Plantar Foot Lesions

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Please Have a look at the attached picture.

This 52 year old male turned up 12 months ago with these lesions on the bottom of his left foot. They had been present for about one year before then. At the time the largest cluster looked like VPs. I treated them with Sal acid and Cryo and suggested patient try otc treatnment himself.

He turned up again recently with a few smaller new lesions.

They are not painful.
Fibrous texture.

Patient is a heavy smoker but no other medical history. He plays tennis regulalry but insists he has no pain from lesions.

Any ideas what they could be and treament.

Thanks

 

Bel might shake her head at me but Verruca ?? certainly look like at from the picture, but I might be getting taken to school soon.

 

I would agree, certainly look like vps.

What made you question your original diagnosis? The fact that the previous treatment didn't work doesn't mean that they are not vps-just means that immune response was not forthcoming.
I wouldn't bother to treat if they are not causing him any problems, but if he is insistent that something is done, how about trying needling?

Regards

CM

 

I would have a guess at VPs.

If they are asymptomatic tell him to ignore them and with a bit of luck they will go away.

regards

Catfoot

 

I was very aggresive with debridement and not even a spot of the red stuff.... thats when I started to have my doubts about VPs

 

Hmmmm,

Maybe giant h mille ??!

Again, if they are non-symptomatic then I wouldn't treat.

If it ain't broke don't fix it, I say .....

regards

Catfoot

 

These look like resolved VPS, in my experience you can still get a build up of callus where the VP used to be, i would debride and suggest filing and moisturising between appointments. Just out of interest is the patient prone to hyperhydrosis?

 

I`m with Mike, CF & CM. I reckon they be VP`s. They don`t always bleed like billio on aggressive debridement.

As my colleagues say, if they don`t hurt, I`d be inclined not to treat.

Cheers,
Bel

 

Like the others, my first impression was that they are verrucae. I know you said the patient reported no pain, but did you try squeezing the larger of them from the sides, as verrucae are generally more painful when pressure is applied in this way rather than direct pressure. They tend to get painful to walk on only if they grow deeper. You are either going to treat them or not. I would not file unless I was going to treat them, otherwise you would be more likely to just spread them to other areas. Like wise, I would advise the patient to avoid filing and touching them other than washing and drying the feet.

 

cambspodman,
It is always difficult to do a diagnosis just from a photo as the actual texture of the lesion cannot be appreciated. Is there any possibility that you could post a photo showing these lesions after debridement ?

Footsiegirl, verruccae do not "grow deeper". They are caused by acanthosis of the prickle-cell layer in response to the invasion of the virus and therefore do not extend into the dermis. If you start telling your patients they may "grow deeper" you will cause unecessary alarm.

Obviously you have not understood the aetiology of this condition and I would suggest you do not give out any more advice until you do.

You'll be telling us next that corns have "roots".

Catfoot

 

from photo look very much like plantar warts catfoot/ vp i concur with other posters multiple vp no treatment as success is unlikley painfull and a needless expense for the patient regards

 

CF I stand corrected, as my terminology was incorrect. However, larger lesions, over an area of pressure are generally those which give rise to pain.

I will, however, continue to post, as and when I feel it is appropriate. In this instance, I feel it is. Do at least try not to be so ascerbic and sarcastic in your comments.

 

These certainly look like "resolved" verrucae. Aggressive treatment, such as liquid nitrogen or electrocautery, can leave residual corneous scar tissue which requires regular debridement if or when symptomatic. Does this man have a past history of verrucae? did he have them treated or did he treat them himself? Given he is a tennis player, and therefore exposed to the hazards of changing room floors, there is a strong indication that these lesions are/were verrucous. More background information would be helpful. I agree with posts above - if it ain't broke, don't fix it.

 

im a bit confused when i resolve a wart with electrosurgery chemical cautery or cryotherapy the foot looks normal not like its covered in warts or any other lesion never seen a resolved verrucae lesion obviously something new since i trained at manchester perhaps i need an ology

 

I have to say I havenever seen a "resolved"verruca looking like this-surely of it is resolved it has gone ? I agree there can sometimes be scar tissue but not in such an organized pattern as this chap has. How would resolved verrucas account for the new ones appearing?

Footsiegirl, I think we all know the test of pinching for differential diagnosis, but in normal activity the vps are not going to be pinched so not too much of a problem especially as he reports no pain.

I wonder if you could point me to the evidence that shows self infection/dissemination as I have not come across it. You seem to be saying that this is what happens if the patient touches it too much.

CM

 

just checked google wikipedia and with my dermatologist buddy none of which has any knowledge of such a resolved lesion

 

I referred only to the pinching technique as a guide to determine whether or not these were verrucae, as the OP asked for advice as to what the lesions were, and several posters referred to verrucae.

It does strike me that much emphasis is placed (by some posters only) on point-scoring and not so much on helping others. What a great shame that is.

 

CM, I do not have time at present to search for the research reference you asked for, but it is my understanding that verrucae can be transmitted via autoinnoculation, and that it makes sense not to touch or file them (without appropriate advice) any more than is necessary, however, I am sure that someone will shed some light on this?

