Dermatology mystery

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Hi guys,

Saw a patient today with this mysterious skin condition nobody seems to have a clue what it is.

Will appreciate any suggestions.


History:
A positive 67 yro female. Slightly overweight, relatively healthy, metformin controlled "pre diabetic" (for 2 yrs) and controlled high blood pressure (over 10 yrs).

Not allergic to anything that patient is aware of.

Never really had skin problem until 30s, first started having crack heels, then regular cellulitis at both anterior shins. Skin became dry and elephant skin like texture. About 10 years ago, is when things started to turn worse, skin became scaly, tender, and fragile. Peels easily and forms thick skin easily. Underneath layers of thick skin are fresh tender bleeding skin (please see pictures for what I mean here).

From then on, patient not been able to put close in shoes on due to build up of lumpy skin and due to it being tender. Can't get feet wet and this makes skin too soft hence sore. Can't exercise or walk much due to skin tender. Also can't have hard skin removed too much either physically or by special cream - once again, this makes feet too sore.

Patient seen one dermatologist, no skin biopsy. Doctor tried few different creams but no help. Gave up on patient. Patient not had time to see another doc.

Patient also seen vascular surgeon for analysis of circulation - good circulation except poor venous return.

Patient's currently got this almost healed and previously infected sun damaged ulcer on dorsum of L lateral midfoot. Patient been on 3 lots of antibiotics to finally clear infection.

She comes to me regularly for general nail and skin care.


Assessment:
Please see pictures (some are after treatment).

Download and enlarge to see fine detail of skin texture.

The callous are not in one large diffuse patch but rather like a "volcanic earth crust" cluster. You can pick it of easily but the skin underneath is very fragile and tender, almost like one small blood vessel feeding each cluster.




URL to photos:
http://dermatologycasestudy.webs.com/apps/photos/album?albumid=12656682



For treatment of her callous issue, her feet will only tolerate moderate sanding and no scalpel debridement.


Hope there's a diagnosis for this skin condition.

Thanks for your time in advance.


Mike

 

Looks like there may be a verrucal element to this, and possibly also some fungus.
A biopsy may be worthwhile, vigorous sharp debridement can sometimes provide some short term relief. I would try a urea cream under occlusion to soften the callus, and review weekly or more often to remove the HK before it grows back. You could also try an ankle block so you could sharp debridement more of the HK.
If it is fungal, systemic antifungals will work quicker and better than any topical.

 

Hi Mike,

This looks like a chronic case of necrobiosis lipoidica diabeticorum, which isn`t always correlated with how well the diabetes is controlled. In fact, many pts diagnosed with this do not have diabetes!

http://dermatology.cdlib.org/1512/articles/etanercept/hsu.html

I also agree with Stephen, there appears to be comorbidities here associated with anhidrosis, including tinea, which may respond well to oral anti-fungals.

Can`t believe the dermatologist didn`t take a biopsy :bang: Squamous cell cancers have been reported in older lesions of necrobiosis lipoidica related to previous trauma and ulceration. That necrotic patch on her right calc, definatley requires biopsy, IMO.

Diff dx include; Sarcoidosis and Xanthomas.

Keep us posted on her progress.

Cheers,
Bel

 

Thanks guys.

Ya, I think there could be some component of fungal infection and possible verrucae.

Sorry I should probably have explained the photos a bit more but the what it seems like the necrotic R heel is actually dry blood sipping between them - like deep crack heels.


From the history, personally I feel this problem probably got triggered by the constant cellulitis she had and somewhat caused some abnormal cellular changes.

Just feel there could be potential heaps of differential diagnosis!

Definitely think skin biopsy is needed will recommend her getting it done.

Will keep you guys posted if I have any further info.

Thanks again.

Mike

 

One more note.

I tried debride heavily at very first time I saw her, almost "killed" her, couldn't walk for days afterwards so requested me just to sand down lightly this time.

Mike