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Corn, Verruca or something else?

Discussion in 'General Issues and Discussion Forum' started by GILES H, Sep 11, 2013.

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  1. GILES H

    GILES H Member


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    I recently treated a lady with a plantar lesion that confuses me. It looks like a corn but is not in an obvious high pressure area, is very painful with pressure (more like corn than v.p), on debridement is relatively soft (unlike a corn) and has vascular elements (only evident on enucleation). I'm a relatively experienced Podiatrist so don't normally have any problems telling the difference between a corn and a v.p so wondered whether any one had come across anything similar? I've had a handful of these in the past that have been similar. Thanks
     
  2. blinda

    blinda MVP

    Hi Giles,

    Could be `something else` but without a pic, it is nigh impossible to offer a dermatological opinion.

    Were the vascular elements thrombosed capillary or a vasculitis manifestation?

    Bel
     
  3. GILES H

    GILES H Member

    Hi Bel,

    Thanks for response. Appreciate the problem of diagnosis without photo and will try and rectify. As I said though it just looks like a H.D. There's no apparent localised inflammation and it's only the fact that when I've seen them they're not in a typical pressure area and the fact they bleed like billlio on enucleation that sets them aside as different. I considered neurovascular corn but these only arrise under pressure areas and usually over long periods of time as far as I'm aware. The vascular elements are not visible as 'thrombosed capillary' as in V.P, in fact I'm not aware they're there until it bleeds (Please don't assume poor enucleation skills). They also appear disproportionately painful.

    G
     
  4. blinda

    blinda MVP

    Never did assume poor enucleation ;)

    Could be a dermatofibroma, xanthoma, calcinosis, amelanotic melanoma, or a whole list of other HD impersonators.

    OK, don`t mean to sound patronising, but without a pic this is difficult. Could you present this pt as if you were still an undergrad. Y`know, onset, duration and extent of lesions, meds, hx, occupation, previous tx, age, footwear etc, etc. Will help muchly.

    Cheers,
    Bel
     
  5. GILES H

    GILES H Member

    o.k Bel. Will try my best. 66 year old lady presented to clinic c/o 'either a verruca or corn'. She complained of pain on standing and was visibly limping. She is in good general health and is not taking any medication. She has an allergy to Codeine. She said she had been treating the lesion for a few weeks (since she had become aware of it) with over the counter freezing device with no effect but hadn't treated the lesion immediately prior to visit. She attended wearing a relatively supportive sandal with no xs wear. o/e her feet were unremarkable with limited physiological callus. The problem area was on her left PCA towards the medial edge. There was some callus in the area but relatively thin. The lesion was <5mm with a hardish central (corn like) mass and a white halo appearance deeper into the tissue. It reminded me a little of a foreign body reaction but the pt stated no history of such and none was visible. It was sore to touch more with direct pressure than squeezing. I debrided the overlying skin and attempted to enucleate the apparently well demarcated 'corn' which was softer than expected and bled despite no obvious cause. No foreign body was evident. I used 75% AgNo3 to stop the bleeding and also to (hopefully) shrink back any vascular elements and applied a dressing and felt padding to comfort and relieve pressure. The patient did not appear to find the treatment particularly painful. I asked her to return in 1/52 for review.

    I actually reviewed this patient today and she said that although initially painful on standing for 2 days post treatment it was now pain free and she was happy. I debrided the overlying eschar/staining left by the AgNo3 and now found a tiny pink lesion not unlike a granuloma surrounded by otherwise healthy tissue. I did not attempt to excise this for obvious reasons. I again applied some AgNo3 and a cover. As the patient is now pain free I have advised her to monitor for change and return should there be any/ pain returns.

    Patient is happy but I am a curious individual and like to improve my knowledge so as to know best practise in future.

    I hope I'm not wasting your time.
     
  6. blinda

    blinda MVP

    Hi Giles,

    You`re not wasting anyone`s time. Wish we had more dermatological cases like this to discuss here. It`s how we all learn and improve practice.

    Forgive my ignorance, but is PCA plantar calc area? If so, what you are describing could be a painful piezogenic pedal papule, eccrine poroma or indeed a pyogenic granuloma. From your good description, I agree this does not sound like your usual heloma durum. Did you take a pic when you reviewed her today? If so, please upload it here, if you have her permission.

    Cheers,
    Bel
     
  7. GILES H

    GILES H Member

    Hi Bel.

    Sorry. Again I didn't take a picture and I must sort myself a simple form for consent. If she comes back again I will take a picture, get permission and show. Thank you for all your help. I shall refresh my memory with the differential diagnoses you suggest.

    Giles
     
  8. bartypb

    bartypb Active Member

    I would always air on side of caution if you have no idea what is going on, and speak to the pt for consent regarding referral to dermatology. I only say this as I have had a couple of "weird" lesions which have turned out to be something nasty!

    See you t the conference Giles

    Barty
     
  9. Jvm620

    Jvm620 Member

    Interesting, I had almost identical case yesterday although the area immediately surrounding the lesion was inflamed & sl swollen, no pain on lateral pressure, I felt either foreign body or vp initially - lesion also bled on enucleation. No obvious cause visible, I have also used silver nitrate on the lesion & am waiting to see..... will also photograph at review appt.
     
  10. GILES H

    GILES H Member

    To those that kindly responded to my post. I sent letter to patients G.P requesting dermatology apt. The dermatologist decided to cut lesion out quickly and send for histology as they thought it was something 'nasty'. Turns out it was just a verruca but I feel slightly vindicated in the fact that the dermatologist wasn't sure either.

    Giles
     
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