DOI: 10.1111/j.1365-3164.2008.00662.
Pathogenesis of canine interdigital palmar and plantar
Blackwell Publishing Ltd
comedones and follicular cysts, and their response to
laser surgery
David D. Duclos*, Ann M. Hargis†,‡,§ and
Patrick W. Hanley§
*Animal Skin and Allergy Clinic, Lynnwood, Washington, USA
†DermatoDiagnostics, Edmonds, Washington, USA
‡Phoenix Central Laboratory, Everett, Washington, USA
§Department of Comparative Medicine, School of Medicine,
University of Washington, Seattle, Washington, USA
Correspondence: Ann M. Hargis, E-mail: hargisann@comcast.net
What is known about the topic of this paper
• Dermatitis with development of nodular lesions and
draining sinuses in interdigital skin in dogs is painful,
often recurrent, and can be difficult to properly diagnose
and manage clinically and surgically.
• There are different causes of interdigital dermatitis and
the role of follicular cysts is controversial.
What this paper adds to the field of veterinary
dermatology
• This paper describes in dogs a previously unrecognized
syndrome consisting of multiple comedones and follicular
cysts in palmar or plantar (ventral) interdigital skin that:
(i) result in sinus tracts that open and drain on the dorsal
interdigital skin surface giving the false impression that
lesions develop dorsally, and (ii) describes a laser surgical
procedure that can cure the syndrome.
Abstract
This study documents the presence of comedones and
follicular cysts of palmar and plantar interdigital skin
as an underlying cause of recurrent dermatitis, and
describes the use of a carbon dioxide laser to surgically
remove lesions. The 28 dogs included in the study had:
(i) recurrent lameness, pain, and nodules, or draining
sinuses in the dorsal interdigital skin, (ii) failed to
respond to antibiotic therapy, and (iii) were negative
for Demodex mites and dermatophytes. All 28 had
laser surgery; nine dogs had two surgical procedures
and two dogs had three surgical procedures for lesion
recurrence. Fifteen dogs had skin samples collected
for histopathology. Clinical features in ventral inter-
digital skin included alopecia, callus-like thickening,
and comedones. Histological features included hyper-
keratosis, acanthosis, comedones and follicular cysts,
furunculosis, draining sinuses, and scarring. Surface
trauma to the ventral interdigital skin appeared to
contribute to lesion development. Laser surgery
allowed removal of multiple layers of cysts and adja-
cent hair follicles and the tracking and removal of
134 © 2008 The Authors. Journal compilation © 2008 ESVD and ACVD. 19; 134–141
sinuses. One dog was euthanized for orthopaedic
lameness 1 month after laser surgery, but post-surgical
follow-up (1.0–8.0 years – mean 3 years) from the
remaining 27 dogs revealed that laser therapy of
affected skin and adjacent hair follicles resulted in
resolution of interdigital lesions in 25. Two dogs con-
tinued to develop interdigital cysts.
Accepted 14 February 2008
Introduction
Interdigital dermatitis (pododermatitis, pedal folliculitis
and furunculosis, interdigital furunculosis) in dogs is a
multifaceted disease that is often recurrent and difficult to
diagnose and treat. Causes are varied and include exogenous
foreign bodies, contact irritants, hypersensitivity reactions,
parasitism (demodicosis, hookworm dermatitis, Pelodera
sp. dermatitis), infections with yeast, fungi, and bacteria,
and disorders associated with immunosuppression.1,2
A variety of types of trauma are thought to contribute
including external contact with irregular or rough surfaces
such as vegetation or gravel, and self-trauma from licking
associated with allergic skin disease.2 It has also been
speculated that trauma to interdigital skin caused by short,
bristly hairs rubbing against the skin of apposed interdigital
webs can play a role.2 In addition, chronic friction, as seen
in callus pyoderma may contribute to obstruction and
subsequent rupture of follicles, especially in dogs with
abnormal foot conformation.2 Recently, a form of lympho-
plasmacytic pododermatitis that responded to immuno-
suppressive therapy has been reported.3 It has been stated
that the cause of interdigital dermatitis (pododermatitis) is
often undetermined, but in no cases are the resulting
lesions cysts.1 In contrast, the presence of follicular cysts
associated with interdigital dermatitis has been documented
in some dogs.2 Clinical lesions include erythema, oedema,
nodules, pustules, ulcers, haemorrhagic bullae, haemorrhagic
draining tracts, and scarring from recurrent episodes.1,2
Histological lesions vary with the cause. Perifolliculitis,
folliculitis, and furunculosis, draining tracts, and scarring
are reported. Treatment includes eliminating specific
aetiological agents when present, soaking paws in
antiseptic solutions, long-term antibiotic therapy, and
surgical debridement.1 In severe cases, podoplasty has
been advocated.4
Herein, the clinical and histological lesions and a proposed
pathogenesis for a subtype of canine recurrent interdigital
dermatitis believed to be secondary to the formation of

