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Hi everyone,

today I had an unusual patient presentation that neither I or my colleagues were sure on how to treat/diagnose and would really appreciate your opinion.

patient was a 60 y/old male with approx. 12 month history of a sore heel, which he originally c/o to a GP about and was told it was a bruise. Fam hx of pressure ulcers at the heel (I think unlikely to be relevant) but no other medical/dermatological hx that was relevant. The patient thought it may be related to contoured heeled sandals he had worn all summer as it was particularly sore.

This picture is before it was debrided. I confirmed that these were all capillaries as they bled when debrided. Additionally a small area on the other heel appears to have a similar presentation.

Could this just be a verruca in a strange position? and if so how would you proceed with treatment over such a large area?

thanks in advance for your opinion,

Bianca

 

Mosaic Verrucae?......its been there a while! Not likely to resolve with the standard therapies I would imagine if it was. Might want to think about oral tagamet (cimetidine) 300mg daily for 12 weeks sparing any contraindications or alternatively surgical debridement. Might be worthwhile taking a biopsy first and sending it for histopathology to make sure :) When in doubt referral works best - local Podiatric Surgeon who can also do the above if you or your colleagues aren't comfortable.

Any other medical history/Meds/Allergies/Info or was that it?

Good luck!

 

Nice pic:drinks

Looks like a dose of talon noir to me, AKA as the imaginatively named `Black Heel`. `Tis the result of trauma (often seen in squash players) causing capillary haemorrhage into the dermal papillae. Sharp reduction offers some relief.

Cheers,
Bel

 

Thanks paul and bel. Just read up on black heel- not one I remember from derm lectures! I don't think this is as simple as this as I was unable to remove the discolouration by debridement, there was also a bit of bleeding suggesting the vessels are deeper than the corneum. There was also a diff dx of acral lentiginous malignant melanoma mentioned in this book. I think most likely a mosaic verruca, but think I may refer for a biopsy just in case.

Thanks again!

 

Good luck! Please post back the results for us.....

 

Hi Bianca,

You are absolutley right to consider melanoma, as Paul pointed out; biopsy is a definate here so it can be quickly differentiated. I think it unlikely to be HPV2 (mosaic VP) as the dermatoglyphics don`t appear have interruption of the epidermal straie. Not saying it`s not a diff dx, but histology will also reveal any viral particles.

Black Heel presents with punctate haemorrhage of capillaries, which cannot be debrided without bleeding. The debridement that I spoke of before was in relation to reduction of associated hyperkeratosis, to ease any discomfort. Take a look at the image on this site;

http://emedicine.medscape.com/article/1087469-clinical

Thanks for highlighting an interesting case:drinks

Bel

 

It looks very much like Verrucous Hyperplasia which we sometimes see around healed diabetic foot ulcer sites. Google is your friend :)

 

What does this chap do for a living and what does he wear on his feet when he does it?
Ros

 

Excellent photo.

Bleeding upon debridement indicates that the cause is from capillaries feeding into the verrucae in addition to the punctate black areas caused from the deposition of hemosiderin within the stratum corneum from the terminal ends of the capillaries.

If there is much more pain when you squeeze the affected area versus direct pressure than that also is indicative of mosaic verrucae.

In the photo, I do not see the transverse skin lines traversing through the affected area which you would see in trauma but not with a verrucae.

In this case, It appears the lesions are in this location due to the pressure and moisture from his contoured heeled sandals pressing against his heel that he wore in the summer.

Steven