[8] This condition typically arises when the feet are exposed to prolonged periods of warmth and humidity, creating an environment suitable to the growth of K. sedentarius and other bacteria.

[9] While the process is not fully known, research suggests that K. sedentarius produces proteases, namely P1 and P2, which degrade various substrates found in human skin, including azocasein, insulin β-chain, and keratin.

[10] This enzymatic breakdown of keratin, a major component of the skin's horny layers,[8] results in the signature pitted appearance observed in affected areas.

Studies indicate that these proteases work best within a slightly acidic pH range of 6.3–6.9,[10] which is why it is important to maintain proper foot hygiene to prevent pitted keratolysis.

Additionally, these enzymatic reactions can generate sulfur compounds such as thiols, sulfides, and thioesters, contributing to the foul odor associated with the condition.

It was likely that the chemo caused injuries in the mucosal barrier, which allowed the bacteria to penetrate the gut and reach the lungs through the bloodstreams.