multiple comedones and follicular cysts in the palmar or
plantar (ventral) interdigital skin are described. These
comedones and follicular cysts are present in multiple layers
of the ventral interdigital skin. Each is prone to rupture
and, because multiple comedones and cysts are present,
their periodic rupture leads to repeated episodes of
pyogranulomatous dermatitis and fistulous tracts. These
tracts migrate to and drain onto the dorsal interdigital
space, leading to the misinterpretation that the lesions
develop in the dorsal interdigital skin. Failure to recognize
the ventral origin of the cysts and remove them leads to
frequent failure of therapy and repeated episodes of lesion
recurrence. A laser surgical procedure that can cure or
improve lesions is also described.
Materials and methods
Selection of affected dogs
The dogs were evaluated at the Animal Skin and Allergy Clinic
between 1997 and 2006, and were included in the study on the basis
of: (i) recurrent lameness, pain, and nodules, or draining sinuses in
interdigital skin associated with multiple ventral comedones and follicular
cysts; (ii) failure to respond to a 30-day course of oral cefalexin
(Ranbaxy Pharmaceuticals, Inc., Jacksonville, FL, USA) 30 mg/kg/bid
and oral rifampicin (Rifadin®, Hoechst Marion Roussel, Inc., Kansas City,
MO, USA) 5–10 mg/kg/sid; and (iii) undergoing laser surgery for the
lesions. Dogs with interdigital dermatitis from other causes such as
antibiotic-responsive bacterial infection, demodectic mite infestation
or fungal infection were not included. All dogs were given a dermato-
logical evaluation including a complete physical examination, skin
scrapings for parasites, hair examination for fungal spores and
hyphae, and cytological examination for microorganisms, and were
reported to have normal thyroid function by referring veterinarians.
Statistical analyses were performed because it appeared that there
might be a breed, age, sex, body weight, paw, and interdigital web
predisposition. Demographic and clinical characteristics were evaluated
between Labrador retrievers and other breeds affected, and for dogs
with and without post-surgical recurrence of disease. Demographic
characteristics included the age at onset of disease, body weight (kg),
and sex. Clinical characteristics included the number of affected paws
and the location of affected interdigital webs (4/5, 3/4, and 2/3).
Statistical association was assessed by chi-squared analysis for
categorical variables and t-test analysis for continuous variables
using Stata 9.0 (Statcorp. College Station, TX, USA).5 Significance was
determined if the P-value was < 0.05.
Biopsy and surgical procedures
Dogs were initially anaesthetized with propofol (PropoFlo®, Abbott
Laboratories, North Chicago, IL, USA) 5.5 mg/kg given intravenously
and titrated against the patient response, and anaesthesia was thereafter
maintained by isoflurane (Aerrane®, Baxter, Thousand Oaks, CA,
USA) inhalation. Interdigital skin was clipped and prepared for a sterile
surgical procedure, and the affected areas were covered with a
sterile drape.
Skin samples were collected from the ventral interdigital skin of 15
of the 28 dogs via punch or incisional sampling either before or during
the laser surgical procedure. Between one and four samples were
collected from lesional skin in each of the 15 dogs. Skin from one dog
was sampled during three separate laser surgical procedures; nine
had biopsy samples collected from one paw, and six had biopsy
samples collected from two paws. The skin samples were taken from
areas with a variety of clinical lesion appearances to investigate
underlying causes and perpetuating factors. In addition to affected
tissue, samples were taken from clinically normal ventral interdigital skin
(one from a Saint Bernard and two from a Labrador retriever). Blood was
blotted from the skin samples, which were then placed in 10% neutral-
buffered formalin, and processed by standard techniques to paraffin
wax. Sections (4–6 mm) were stained with haematoxylin and eosin.
© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.
