Itchy Centre of Corns?

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Hi All,
Just wondering if I could have some help with a patient who has be a bit bamboozled, but the answer is probably right in front of me.
The patient in question is a 44 year old woman with raynauds and scleroderma. Her podiatric problems are 2 large corns/HD's on the 2nd metatarsal heads for which we see her regularly. They are very large and also very painful to enucleate. For the past couple weeks the patient has remarked that the centre of the corns are really itchy and that the itching is not even relieved right after enucleation, she can also feel it at night and it has woken her up in the past.
She's been to her GP about it but he has apparently just told her to ask us good old Pod's.
Does anyone have any ideas on this please?
Any help much appreciated

 

Hi Kerrie,

What type of scleroderma does the pt have? There are 3 main groups of pts with scleroderma or sytemic sclerosis;

1. limited – history of raynauds
2. diffuse – internal involvement
3. morphea – patches (mainly in children)

The lesions that you are describing sound very much like calcinosis, which is often present with scleroderma. These look like HD`s but are in fact not! Enucleation is not recommended as they are liable to ulcerate over bony prominences as the skin is stretched and there is vascular deficiency (could explain the itch?). They need protecting/offloading with lots of cushioning (soft and squishy technology).

Hope this helps
Bel

 

Hi,
Thank you so much for the reply. That actually sounds bang on really as she also reported that they really feel like they also stretch when she walking.
With regards to the scleroderma it is limited, she has severe raynauds.
Now this may be a very silly question but do these calcinosis almost 'sweat' on debridement as when they are lightly debrided it appears that they are sweating, not exude as there is no odour or colour but the surrounding callus becomes moist.
Is there any way that the diagnosis of calcinosis can be made exactly and can anything be done for the itching?
Sorry for all the bombarding of questions just never come across this before and finding it very interesting
Thanks again

 

Hi Kerrie,

No problem, dermatology IS fascinating eh?:drinks

The systemic forms of scleroderma, which it sounds like your pt has, can cause these small white calcium lumps to form under the skin, ofetn in painful clusters.

The lesions do leak a chalky white liquid, this is part of the clinical diagnoses, along with med hx for CREST syndromes.

As i said before, DON`T attempt to debride/enucleate these as they are liable to ulcerate. Protect them instead. If you need advice on soft and squishy technology to cushion lesions, Robert Isaacs is your man.

With regards to any discomfort/itching that your pt is experiencing, some studies have shown that Colchicine (used for acute episodes of gout) can be used to reduce the inflammation associated with calcinosis.

Cheers,
Bel

 

Hi Kerrie, Bel

Would x ray confirm calcinosis or would diagnosis be purely clinical?

cheers,

Jackie

 

Hi Jackie,

X-ray probably will identify calcinosis, but clinical dx of SSc and calcinosis is usually ascertained through med history, particulalry if the pt falls within the CREST syndrome;

Calcinosis, Raynaud's, loss of muscle control of the Esophagus, which can cause difficulty swallowing; Sclerodactyly, a tapering deformity of the bones of the fingers; and Telangiectasia.

That said, X-ray is often used to detect calcification of the soft tissues and/or arteries, which is also associated with SSc.

Cheers,
Bel

 

Hi Kerrie,

This also came to light within my clinic almost 4months ago, a female of 50 years had seen several FHPs with regards to a lesion on her left 3rd apex. Initially the appearance suggested HD however i was not 100% and had a nagging flashback in my head of a lecturer of mine talking about the importance of NEVER enucleating what you are not sure of!

I sent the patient away having protected the lesion for 24 hours while i investigated. On her return i explored several possibilities and her medical history showed raynauds and other vascular conditions. The patient also mentioned she had a similar lesion on her finger which had broken through the skin with a chalky discharge and it soon became apparent that these lesions were in fact calcinosis - fitting two of the five for CREST or CRest in this case.

It really makes you think twice before getting the scalpel out for enucleation!
Thankyou Bel for your direction towards Robert Isaacs.

However i have not had the sensation of itchiness reported? Have you investigated this further?

 

Don´t stop now Bel after you great posts and refer to Robert he´s got no time too many emails in his in box.

If we have this patient come back in and say you and Kerrie are seeing the patient. You both decide that CREST is the cause what would you both do ? , or what though process would you have with soft and squishy appart from Mr Isaacs of course. Maybe break it down into short term and long term management ideas.

So if we start with

Goal of Treatment ?
Site of lesion - Which is 2nd met heads - is it both feet or just one and if so what side ? Kerrie?
Short term treatment - What could you do in an 1/2 hour appointment to make the patient more comfortable , This may also help us decide the long term tx options.

 

Hi Michael,
They are on both feet yes
To answer your 3 questions
Goal of treatment: To relieve the pain for the patient and prevent ulceration (she was crying in pain with them when she first came to us and ulcerated about 5 years ago on the right one) Incidentally I have only been seeing her for about 3 months and she has been coming to us for 5 years.
Site of lesion: Both 2nd MTPJ's
Short term treatment: She has offloading insoles but we also pad her up nicely at each appointment and she see us 3/52

I've looked at some pictures of calcinosis and it doesn't really look like this as there is no chalkiness or chalky discharge. They have the flat yellowish appearance of a HD, although saying that I guess that the perfect flat circular centre does have a chalky tinge.
So is it an idea to request an x-ray to look into calcinosis?
Thanks so much for the help everyone

 

Ok Kerrie thinking Biomechanically, if you want ?



