An innovative technique, the “reading man flap,” was developed for closure of circular skin defects. At locations such as the face, trunk, thigh, and calf, the “reading man” procedure provides tension-free closure with minimal additional healthy skin excision, and it does not cause “dog ear” formation. The potential exists for replacement of plantar defects with skin of the same quality using this procedure. In the present study, we report on 2 clinical cases in which intermediate-size plantar defects were reconstructed using the reading man flap. This method can provide tissue as durable, yet as sensitive, as skin that matches the unique characteristics of the plantar skin.

Intraganglionic AAV6 Results in Efficient and Long-Term Gene Transfer to Peripheral Sensory Nervous System in Adult Rats

We previously demonstrated safe and reliable gene transfer to the dorsal root ganglion (DRG) using a direct microinjection procedure to deliver recombinant adeno-associated virus (AAV) vector. In this study, we proceed to compare the in vivo transduction patterns of self-complementary (sc) AAV6 and AAV8 in the peripheral sensory pathway. A single, direct microinjection of either AAV6 or AAV8 expressing EGFP, at the adjusted titer of 2×109 viral particle per DRG, into the lumbar (L) 4 and L5 DRGs of adult rats resulted in efficient EGFP expression (48±20% for AAV6 and 25±4% for AAV8, mean ± SD) selectively in sensory neurons and their axonal projections 3 weeks after injection, which remained stable for up to 3 months. AAV6 efficiently transfers EGFP to all neuronal size groups without differential neurotropism, while AAV8 predominantly targets large-sized neurons. Neurons transduced with AAV6 penetrate into the spinal dorsal horn (DH) and terminate predominantly in superficial DH laminae, as well as in the dorsal columns and deeper laminae III-V. Only few AAV8-transduced afferents were evident in the superficial laminae, and spinal EGFP was mostly present in the deeper dorsal horn (lamina III-V) and dorsal columns, with substantial projections to the ventral horn. AAV6-mediated EGFP-positive nerve fibers were widely observed in the medial plantar skin of ipsilateral hindpaws. No apparent inflammation, tissue damage, or major pain behaviors were observed for either AAV serotype. Taken together, both AAV6 and AAV8 are efficient and safe vectors for transgene delivery to primary sensory neurons, but they exhibit distinct functional features. Intraganglionic delivery of AAV6 is more uniform and efficient compared to AAV8 in gene transfer to peripheral sensory neurons and their axonal processes.

Knee Arthrodesis in Navajo Familial Neurogenic Arthropathy: A Case Report and Review of the Literature.

Navajo familial neurogenic arthropathy (NFNA) is a rare form of hereditary sensory autonomic neuropathy found in the Navajo population. It usually becomes clinically apparent during the first two decades of life, with unrecognized fractures, Charcot joints as a result of sensory deficits to deep pain, hypohidrosis, and heat intolerance1. Orthopaedic manifestations secondary to NFNA have been described2; however, to the best of our knowledge, reports of treatment outcomes in the literature are limited. An online database search on MEDLINE was conducted with the words “Navajo Familial Neurogenic Arthropathy” as Medical Subject Headings and keywords. Because of the limited amount of published information on the subject matter, no language restrictions or limitations were applied. This case report describes a fifteen-year-old Native American boy with NFNA that resulted in complete destruction of the right knee. He was treated with knee arthrodesis; follow-up occurred nearly two years postsurgery. Despite residual limb-length inequality and peroneal nerve palsy, knee arthrodesis restored the boy’s ability to walk. The patient and his parents were informed that data concerning the case would be submitted for publication, and they provided consent. An eight-year-old Navajo boy presented for pediatric orthopaedic consultation with a painless right knee effusion several weeks after injuring the knee while wrestling with his father. The patient had no notable medical history, and there was no family history of musculoskeletal problems. It was noted that he frequently became overheated. Physical examination revealed a knee effusion, a posterior drawer sign, a positive Lachman sign of approximately 8 mm, and a grade-I pivot shift. The patient exhibited dry, thickened palmar and plantar skin, absent muscle stretch reflexes, and generalized lack of pinprick sensation. Radiographs of the knee revealed a large joint effusion, osseous sclerosis, and osseous defects involving the lateral femoral condyle and patella (Fig. …

Role of Pituitary Adenylate-Cyclase Activating Polypeptide and Tac1 gene derived tachykinins in sensory, motor and vascular functions under normal and neuropathic conditions