Palmar and plantar interdigital follicular cysts
Carbon dioxide (CO2) laser surgery methods
A Luxar LX 20 SP Novapulse® 20-watt laser system (Aesculight Inc,
Woodinville, WA, USA) with a pre-sterilized NovaScan scanning hand-
piece was used. An Acu-Evac® filtration particulate and smoke evacuator
(Acuderm Inc, Ft. Lauderdale, FL, USA) was used to remove aerosolized
tissue and debris. The CO2 laser is named from the medium used to
generate the laser beam. When CO2 gas contained in a vacuum
tube is energized, it emits a beam of light in the near infrared spectrum
(10 600 nm). This beam, is concentrated by lenses and mirrors
through the end of the handpiece, is highly absorbed by water, and
quickly vaporizes tissues with high water content (e.g. cells comprising
cutaneous soft tissue) into carbonized debris.6 Tissues or substances
with low water content such as keratin need more laser energy to
achieve ablation and hence are more slowly removed by the CO2 laser.
The initial laser setting for removal of surface tissue, comedones, and
follicular cysts was continuous wave (CW) at 8–10 watts of power.
Depending on the number of cysts, the duration of the CW mode was
approximately 5–20 min. The remainder of the surgical procedure was
performed with reduced laser settings (super pulse mode at 4–5
watts) necessary to prevent unwanted destruction of normal tissue.
Depending on the severity of lesions, the duration of SP mode was
approximately 5–10 min. The total procedure lasts about 30 –45 min
per foot. The scanner head was slowly passed over the surface of the
surgical site ablating to a depth of approximately 0.3 mm of tissue
with each pass. Ablated tissue and debris were removed with sterile
saline by irrigation or on gauze pads. After final thorough irrigation, the
wound was packed with mupirocin 2% ointment (Taro Pharmaceuticals
Inc., Brampton, Ontario, Canada), and a compression bandage was
applied. The treated site was allowed to heal via granulation tissue.
Post-operative care
The dogs were treated with oral cefalexin (30 mg/kg/bid), and topical
mupirocin 2% ointment, at the time of bandage changes; both pro-
cedures were continued until the surgical wounds healed. Some
dogs required pain management and were given oral deracoxib
(Deramaxx® Novartis Animal Health, Greensboro, NC, USA) at 1–
2 mg/kg/day as needed during the first 7–14 days. Most required
bandaging for 4–5 weeks, and a few for 6 weeks. During the first
2 weeks after surgery, the bandages were changed at least every 3–
4 days while over the next 2–4 weeks a weekly change was usually
adequate. Waterproof coverings, including empty intravenous fluid
bags or commercial dog boots, were used to keep the bandaged
paws dry. The clients were instructed to keep their dog in a restricted
area to prevent activity and trauma to the interdigital skin. Information
on post-operative outcome was obtained during office visits for band-
age changes and assessment for healing and clinical improvement,
and via telephone calls to owners.
Results
The breeds and sexes of the 28 affected dogs are listed in
Table 1. They had a mean weight of 45 kg (range 15.3–74.6),
and a mean age at lesion onset of 2.9 years (range 1–
9 years). The mean duration of clinical signs before laser
surgery was 2.4 years (range 0.5–7 years).
Clinical lesions included nodules (Fig. 1) or draining
sinuses in dorsal interdigital skin. Dorsal lesions were not
always visible unless the hair was clipped. The ventral
interdigital skin opposite the dorsal lesions contained an
area of alopecic, thickened, firm, callus-like skin with multiple
comedones (Fig. 2). Four affected dogs (three Labrador
retrievers and one Labrador retriever husky crossbred) had
thick, hard, rough tissue overlying the area of alopecia and
comedones, and had broadening of the digital pads. This
and the callus-like thickenings suggested that either
weight bearing was occurring in the haired skin adjacent
to the digital pads or that there was frictional trauma
between haired skin and another pad (Fig. 3). Punch biopsy
135
Duclos et al.