Have you done any biomechanical assessment type stuff with this patient ?

Maybe new eyes may make the difference !!

 

You know me I'm always up for bipomechanics
I have been thinking about doing as assessment so I think I will do that whenI see her next

 

Do that get as much info as possible and then we can go from there.

When doing the assessment try and think you have never seen the patient before so you don´t miss anything.

 

Dunno what you mean Mike, he told me he`s got loads of time on his hands at the moment

You`re right. I should have elaborated on tx plans, but dont have time at this moment as next pt is in the waiting room.

Will post more this evening....

Cheers,
Bel

 

Kerrie, do the lesions look a little like these?



As you can see these clusters of calcinosis look like corns and if they were on a weight bearing site, such as met heads, they would look even more remarkably so. You mentioned in an earlier post that they are `moist`, `sweat on debridement`(not features of HD`s) and that the right one has a history of ulceration, this would indicate calcinosis, in view of med hx. You can obtain a definative diagnosis with histology, but beware because any surgical trauma, even in the form of enucleation, can stimulate further calcification.

OK Mike,

I agree with Kerrie that a biomechanical assessment and orthoses are essential, not just to identify and aleviate the tissue under stress but to deflect pressure away from these very vulnerable, inflamed sites as I stated above; trauma can stimulate further calcification.

Kerrie, do you know how much intermetatarsal movement is available? I picked up this useful tip; by pushing down on the dorsum of the 2nd - 4th mets whilst pushing up on the 1st & 5th, you can see how much the met head can `drop`. If it`s 6mm then a 3mm cavity will acheive little but if it `drops`(dont like that word) 3mm then a 6mm cavity will deflect nicely. But, iIf there is little IM movement then deflection is not so easy so the ol` "stick something soft under something hard" principle comes into play.

I would also liase with the pts Rheaumatologist and GP as there are quite a few corticosteroids which are benefical because of their anti-inflammatory and inhibitory effects on fibroblast activity, as well as meds such as probenecid and colchicine.

As with all Rheumatic disease, the key is in control of the inflammatory process.

Cheers,
Bel

 

Hi Kerrie

This thread has been very interesting with some very good CPD input by Bel. However, without pictures of the condition it is very hard to make a diagnosis- in this case the lady has been treated every 3 weeks for 5 years - if calcinosis was the case then the threat of ulceration ( bar one episode), has not come to fruition and I assume that the lesions have been debrided regularly?
From your description the areas are large and look like corns , and that is how you and your colleagues have diagnosed them all this time, so it seems likely that a practitioner somewhere along the way would have had doubts if calcinosis had been the case.

Are you able to post any pictures?

Cornmerchant

 

Thanks for the compliment, Heather. I agree 100%, without actually seeing the lesions we cannot provide a diagnosis. Pictures are always useful in these threads.

That said, would you not agree that a lesion that is described as moist, uncomfortable and constantly itchy even immediately after enucleation, to the point of sleep disturbance, is probably not your common garden variety of HD?

Given the pts med hx, IMHO Itchiness = histamine = inflammation. But, as you say, without observation we can only guess.

Cheers,
Bel

 

Hi Bel

Against that is that the distribution seems to be symetrical- would that really happpen if it was calcinosis? And after 5 years of enucleation it has not really ulcerated. The itchness seems also to be a new problem, not something that has been apparent before.
Pictures would be extremely helpful.

Regards
Cornmerchant

 

That a good point well put...although calcinosis can occur in preexisting skin lesions and often in areas of trauma. Trauma is sometimes symmetrical, as seen with some HD`s and HM`s. I don`t think it unreasonable to consider that these lesions probably were/are original sites of nonpathological hyperkeratosis, but the clinical description provided by Kerrie does point to an inflammatory condition.

We cannot ignore the fact that one of the lesions HAS ulcerated before. This pt is receiving very regular podiatric care for these, probably consisting of reduction of the hyperkeratosis and deflective padding. The padding alone would reduce the risk of ulceration.

But all this is pure speculation!

Cheers,
Bel

 

Exactly, I agree, it is speculation.

I always remember Ivans advice about hearing hooves and not necessarily suspecting zebras! Maybe a good biomechnical examination with a view to a palliative offloading insole would be the way to go regardless of the diagnosis?

regards
cornmerchant

 

Ivan? Who`s that then?

Indeed:drinks

 

Hi..
A 59 yo patient came to my clinic this morning.I have not seen her before, but she reports having a corn removed from her right 1st mtpj last year and thought that it needed doing again. This Lady has SLE and seems to have had a lot of the complications associated with it. I looked at her lesion and immediately thought of this thread which I had read only a few days before. The lesion was 1cm in diameter and covered with a rough chalky deposit that was very hard, and painful to the touch. I have uploaded a photo to get some opinions as to whether this is calcinosis (I understand that this is rare in SLE). I would value everyone's input.