Pituitary Adenylate-Cyclase Activating Polypeptide (PACAP) and Tac1 gene-encoded tachykinins (substance P: SP, neurokinin A: NKA) are expressed in capsaicin-sensitive nerves, but their role in nociception, inflammation and vasoregulation is unclear. Therefore, we investigated the function of these neuropeptides and the NK1 tachykinin receptor (from Tacr1 gene) in the partial sciatic nerve ligation-induced traumatic mononeuropathy model using gene deficient (PACAP−/−, Tac1−/−, and Tacr1−/−) mice. Mechanonociceptive threshold of the paw was measured with dynamic plantar aesthesiometry, motor coordination with Rota-Rod and cutaneous microcirculation with laser Doppler imaging. Neurogenic vasodilation was evoked by mustard oil stimulating sensory nerves. In wildtype mice 30–40% mechanical hyperalgesia developed one week after nerve ligation, which was not altered in Tac1−/− and Tacr1−/− mice, but was absent in PACAP−/− animals. Motor coordination of the PACAP−/− and Tac1−/− groups was significantly worse both before and after nerve ligation compared to their wildtypes, but it did not change in Tacr1−/− mice. Basal postoperative microcirculation on the plantar skin of PACAP−/− mice did not differ from the wildtypes, but was significantly lower in Tac1−/− and Tacr1−/− ones. In contrast, mustard oil-induced neurogenic vasodilation was significantly smaller in PACAP−/− mice, but not in Tacr1−/− and Tac1−/− animals. Both PACAP and SP/NKA, but not NK1 receptors participate in normal motor coordination. Tachykinins maintain basal cutaneous microcirculation. PACAP is a crucial mediator of neuropathic mechanical hyperalgesia and neurogenic vasodilation. Therefore identifying its target and developing selective, potent antagonists, might open promising new perspectives for the treatment of neuropathic pain and vascular complications.

Decreased skin temperature of the foot increases gait variability in healthy young adults

We investigated the effects of reduction in plantar skin temperature on gait. Thirty-four healthy subjects (20 men and 14 women; mean age 22.2±2.5 years; mean height 166.8±8.3cm) walked 16m under two different conditions – normal conditions (NC) with the skin at a basal temperature, and cold conditions (CC) after cooling of the plantar skin to about 15°C. Wireless motion-recording sensor units were placed on the back at the level of L3 and on both heels to measure acceleration and angular velocity. Gait velocity and mean stride, stance and swing times were calculated. The variability of lower limb movement was represented by the coefficients of variation (CVs) of stride, stance and swing times, and that of trunk movement was represented by autocorrelation coefficients (ACs) in three directions (vertical: VT; mediolateral: ML; and anteroposterior: AP). Gait velocity was significantly lower under CC conditions than under NC (p<0.0001). None of the temporal parameters were changed by plantar cooling. However, all parameters of gait variability were significantly worse under CC, and AC-VT, AC-ML, and AC-AP were significantly lower under CC than under NC, even after adjusting for gait velocity (p=0.0005, 0.0071, and 0.0126, respectively). Our results suggest that reducing plantar skin temperature induces gait variability among healthy young adults. Further studies are now needed to explore the relationship between plantar skin temperature and gait in the elderly.

Association of Denervation Severity in the Dermis with the Development of Mechanical Allodynia and Hyperalgesia in a Murine Model of Postherpetic Neuralgia

Postherpetic neuralgia (PHN) is a common complication of herpes zoster and remains a challenging condition of neuropathic pain. Allodynia, a prominent feature of PHN, extends beyond the margins of the initial rash area. In the present study, we investigated the association between cutaneous denervation and the development of postherpetic allodynia and hyperalgesia by using a murine model of PHN. Female C57BL/6j mice were used. Herpes simplex virus type-1 (HSV1) was inoculated on the unilateral shin, a region that is predominantly innervated by L3 dorsal root ganglion (DRG) neurons. After the zoster-like skin lesions healed, mice were classified by the presence of mechanical allodynia and hyperalgesia in the plantar aspect of the ipsilateral hindpaw. Scarred lumbar (innervated by L2-4 DRG neurons) and the ipsilateral plantar (innervated by L3-5 DRG neurons) skin sections were immunostained with an antibody against protein gene product (PGP)9.5. The number of PGP9.5-immunoreactive (IR) profiles in the epidermis and dermis were analyzed for quantification of cutaneous innervation. In the epidermis of the scarred lumbar skin, the intraindividual mean number of PGP9.5-IR profiles was significantly decreased in mice inoculated with HSV1. The intraindividual maximum and mean numbers of PGP9.5-IR profiles in the epidermis of the scarred skin were not significantly different between mice with and without postherpetic allodynia and hyperalgesia. In the dermis of the scarred lumbar skin, the intraindividual maximum and mean numbers of PGP9.5-IR profiles were significantly decreased in mice with postherpetic allodynia and hyperalgesia, but not in mice without these symptoms. The intraindividual minimum number of PGP9.5-IR profiles in the dermis and epidermis was significantly decreased by HSV1 inoculation. HSV1 inoculation significantly decreased the intraindividual mean number of PGP9.5-IR profiles in the epidermis, but not dermis, of the plantar skin on the inoculated side. The present results suggest that the severity of dermal denervation in the scarred skin is associated with the development of postherpetic allodynia and hyperalgesia that extend beyond the margins of the initial rash area. The decrease of epidermal nerve density in the scarred and stimulation skins may not be associated with postherpetic allodynia and hyperalgesia.