Table 1. Demographic characteristics of dogs with interdigital cysts

n (28) %
Age at onset (years)
≤3 21 75.0
>3 7 25.0
Body weight (kg)
< 30 2 7.1
30–50 16 57.1
> 50 10 35.7
Sex
Male 19 67.9
Female 9 32.1
Neutered
Yes 20 71.4 Figure 3. Thick, hard, rough tissue (arrows) overlying the area of
No 8 28.6 alopecia and comedones in ventral interdigital skin adjacent to digital
Breed pad. In this dog the thickened area rubbed against the metacarpal pad.
Labrador retriever 13 46.4 Note the adjacent digital pad (arrowheads).
Other breeds* 15 53.6
*Labrador mix (2) Irish setter (2), Saint Bernard (2), Malamute and
Malamute crossbred (2), and one each Shepherd mix, Bull mastiff,
Great Pyrenees (Pyrenean mountain dog), Rottweiler, Doberman
pinscher, Brittany spaniel, and English bulldog.

Figure 4. An example of a large follicular cyst below the thickened

skin. Note the cyst contents (arrow) and the follicular wall (arrowheads).

bandaging paws) without resolution of lesions. The lesions

Figure 1. Nodular area on dorsal interdigital skin between digits 4
and 5. Note the swelling and erythema, and inflammation about to
rupture through the skin surface (arrow).
Figure 2. Alopecia and comedones (arrows) in ventral interdigital skin
revealing expression of follicular contents (arrowheads) caused by
pressure from the dorsal surface.
sampling (Fig. 4) or laser surgery revealed the presence of
comedones and follicular cysts beneath the thick, alopecic,
callus-like skin. Prior to referral, different veterinarians
treated the dogs with a variety of systemic and/or topical
therapeutic regimes (e.g. antibiotics, steroids, sometimes
surgical lancing, soaking paws in antiseptic solutions, and
were considered to be ‘refractory’ to therapy. The dose,
duration, and frequency of specific medications given
varied with the referring veterinarian and were not
always available. In addition, prior to inclusion, a 30-day
course of an oral cephalexin 30 mg/kg/bid and rifampicin
5–10 mg/kg/sid was given to all 28 dogs, and none
responded to the antibiotic therapy.
The majority of the 28 dogs (26) had cysts involving at
least one front paw, and 14 had cysts affecting both front
paws (Table 2). In contrast only seven had cysts affecting
at least one rear paw, and six had cysts affecting both rear
paws. Twenty-six had lesions in the haired interdigital skin
of the palmar or plantar (ventral) surface (Table 2). One had
cysts at the haired skin paw pad junction only, and another
had lesions in the haired ventral interdigital skin and at the
haired skin paw pad junction. Twenty-six dogs had lesions
between digits 4 and 5 (Table 2), indicating that the ventral
interdigital webs of the lateral digits of the front paws
were the areas most often affected.
For interdigital lesions, no significant differences were
identified with regard to age at onset of lesions, body
weight (kg), sex, number of affected paws, or location of
affected interdigital webs between Labrador retrievers
and other breeds. No significant differences were identified
with regard to age at onset, body weight (kg) or affected
paws or toe webs between dogs that had a recurrence of
disease and those that did not.

136 © 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.
 Palmar and plantar interdigital follicular cysts

Table 2. Locations of interdigital cysts in dogs

n (28) %
Feet affected
One front foot (left or right) 7 25.0
Both front 14 50.0
Both rear 2 7.1
All feet 2 7.1
Other* 3 10.7
At least one front foot† 26 93.0
At least one rear foot† 7 25.0
Sites affected
Ventral haired skin 26 92.9
Haired skin and footpad junction 1 3.6
Both ventral haired interdigital skin, 1 3.6 Figure 6. Ventral interdigital skin with superficial tissue ablated by
and haired skin and footpad junction the laser. Abscesses (large arrows) were identified after layers of
Interdigital webs affected‡ comedones and cysts were removed by laser surgery. Note the
Lateral (4th/5th digital space) 26 92.9 contents (small arrow) expressed from a follicular cyst at the edge of
Central (3rd/4th digital space) 7 25.0 the surgical field.
Medial (2nd/3rd digital space) 3 10.7
*Represents either a dog that had both rear feet and one front foot
affected or a dog that had both front feet and one rear foot affected.
comedones and cysts. As the follicular contents were
†Five dogs are listed twice because they had both a front and a hind
released, frequent cleaning of the surface with sterile
foot affected. Each category (front vs. hind) is a percentage of the
28 dogs. saline (on gauze sponges and by irrigation) was required to
‡Dogs could have multiple webs affected. Each interdigital web space remove debris and keratin, and maintain good visualization
is a percentage of the 28 dogs. of the surgical field.
Multiple layers of comedones and cysts became visible
as the layers of tissue were gradually ablated. Typically,
once one level of comedones and cysts was removed
the tissue became more normal in appearance; however,
continued laser ablation revealed additional levels of come-
dones, cysts, and sometimes small abscesses (Fig. 6). In
most dogs there was at least one and sometimes multiple
haemorrhagic, draining sinuses between the last layer of
cysts and the dorsal interdigital skin.
Placement of a sterile cotton-tipped applicator in the
opening of the haemorrhagic sinus on the dorsal surface
and applying pressure with this applicator helped identify
the location of the draining sinus in the surgical field on the
ventral surface, enabling the laser to be directed dorsally
Figure 5. Ventral interdigital skin with the surface ablated by the
towards the sinus (applicator). This pressure occasionally
laser. Note the lack of haemorrhage. The follicular walls (arrowheads) caused the expression of keratin from the cysts in the
border expressed follicular content (arrows). palmar or plantar skin, thereby providing an additional visual
aid for cyst location. Great care was used when surgery
approached large digital vessels and nerves to avoid
Other health or skin problems in dogs with interdigital damaging them. In some dogs, the laser surgery extended
dermatitis included atopic dermatitis (seven dogs) and completely through the interdigital skin to open on the
orthopaedic lameness (two dogs). Nineteen had no other dorsal interdigital surface.
problems. In an attempt to prevent future development of come-
dones and cysts in follicles adjacent to the surgical site,
Laser surgical procedure hair follicles in normal skin approximately 5 mm around all
Surgery on the paws always began on the ventral surface. sides of the affected area (lateral, proximal, distal, and dorsal)
The CO2 laser ablated the tissue, sterilized the surface, were also ablated.
and sealed the small capillaries, which helped to prevent
haemorrhage and improved visualization of the surgical Skin sample evaluations
site (Fig. 5). The CO2 laser energy quickly ablated tissue The skin samples varied in size from 4 mm to 2.5 cm, but
with high water content (e.g. soft parenchymal tissues most were small and not representative of the entire surgical
bordering cysts), leaving tissue with low water content field. The samples were selected to evaluate specific
(e.g. keratin) unaltered. This differential in speed of ablation features in the surgical site. Histological lesions of the
helped identify the comedones and cysts in the tissue palmar or plantar (ventral) interdigital skin included moderate
during surgery (see Fig. 5). Digital pressure on the dorsal to extensive compact hyperkeratosis and acanthosis of
interdigital space helped to expose and stabilize the epidermal and follicular infundibular epithelium (Fig. 7).
affected tissue, improved visualization of the ventral surgical Multiple follicles were cystically dilated, often extensively.
site, and helped to express the contents of the follicular Thirteen of the dogs sampled had follicular cysts and two

© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD. 137
Duclos et al.
Figure 7. Photomicrograph of ventral interdigital skin. Note compact
hyperkeratosis (arrowheads) covering acanthotic epidermis. Follicular
cysts are present (arrows). Haematoxylin and eosin. Low magnification.
others had draining tracts containing hair or keratin. The
number of cysts in one histological section varied from 1
to 14, but it was not always possible to determine with
certainty if cysts were interconnected outside the plane of
the section. Two dogs had coccoid bacteria and five dogs
had Malassezia sp. in the cysts. Fourteen of the dogs with
interdigital lesions had furunculosis. The released follicular
contents were associated with a granulomatous inflam-
matory response. In some dogs with chronic lesions, hair
shafts were embedded in areas of scarring. Five dogs with
interdigital lesions had histologically visible tracts from
areas of furunculosis to other areas of the skin sample.
Two skin samples from clinically normal ventral interdigital
skin had no significant lesions. In the remaining sample,
the epidermis was moderately acanthotic and covered by
compact stratum corneum. In this sample, there was mild
follicular hyperkeratosis and dilation, with small numbers
of periadnexal lymphocytes, plasma cells, a few neutrophils
and histiocytes. One small focus of granulomatous
furunculosis was identified, compatible with a subclinical
lesion.
Post-surgical outcome
Twenty-five of 27 dogs with the palmar/plantar interdigital
comedo and follicular cyst syndrome were cured by
laser surgery (follow up time 1–8 years; mean 3 years).
The 28th dog was euthanized for orthopaedic lameness 1
month after laser surgery preventing acquisition of long-
term follow-up information. Seventeen dogs required one
laser surgical procedure, nine required two procedures
and two required three procedures. Two of the dogs con-
tinued to develop interdigital cysts after lesion ablation;
repeat surgery has been recommended for one, but as the
cysts in the other dog were mild additional surgery was
not considered necessary. In addition, three dogs developed
ventral interdigital cysts on a previously unaffected paw.
Discussion
The pathogenesis of interdigital follicular cysts in the dogs
appeared to result from external surface trauma to the
138
haired skin of the palmar and plantar webs causing epidermal
and follicular infundibular hyperkeratosis and acanthosis,
plugging or narrowing of the follicular ostia, and retention
of follicular contents (Fig. 8). Since the compound hair
follicles of dogs can have 15 or more secondary follicles
entering and exiting one compound follicle unit,7 the
narrowing or plugging of one follicular ostium could lead
to the formation of multiple cysts. Dilated cysts are prone
to rupture, which creates a foreign body inflammatory
response and often a secondary bacterial infection. The
presence of the released follicular contents causes an
endogenous foreign body reaction and is the probable
reason why lesions fail to completely respond to antibiotic
therapy. Exudate from ruptured follicles can coalesce
and lead to the formation of draining sinuses. However,
because both the palmar and plantar interdigital skin is
thickened by hyperkeratosis, acanthosis and scarring, it is
unlikely that a draining sinus could easily penetrate this
dense tissue and open on these thickened surfaces.
Instead, as discovered during the laser surgical procedure,
the draining sinuses extend towards the more normal less
inflamed and scarred tissue of the dorsal interdigital
space. Support for this hypothesis comes not only from
the clinical and histological lesions and surgical dissection
in the present study, but also from comparison of the
interdigital lesions to calluses that develop in interdigital
skin and at other sites, and from other studies that
describe development of interdigital lesions in dogs and
measure forces affecting digital pads and limbs.8,9
For example, trauma was proposed as a cause of
interdigital dermatitis and cysts in an epidemiological
study of 732 laboratory beagles in which the interdigital
lesions were described as raised, firm areas located in the
dorsal aspect of the interdigital space. The prevalence of
interdigital lesions in beagles was greater in the front than
the hind paws,8 and in those beagles with a large body
condition score. The lesions developed more commonly in
beagles exposed to one type of suspended cage flooring
(flat bar coated flooring), which may have increased contact
of the ventral interdigital skin with the coated bars, as the
number of affected beagles increased as the time of
exposure to this flooring increased.8 These findings provided
support for the role of surface trauma to the bottom of the
paws in larger/heavier beagles as a contributory factor in
the development of raised, firm dorsal interdigital lesions.
However, as this was an epidemiological study, there was
no accompanying histopathological description, which
prevents the identification of the nature of the lesions and
knowledge of the presence or absence of follicular cysts.
In addition, vertical forces affecting paw pads have been
studied during walking in greyhounds and Labrador
retrievers,9 in both of which the vertical forces in the fore
limb were greater than those in the hind limb.9 Digital pads
3 and 4 were identified as the major weight-bearing pads,
but digital pad 5 and the metacarpal and metatarsal pads
also carried a substantial amount of the load. These findings
indicate that more weight bearing occurs on the front than
on the hind paws of dogs, and that the digital pads 3, 4,
and 5 bear more weight than digital pad 2. This may help
explain the results in the current study where front paws
were more commonly affected than hind paws; where the
interdigital webs between pads 3/4 and 4/5 were more
© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.