 

Just as an aside, I am sure that while I was training it was suggested that there was a link between hyperkeratosis and lung cancer. I have certainly obseved heavy areas of plantar callus on the feet of terminal lung cancer patients. I only mention this because in the original postit was mentioned that the patient is a heavy smoker.

 

advice and no pointscoring i hope dear cambspodman it is obvious that you cannot make a diagnosis on this one i also have the same problem now and again best advice tell him to see his gp most are in group practice and at least one of them will have done a diploma in dermatology at a post grad level hope this solves your dilema

 

The posts above which took issue with my use of the term "resolved" obviously missed my use of the term in inverted commas. The aggressive treatment of the original viral infection of the outer skin layers can eliminate the causative virus but damage the surrounding and underlying skin leaving corneous scar tissue; I have several such patients, my wife being one such and I can assure any doubters that such an iatrogenic (induced by a physician's treatment - I suppose it includes surgeons as well) phenomenon does exist.

 

ill believe you its just that this patient has 10 lesions so i would hope not all 10 would likely to be iatrogenic must have been quite an unlucky chap

 

I didn't really want to get into this discussion as it is nigh impossible to give a diagnosis when all we have is a photo and not all the facts.

However, I think Lizzy1so has flagged up an important consideration, which should not be overlooked if we are to take a holistic view of this patient.

Pain is, of course, subjective, but those lesions with their build-up of overlying callus looks pretty uncomfotable to me, and yet the patients says they don't hurt.
We know the pt is a heavy smoker but do we know any more about his (unwise) lifestyle choices? Could we be looking at an incipient neuropathy here? And if so what should be done about it?

In view of all this all the lesions, could be debrided not with a view to treatment, but to to aid a differential diagnosis. I have done this in the past with some unexpected results such as finding ulceration, tissue maceration and necrosis, sinii, foreign bodies, and fibrous corns.

A neurological assessment might give more information - we could be looking at more than one pathology here.

Incidentally, there is no such thing as a "resolved" verruca, or as our unregulated friends would say a "dead" verrucca. You either have one or you don't.

Too many questions and not enough info, but at the end of the day cambspodman, it's your call.

regards Catfoot

--------------------------------------------------------------------------------------

Footsie, I have, on more than one occasion, had concerned mums and worried children in the surgery ( for a second opinion) after having the fear of God put into them by some minimally-trained footcare person telling them that their VPs need treating before they " grow into the foot". That behaviour is not only unprofesional, it's morally reprehensible.

Post as much as you like but don't expect to be taken seriously when you air your half-baked notions. Posts like that one justify all the arguments I know about not letting the minimally-trained treat feet.

And incidentally the size of the verrucca is not directly proportional to the amount of discomfort felt, as we have seen in this instance.

 

Yep. What the cat said.

 

Hi Fishpod my suggestion of "resolved" VP is purely anecdotal, can't prove it and I don't claim to have invented a new podiatry term, i was simply trying to illustrate that often after a wart "resolves" or "goes away" there is sometimes an area of callus left to debride. I am sorry if i have caused any misunderstanding.
Regards
Lizzy

 

Hi Fishpod my suggestion of "resolved" VP is purely anecdotal, can't prove it and I don't claim to have invented a new podiatry term, i was simply trying to illustrate that often after a wart "resolves" or "goes away" there is sometimes an area of callus left to debride. I am sorry if i have caused any misunderstanding.
Regards
Lizzy

 

ta cat im glad in not going doolaly the resolved crap commas or not is bogus .dead verrucae thats a new totally bogus saying where have i been hiding all these years

 

no problemo lizzy over and out on this one

 

Lizzy
I understand what you are saying and agree that successfully treated verrucas can have residual callus. However, you would expect to see normal skin striations when debrided . For this reason it would be very helpful to have a close up photograph to see the lesions more clearly.

Mr kerans, is it really feasible that a patient could have 10 instances of iatragenic phenomena on one foot?

Footsie girl. You have a tendency in your helpful approach to sound like you are teaching granny to suck eggs. This does not really sit comfortably with some pods who have a great deal more clinical experience than you. It is not about scoring points, it is more about understanding whereabouts in the hierarchy you fit. I await your evidence for autoinnoculation with interest . In the meantime what patients do with their own verrucas at home is their own business not yours.

CM

 

Yep. What the corncutter said.

 

When in doubt, biopsy. sent to path for micro. Have not read anything in this post about porokeratosis which can mimic plantar warts.
One other thing that I did not see is the use of cimetadine at @20mg/kg/day--published in Am. J. of Ped Derm about 15-18 yrears ago.
There have been some other recent posts about taking a piece of the wart and surgically implanting part of it in local muscle belly to impart an immune response--THAT IS PUSHING IT!!!!!!
Point is well taken regarding nonpainful nature and treatment. Average life of a "wart" in adult is 4 years until spontaneous resolution---2 years in pediatrics. If you don't get punctate bleeding on debridemont and it has been present >4 years i would be suspicious of something other than papilloma virus

 

Have you considered Molluscum contagiosum?