Vascularized Plantar Myocutaneous Free Flap Transfer for Amputee Stump Preparation: A Proof of Concept Cadaver Study

Lower extremity amputee stump ulceration, irritation, and pain have been a deterrent to consistent long-term or continuous use of lower extremity prosthetics. This study is the first in a series that hypothesizes that these complications can be minimized through the insetting of a vascularized plantar free flap (VPFF) on the amputee stump. Using three hip disarticulated cadaver specimens, a VPFF was designed, dissected, and implanted on one transfemoral and two transtibial stumps. Using accepted vascular anastomosis techniques, the posterior tibial artery was anastomosed to the distal femoral or popliteal artery with corresponding anastomoses for venous drainage. In addition, the possibility of a limited to partial sensate flap may be created with a neurorrhaphy of the associated nerves. This potentially sensate area would provide plantar skin that aids the existing local sensate flap used to close the defect. It is hypothesized that this procedure offers significant rehabilitative and long-term benefits to battlefield or other acute causes for lower extremity amputation. The procedure can be accomplished in battlefield surgical setting as an immediate or delayed inset for some but not all traumatic amputations. Salvaging a partial or complete VPFF from a traumatized foot will obviously be predicated on the degree of trauma to the donor tissue.

Free sensate medial plantar flap for contralateral plantar forefoot reconstruction with flap reinnervation using end‐to‐side neurorrhaphy: A case report and literature review

Reconstruction of weight-bearing plantar defects remains a challenge due to the unique characteristics of the plantar skin and thus the limited available options. The medial plantar flap, either pedicled or free, represents an ideal option, but its use as sensate flap for forefoot defects has been scarcely reported. We present a case of plantar forefoot reconstruction with a free sensate medial plantar flap, with end-to-side coaptation of the cutaneous sensory fascicles of the flap to the medial plantar nerve of the recipient. Last follow-up, at 2 years post-op, verified a very good functional and aesthetic outcome, indicating that the suggested approach may prove the treatment of choice in selected cases of plantar forefoot reconstruction.

2P1-G01 歩行安定性評価を目的とした特徴点検出を用いた足裏皮膚変形計測に関する研究(感覚・運動・計測(3))

This paper reports experimental results on walking feature in young and elder by using plantar skin deformation. We had human subjects (10 normal young males (22±2 years) and 20 normal elders (73±5 years) ) walk on a walkway four times per one trial. Images of plantar skin of the right foot while stance phase were collected by a high speed camera under a transparent force plate. Walking feature was calculated by contact area of plantar skin area and feature point of plantar skin area. The feature points of plantar skin were calculated by using Harris corner image processing method. The contact area of plantar skin area was calculated by binarization. The experimental results suggest that the plantar skin deformation measurement has a potential to estimate the walking stability and risk of falling.