Figure 8. Schematic illustration of the proposed process of lesion development. The ventral interdigital skin becomes hyperkeratotic and acan-
thotic, and primary and secondary follicles become dilated with keratin. Hairs on this surface are lost as the lesions become more severe, and the
interdigital skin thickens. Follicles can rupture causing an inflammatory response and the development of draining tracts that migrate dorsally and
open within the dorsal interdigital space.
commonly affected than that between pads 2/3; and
where affected dogs were also heavy large breeds.
The study of vertical forces affecting paw pads in
greyhounds and Labrador retrievers also revealed a breed
difference in paw conformation.9 Greyhounds had long,
narrow paws with little distance between the digital pads.
In contrast, the Labradors had wide-based paws with
greater distance between pads.9 This latter characteristic
suggests the possibility that weight bearing, especially in
a heavy dog, might be more likely to be distributed to
haired interdigital skin adjacent to digital pads. Interestingly,
the four dogs with the thick, firm, rough tissue covering
callus-like areas in interdigital skin in the present study
were Labrador retrievers (three dogs) and a Labrador
retriever husky crossbred.
Finally, callus formation with dermatitis (callus pyoderma)
of the skin over the sternum, elbow, or hock joints has
clinical, histological, and aetiological similarities to the cases
of chronic interdigital dermatitis and follicular cyst forma-
tion in the dogs in the current study.2 Clinically, calluses
are alopecic thickened areas of skin subject to repeated
pressure or frictional trauma.2 Histologically, they frequently
contain dilated hair follicles filled with keratin (e.g. come-
dones and follicular cysts).2 These dilated follicles can rupture
causing furunculosis, a foreign body response to the
released follicular contents and a secondary bacterial
infection. Fistulas may develop in some cases. It has also
been suggested that friction or other trauma to interdigital
© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.
Palmar and plantar interdigital follicular cysts
skin may promote formation of keratin-filled follicles that
can rupture as seen in callus pyoderma.2 Thus the studies
of interdigital lesions in laboratory beagles, studies of
vertical forces on paw pads of dogs, and similarities to
callus formation in interdigital skin and at other sites help
provide evidence for weight bearing and interdigital
trauma as contributing causes for lesions in the dogs in
the present study.
Laser surgery was a useful method for resolving lesions
because it was effective in 25 of 28 dogs in which follow-
up of at least 1 year was available. As the laser cauterizes
the small capillaries and prevents bleeding, it facilitates
differentiation between affected and normal tissue. In
super pulse mode it allows removal of minute amounts
of tissue with each pass, thereby avoiding unnecessary
damage to the surrounding tissue and making the laser an
ideal surgical tool for this condition. Moreover, the CO2
laser ablation procedure facilitates removal not only of the
follicular comedones and cysts, but also the adjacent
hair follicles, which may help prevent recurrences. Even
so nine dogs required two laser surgical procedures, two
required three procedures, and two of the dogs continued
to develop interdigital cysts.
The reason why interdigital cysts in the palmar or plantar
skin recurred in some dogs but not others is unclear.
No other contributory disease process was identified. The
most likely explanation is development of comedones and
follicular cysts in remaining hair follicles near the surgical
139
Duclos et al.

