Assistance / advice required

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A 69 y/o, 150 kg (medical practitioner) has been treated at the ambulatory wound clinic for the last 12/12 for lymphoedema compression bandaging. She also is on high dosage cortisone for rheumatoid arthritis.
She had a 1/12 hospital stay bed-bound for pneumonia 4/12 ago.
The pain, on plantar surface of heel initially, can continue through the night.
On walking, the most painful time is when she lifts her foot! Otherwise the 'throbbing' pain, in her ankle/foot can keep her up most nights.
A pale coloured lesion was noticed 2/12 ago and has grown more prominent and hopefully i'll attach it.
The patient has seen a rheumatic specialist, a vascular surgeon (who attempted to lance his diagnosed abscess with no success, he now thinks it's 'fatty pad' related), a sports medicine practitioner, several podiatrists to very little avail. The lesion and surrounding plantar rearfoot surface is too painful to touch.
The photo doesn't make the pale lesion, at the distal end of the exfoliation, as white at it appears to the eye.
The feet are extremely swollen, she wears a post op wrap-around velcro boot, and he contralateral heel is beginning to get 'very sore', confirmed with palpation of the plantar medial tubercle region.

Differential dx, tx, any advice appreciated, mark

 

Given that the white area is not fluid filled, is it rubbery or hard?
If hard it could be a calcified gouty tophi.
Otherwise the area looks a fair bit like an early pressure ulcer.
Is there a history of RA? if so possible RA Nodule.

Tx. Decrease pressure, easier said than done on a heel, but if you can get a CAM walker to fit around the leg, it should reduce some of the heel pressure, otherwise try an MPO

 

Thanks Stephen, I'm unable to palpate, she starts screaming at the thought of being palpated, I'll mention the gouty arthritis to her, she definitely has Rheumatoid Arthritis, has been on cortisone for ~ 4 months. I should take a medial view of the foot and any view of her lower leg, wouldn't get it into a walker, an Australian retailer for the MPO?, thanks again, mark

 

If not Gouty tophi, I just wondered whether the compression bandaging had caused a pressure ulcer?

...and has a blood test eliminated diabetes?

 

All,
I have seen these type of lesions in areas of high pressure, usually they form as a precursor to tissue breakdown.
I would agree that offloading is the answer if this can be achieved.

regards

CF

 

Given the possibility of gouty tophi/Rheumatoid nodule, it may well be worth further investigations in the form of Xray and MRI.

Let us know how it goes

All the best

Bill

 

Possibly localized vasculitis inflammation. I had an RA patient with a very deep painful heel ulceration, I hadn't seen how it started and no pictures of it's development as I was a student. We were treating as vasculitis ulceration as it had angry red inflammed borders and was acutely painful. I hope your patient does not develop one of these.

http://www.dermnetnz.org/immune/rheumatoid.html

May simply be RA related skin issues. Steroids also cause skin thinning and weakening/striae stretch marks.
"General cutaneous manifestations

Patients with rheumatoid arthritis may experience a wide array of non-specific skin changes. General signs and symptoms include:

Skin becomes atrophic (thin and wrinkled), making it fragile and easy to bruise
Skin on the back of the hands may become pale or even translucent
Nails may become brittle and split length-wise
The palms become reddened (palmar erythema)"

Good luck. I hope there will be a definitive cure one day, RA is a nightmare.

Sarah

 

The lesion, whatever it is, seems to be at the very least subcutaneous deep, mark