Syndromes That Include Both Palmoplantar Keratoderma And Severe Periodontitis: A Review

Palmoplantar keratodermas (PPK) include a heterogeneous group of disorders with overlapping clinical features. The main aspect of PPK is thickening and hyperkeratosis of the palmar and plantar skin, that may be hereditary or acquired; diffuse, focal, or punctuate; and transgrediens or progrediens. PPKs are further distinguished by their mode of inheritance and by the presence of certain associated clinical features. Periodontitis was reported in association with more than one syndrome characterized by PPK. An extensively reported one is the Papillon-Lefevre syndrome (PLS) which is characterized by early onset of PPK and periodontitis affecting the primary and secondary dentitions. In addition to PLS, Haim-Munk, HOPP, Variant Carvajal and Weary-Kindler are other syndromes manifested by PPK and reported in association with severe periodontitis. Atypical cases of PLS were also reported, such as partial expression or a late presentation of the syndrome. The aim of this articleis to critically review the literature concerned with Papillon-Lefevre syndrome in its typical and atypical clinical presentation, in addition to other syndromes manifested at the same time by PPK and severe periodontitis. Thorough history and medical examination, together with periodontal, dermatologic, and genetic counseling, are important to exclude other existing medical conditions or other syndromes that might need special attention and care.

Pineal gland and neuropathic pain

The pineal gland is a small neuroendocrine organ involved primarily in the circadian rhythm by the secretion of melatonin [1]. In addition, the pain modulatory properties of melatonin are generally recognized but its involvement in neuropathic pain regulation is not fully understood. In fact, it is known that the activation of the endogenous melatonin system in the spinal cord can reduce the generation, development and maintenance of central sensitization [2]. Moreover, melatonin showed an analgesic effect, in fact several works in animals [2] and in humans [3] underline its ability to inhibit hyperalgesia. In particular, intracerebroventricular and intraperitoneal melatonin, with its higher doses, produces a blockade of thermal hyperalgesia in mice with partial tight ligation of the sciatic nerve. The aim of our work is to characterize the morphological changes in peripheral structures, such as plantar skin and dorsal root ganglia (DRG) of rats in a neuropathic pain model (chronic constriction injury) after a single melatonin treatment monitoring the behaviour and the changes in NO-system using immunohistochemical techniques. The behavioural results show an increase of withdrawal latency during plantar test already after 30 min from melatonin administration. The immunohistochemical results suggest that melatonin plays a crucial role in keratinocytes-mediated neuropathic pain transmission through the modulation of nitroxidergic system, which could have also a protective role at this site. In addition, at DRG level the NO-system is maintained at low level. These results suggest that melatonin administration or modulation of pineal gland activity may have clinical utility in neuropathic pain therapy in the future.

Mesenchymal Stem Cell-Like Cells Derived from Mouse Induced Pluripotent Stem Cells Ameliorate Diabetic Polyneuropathy in Mice

Background. Although pathological involvements of diabetic polyneuropathy (DPN) have been reported, no dependable treatment of DPN has been achieved. Recent studies have shown that mesenchymal stem cells (MSCs) ameliorate DPN. Here we demonstrate a differentiation of induced pluripotent stem cells (iPSCs) into MSC-like cells and investigate the therapeutic potential of the MSC-like cell transplantation on DPN. Research Design and Methods. For induction into MSC-like cells, GFP-expressing iPSCs were cultured with retinoic acid, followed by adherent culture for 4 months. The MSC-like cells, characterized with flow cytometry and RT-PCR analyses, were transplanted into muscles of streptozotocin-diabetic mice. Three weeks after the transplantation, neurophysiological functions were evaluated. Results. The MSC-like cells expressed MSC markers and angiogenic/neurotrophic factors. The transplanted cells resided in hindlimb muscles and peripheral nerves, and some transplanted cells expressed S100β in the nerves. Impairments of current perception thresholds, nerve conduction velocities, and plantar skin blood flow in the diabetic mice were ameliorated in limbs with the transplanted cells. The capillary number-to-muscle fiber ratios were increased in transplanted hindlimbs of diabetic mice. Conclusions. These results suggest that MSC-like cell transplantation might have therapeutic effects on DPN through secreting angiogenic/neurotrophic factors and differentiation to Schwann cell-like cells.

Use of split thickness plantar skin grafts in the treatment of hyperpigmented skin-grafted fingers and palms in previously burned patients

Use of split thickness plantar skin grafts in the treatment of hyperpigmented skin-grafted fingers and palms in previously burned patients

Differential effects of activity dependent treatments on axonal regeneration and neuropathic pain after peripheral nerve injury