site or between other digits due to continued external
trauma. The capacity to develop ventral cysts in other digits
was demonstrated in three dogs in the present study where
such cysts developed in a previously unaffected paw.
Because there are many causes of interdigital dermatitis
that can successfully be treated medically or with less
extensive surgical procedures, prior to contemplating
laser surgery, it is necessary to evaluate and exclude those
cases that are not due to the ventrally developing comedo
and follicular cyst syndrome. Clinical evaluation of the
palmar and plantar interdigital skin for alopecia, come-
dones, and callus-like lesions; thorough dermatological
evaluation for other aetiological factors (bacterial, para-
sitic, yeast, fungal infections, exogenous foreign bodies,
inflammation associated with allergies, etc.); an appropriate
antibiotic trial; and/or skin sampling of ventral interdigital
areas should enable identification of dogs with interdigital
cyst syndrome. Also, as presenting signs in dogs with
the comedo and follicular cyst associated interdigital
dermatitis include pain manifested as lameness and
sometimes licking, it is also important to exclude dogs in
which lameness is due to involvement of other tissues
such as the bones or joints. In this study, one dog with the
interdigital cyst syndrome also had orthopaedic lameness
involving the elbow joint. This dog was euthanatized 1
month after laser surgery of interdigital skin when it was
realized that a significant proportion of the lameness was
orthopaedic in origin; although the interdigital lesions had
healed, the dog remained lame and in pain.
In summary, the results reveal that the ventral interdigital
skin in some dogs develops follicular cysts, which can
rupture, cause inflammation and bacterial infection, and
form fistulas that drain onto the dorsal interdigital surface.
The lesions appear to arise from external trauma to the
ventral interdigital skin. Most lesions can be successfully
treated by laser surgery, but affected dogs should be
clearly identified as having the palmar plantar interdigital
cyst syndrome before having this invasive laser surgery
performed.
Acknowledgements
The authors acknowledge H. Denny Liggitt for pathology
consultations, and Benjamin J. Weigler and Ronald F.
DiGiacomo for statistical consultations.
References
1. Scott DW, Miller Jr. WH, Griffin CE. Muller and Kirk’s Small Animal
Dermatology, 6th edn. Philadelphia, PA: W.B. Saunders, 2001:
304–6.
2. Gross TL, Ihrke PJ, Walder EJ, Affolter VK. Skin Diseases of the
Dog and Cat Clinical and Histopathologic Diagnosis, 2nd edn.
Ames, IA: Blackwell Science Ltd, 2005: 184–5, 431–5.
3. Breathnach RM, Baker KP, Quinn PJ et al. Clinical, Immunological
and histopathological findings in a subpopulation of dogs with
pododermatitis. Veterinary Dermatology 2005; 16: 364–72.
4. Swaim SF, Lee AH, MacDonald JM et al. Fusion podoplasty for the
treatment of chronic fibrosing interdigital pyoderma in the dog.
Journal of the American Animal Hospital Association 1991; 27:
264–74.
5. Moore DS, McCabe GP. Introduction to the Practice of Statistics,
5th edn. New York: W.H. Freeman, 2005: 581–609.
6. Peavy GM. Lasers and laser–tissue interaction. Veterinary Clinics
of North America Small Animal Practice 2002; 32: 517–34.
7. Calhoun ML, Stinson AW. Integument. In: Dellmann HD, Brown EM,
eds. Textbook of Veterinary Histology. Philadelphia, PA: Lea &
Febiger, 1987: 382–415.
8. Kovacs MS, McKiernan S, Potter DM et al. An epidemiological
study of interdigital cysts in a research beagle colony. Contemporary
Topics in Laboratory Animal Science 2005; 44: 17–21.
9. Besancon MF, Conzemius MG, Evans RB et al. Distribution of
vertical forces in the pads of greyhounds and Labrador retrievers
during walking. American Journal of Veterinary Research 2004; 65:
1497–501.