As an aside, one of my patients after being told she had this condition, looked it up on the internet and then rang me in distress. She had found a "reputable" site that informed her that Moll. contagiosum was only found in the genital area of same sex couples. It took a while but I was able to assure her that it does indeed occur in other areas and that the website's information wasn't complete.

Don't you just "love" the internet when this happens. :bang:

 

Cambspodman,
There was a discussion earlier on "Smokers corn". a non painful fibrous lesion slightly elevated found in pple who smoke. it was assumed that this lesin was a result of the effect of nicotine on skin collagen.

Looking at the picture these lesions are on weight bearing areas. has he got similar lesions on hands? elbows? if so "Plamoplantar keratosis" could be a differential.

Tx: if it is PPK 5-Flourouracil cream could be useful. alternatively try Vit A cream. Rule of thumb for PPK is Vit A for a week followed by 5-Flourouracil. AND OFFLOADING.

Hope this helps.

 

Just wondering where in the hierarchy I sit for future reference, since it seems so important to some.

I hate 1 thing more than anything in the world at that Bullying (which for me includes racism, but thats for another time).

I have been a victim, but then I grew at a 12 years old the bully's stopped may have something to do with some bloodshed of a 17 year old who though it was ok to pick on the little kid.

Since then Ive intervened where I can, I don´t mind discussion re subjects getting heated. I don´t mind humor ( a piss take ) and there is line, I may cross it myself and regret it later ( one reason I don´t post reply to some people, better not to say anything at all ).

But I think a few people (me included) may need to aware of the line - just a thought.

ps this is not written as a moderator, welcome committee but by me

 

M Weber,
My response will probably take this thread off track however:

This seems like an "Emperor's new clothes" scenario to me.

John Major talked about a "classless society " but it doesn't exist. There are hierarchies everywhere, even in the ant kingdom. If this goes against the grain with some, then I'm sorry, but that's how it is.

Now, let's consider another scenario. I study to become a Legal Assistant and then join a forum for Barristers. I start posting, advising them on points of law and giving my opinion on cases they are discussing even thought I don't fully understand the points of law. Can you imagine what response I would get?

I have made no secret of the fact that I do not agree with the minimally-trained treating feet. One of the reasons for this is at the base of my post 23# -

You don't like bullying - OK, neither do I, but I think there is a difference between bullying and telling someone the truth.

regards

Catfoot

 

hi back in this thread again all very interesting mr weber i know nothing about you at all for all i know you might be the priniple of cambridge university but you know all about yourself so you know where you are in the food chain so you can answer the question you posed yourself hope you like your answer if youre happy with the answer no worries

 

To elaborate upon my use of the word 'hierarchy" in my previous post-
I should have made it clear that I was referring to the levels of training that gives you your standing in the "foot health providers" chain. ie those with degrees/diplomas and regulated registration are at the top of the ladder. I see unregulated practitioners who come in by the back door at the bottom of the ladder. We all know this but some choose not to say it. It is not bullying.

Fishpod- you are growing on me!

Catfoot- I like the analogy.

CM

 

i love plain speaking tell it as it is even if its not pallitable lets not skirt around things no inuendos were not politicians. all areas of life have a hierarchical structure the country club the beach club even the boy scouts ive been in the service a corporal is not the same as a colonel its not an opinion just a boring plain old fact as night turns to day.

 

Hmmm. So, as I was originally grand-parented scum, where do I sit in this `food chain?`

Interesting that research into bullying suggests that a prejudicial view of `subordinates` can be particularly a risk factor*. I`m in full agreement with Mike. There is an element of bullying manifesting in virtually all threads which contain posts made by either FHPs, or practitioners who have obtained hpc registration via the grandparenting mechanism. I do, to an extent, understand the dissatisfaction felt by those who view the unregulated sector (which does also include FCA`s and Age Concern nail cutters) as minimally trained. It has also been pointed out that this is the status quo and will not change. However, it is incredibly sad that such ones, many of whom join to arena to investigate the possibility of embarking upon the pod degree, are not encouraged to learn and are alienated by a few. Hostility does not encourage them to investigate podiatry; it just compounds the animosity and prevents them from making appropriate referrals and progressing in their choice of career.

I have been accused of `championing the FHP`, whatever that means. I am not on an `improving the skills of the unregulated sector` crusade, I have always encouraged anyone who has an interest in foot health to do the fulltime degree. If, for whatever reason, this is beyond their personal circumstance, I keep the lines of communication open to FHP`s so that they feel comfortable with referring patients beyond their scope of practice to me. As far as my private practice is concerned, this is just good business sense and beneficial for the patient and me.

But, that`s just my opinion.

Cheers,
Bel


*Petty tyranny in organizations , Ashforth, Blake, Human Relations, Vol. 47, No. 7, 755-778 (1994)

 

Bel

Do lighten up, its not always about you! I believe you now fall into the degree/registered/regulated category as you well know.
You may well see it as bullying and provide papers to that effect- that is your opinion and you are entitled to it. It is not bullying just straight talking-oh forgot, thats not politically correct.

While the sun rises and sets , I will not give time to unreguated professionals , the large majority of whom are not going to upgrade their skills. They do not refer to me but I do have to put right their c*** ups .

Beam me up Scotty


CM