Activity treatments are useful strategies to increase axonal regeneration and functional recovery after nerve lesions. They are thought to benefit neuropathy by enhancing neurotrophic factor expression. Nevertheless the effects on sensory function are still unclear. Since neurotrophic factors also play a fundamental role in peripheral and central sensitization, we studied the effects of acute electrical stimulation and early treadmill exercise on nerve regeneration and on neuropathic pain, and the relation with the expression of neurotrophins. After sciatic nerve section and suture repair, rats were subjected to electrical stimulation (ES) for 4h after injury, forced treadmill running (TR) for 5days, or both treatments combined. Sciatic nerve section induced hyperalgesia in the medial area of the plantar skin in the injured paw. TR and ES differently but positively reduced adjacent neuropathic pain before and after sciatic reinnervation. ES enhanced motor and sensory reinnervation, and combination with TR induced strong agonistic effects in relieving pain. The differential effects of these activity treatments were related to changes in neurotrophic factor mRNA levels in sensory and motor neurons. ES speeded up expression of BDNF and GDNF in DRG, and of BDNF and NT3 in the ventral horn. TR reduced the levels of pro-nociceptive factors such as BDNF, NGF and GDNF in DRG. Combination of ES and TR induced intermediate levels suggesting an optimal balancing of treatment effects.

Effects of acid sensing ion channels inhibitor amiloride on pain behavior in a rat model of post-incision pain

Objective To explore the effects and underlying mechanisms of acid sensing ion channels(ASICs) on pain behavior in a rat model of post-incision pain. Methods Fifty-eight adult male Sprague Dawley rats were used in this study, four rats were used for immunofluorescence test, thirty rats were employed for pain behavior test, and twenty-four rats were used for Western blot. Rats used for pain behavior test and Western blot were randomly divided into 3 groups: control group (C group), incision pain model group (I group) and amiloride group (A group). Plantar skin of rats in A group were infiltrated with 20 μl(200 μg)amiloride solution. Paw withdrawal mechanical threshold(PWMT) and paw withdrawal thermal latency(PWTL) of all rats in pain behavior test was tested at 24 h preoperative, 2 h, 4 h, 8 h, 12 h, 24 h postoperative. Western blot was tested at 4 h postoperative. Results Immunofluorescence test displayed ASIC3 was expressed in plantar skin of all rats. The basal level of PWMT and PWTL of all rats in three groups was C group((23.15±5.10)g, (11.32±1.21)s), I group((23.26±5.69)g, (11.75±2.01)s), A group((23.63±4.96)g, (11.47±1.96)s) respectively, which was no significantly difference (P>0.05). PWMT and PWTL of I group and A group was significantly lower than that of C group at all time points postoperative (P < 0.05); PWMT and PWTL of A group was at 2 h((13.75±3.25)g, (9.96±1.32)s), 4 h((14.05±3.75)g, (9.17±2.11)s), 8 h((9.75±2.74)g, (8.11±1.22)s) postoperative, which was significantly higher than that of I group(P<0.05). Compared with that of C group, the level of pERK1/2 expression was significantly increased in I group at 4 h postoperative (P<0.05), which could be inhibited by amiloride local infiltration (P<0.05). Conclusion ASIC3 can mediate incision pain in a rat model of post-incision pain, through pERK1/2 signaling pathway, which can be inhibited by amiloride. Key words: Pain; Post-incision pain; Acid sensing ion channels; Amiloride

Pitted keratolysis; physicians’ treatment and their perceptions in Dutch army personnel

Pitted keratolysis (PK) is a common plantar skin manifestation in army personnel, farmers and athletes. Due to pain while walking and marching, the condition can cause reduced operational deployability (in case of army personnel). We used a questionnaire to investigate currently used treatment options of PK and perceptions on perceived efficacy of these treatments among Royal Netherlands Armed Forces primary health care physicians. A cross-sectional anonymous postal questionnaire survey was conducted among all Royal Netherlands Armed Forces primary health care physicians. In addition to question about prescription behaviour on the treatment of PK by topical and oral therapies and given non-pharmacological treatment, several questions assessed perceived efficacy of these therapies. Of the 164 eligible primary health care physicians, 51 (31.1%) completed the questionnaire. Half of physicians had seen less than five patients with PK in the preceding year. Two-thirds of physicians reported problems with operational deployability in less than 10% of army personnel with PK. PK was treated mostly with topical and non-pharmacological treatments. Oral therapy was seldom prescribed. For hyperhidrosis, aluminium chloride hexahydrate was used in most cases. PK and related reduced operational deployability were less often reported than expected in this study. Dutch physicians prefer combined topical antibiotic therapy with non-pharmacological treatments and perceive the efficacy of topical antibiotic therapy superior to non-pharmacological treatments. Preventive measures, topical antibiotic therapy and adequate treatment of hyperhidrosis are the mainstay methods in the management of patients with PK.