Résumé Cette étude rapporte la présence de comédons et de kystes folliculaires au niveau de la peau
palmaire et plantaire interdigitée comme une cause de dermatose récidivante, et décrit l’utlilisation d’un
laser au dioxyde de carbone pour éliminer surgicalement les lésions. Les 28 chiens inclus dans cette étude
avaient: 1) une boiterie récurrente douloureuse et des nodules ou des fistules au niveau interdigité, 2) une
absence de réponse à l’antibiothérapie et 3) absence de Demodex et de dermatophytes. les 28 chiens
ont eu une chirurgie au laser, neuf ont eu deux chirurgies et deux trois chirurgies à cause de récidives. Un
examen histopathologique a été réalisé pour 15 chiens. Les signes cliniques en zone interdigitée ventrale
incluaient alopécie, épaississement et comédons. Les signes histopathologiques regroupaient une
hyperkératose, une acanthose, la formation de comédons et de kystes folliculaires, une furonculose, des
fistules et une fibrose. Des traumatismes de surface à la peau interdigitée semblaient aggraver les lésions.
Le laser a permis l’élimination de nombreuses couches kystiques et l’élimination des follicules adjacents
et des fistules. Un chien a été euthanasié pour boiterie un mois après le laser, mais une résolution a été
observée chez 25 cas après un suivi de (1.0 à 8.0 ans – moyenne 3 ans). Deux chiens ont présenté des
récidives.

Resumen Este estudio demuestra la presencia de comedones y quistes foliculares en la piel intedigital
palmar y plantar como causa de dermatitis recurrente y describe el uso de láser de dióxido de carbono para
retirar las lesiones quirúrgicamente. Los 28 perros incluidos en el estudio tenían: 1) cojera recurrente, dolor
y nódulos o senos de drenaje en la piel interdigital dorsal, 2) no respondieron a tratamiento con antibióticos,
y 3) fueron negativos para Demodex y dermatofitos. Todos los perros se trataron con cirugía de láser; nueve
perros tuvieron dos procedimientos quirúrgicos y dos perros tuvieron tres debido a lesiones recurrentes.
Se tomaron muestras de piel para histopatología de quince perros. Las características clínicas en la piel
interdigital ventral incluyeron alopecia, engrosamiento tipo callosidad y formación de comedones. Las
características histopatológicas incluyeron hiperqueratosis, acantosis, formación de quistes y comedones,
furunculosis, senos de drenaje y cicatrización. Trauma superficial en la piel interdigital ventral parecía

140 © 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.
 Palmar and plantar interdigital follicular cysts

contribuir al desarrollo de las lesiones. La cirugía con láser permitió retirar niveles múltiples de quistes y los
folículos adjacentes así como la localización y extirpación de los senos de drenaje. Un perro fue eutanasiado
debido a cojera ortopédica un mes después de la cirugía con láser, pero el seguimiento post-operatorio
(1–8 años, media 3 años) del resto de los 27 perros indicó que el tratamiento con láser de la piel afectada
y los folículos adjacentes produjo resolución de las lesiones interdigitales en 25 perros. Dos perros continuaron
desarrollado quistes interdigitales.

Zusammenfassung In dieser Studie wird das Auftreten von Komedonen und follikulären Zysten der
palmaren und plantaren Zwischenzehenhaut als zugrunde liegende Ursache einer wiederkehrenden
Dermatitis dokumentiert. Die Verwendung eines Kohlendioxidlasers zur chirurgischen Entfernung dieser
Veränderungen wird beschrieben. Die 28 Hunde, die in die Studie aufgenommen wurden, hatten: 1)
rezidivierende Lahmheit, Schmerz und Knoten oder abfließende Sinusse in der dorsalen Zwischenzehenhaut,
2) reagierten nicht auf Antibiose und 3) waren negativ für Demodexmilben und Dermatophyten. Bei allen
28 Hunden wurde Laserchirurgie durchgeführt; neun Hunde hatten zwei und zwei Hunde hatten drei
chirurgische Interventionen aufgrund von erneutem Auftreten der Läsionen. Bei fünfzehn Hunden wurden
Hautproben für eine histopathologische Untersuchung genommen. Der klinische Befund der ventralen
interdigitalen Haut bestand aus Alopezie, kallusartiger Verdickung und Komedonenbildung. Der histologische
Befund bestand aus Hyperkeratose, Akanthose, Komedonen und follikulärer Zystenbildung, Furunkulose,
abfließenden Sinussen und Narbenbildung. Ein oberflächliches Trauma der ventralen Zwischenzehenhaut
schien zur Entstehung der Läsionen beizutragen. Die Laserchirurgie ermöglichte das Entfernen von Zysten
in zahlreichen Schichten und der angrenzenden Haarfollikel und das Auffinden und die Entfernung der
Sinusse. Ein Hund wurde einen Monat nach der Laserchirurgie aufgrund von orthopädischer Lahmheit
eingeschläfert, aber die Kontrolluntersuchung nach der Chirurgie (1.0 bis 8.0 Jahre – Durchschnitt 3 Jahre)
der übrigen 27 Hunde zeigte, dass die Laserchirurgie der betroffenen Haut und der angrenzenden Haarfollikel
bei 25 Hunden in einer Heilung der interdigitalen Veränderungen resultierte. Zwei Hunde entwickelten
weiterhin interdigitale Zysten.

© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD. 141