A 51-year-old male presented to the office with the chief complaint of a skin growth on his right medial heel. He related that the mass has grown slowly over the prior year. He did not have any severe pain with it other than shoe irritation. The skin lesion would bleed easily with any pressure on it.
He denied any injury or punctures to the skin. His past medical history was remarkable for diabetes, coronary artery disease, hypertension, anemia, chronic obstructive pulmonary disease (COPD), sleep apnea, obesity and gastroesophageal reflux disease (GERD).
The physical exam revealed a poorly conditioned male who appeared older than his stated age. He was obese and somewhat short of breath. His podiatric examination revealed weakly palpable peripheral pulses with warm pink skin. Capillary refill was less than four seconds to the toes. The neurologic exam revealed symmetric deep tendon reflexes of the patella and Achilles. He had a loss of protective sensation (LOPS) to his toes.
The dermatologic exam revealed dry, scaly skin, thickened nails with dystrophy and a bright red, pedunculated skin lesion measuring 1 cm in diameter. The lesion would bleed with pressure. He did not have any significant pain with manipulating the lesion. No cellulitis or infectious processes were present. The orthopedic exam revealed a symmetric pain free range of motion of the foot and ankle.
What You Should Know About The Differential Diagnosis
When a patient presents to the office with a vascular mass that bleeds and is devoid of any color, obtaining a biopsy is a must. The most commonly seen cutaneous vascular lesion on the foot is a pyogenic granuloma. The most common location is the nail fold of a digit with a concomitant ingrown toenail.
When a lesion resembling a pyogenic granuloma is present in an unusual location such as the heel (as with this patient), there is a heightened concern about a more serious condition.
Differential diagnoses include but are not limited to basal cell carcinoma, squamous cell carcinoma, amelanotic malignant melanoma, hemangioma, eccrine poroma, Kaposi’s sarcoma, glomus tumor and metastatic carcinoma.
Pyogenic granuloma. Usually caused by some sort of skin trauma, pyogenic granuloma is a benign vascular lesion common to hands and feet. These lesions histologically are lobulated capillary hemangiomas. Treatment is generally curettage and cauterization, which usually resolves the condition. Recurrences can happen after cauterization.
Basal cell carcinoma. As the most common type of skin cancer, basal cell carcinoma is most common on the face but can occur anywhere on the body. Basal cell rarely will metastasize. Treatment involves curettage or excision of the skin lesion.
Squamous cell carcinoma. This is cancer of tissue containing squamous cells. This disease affects not only the skin but can also affect the esophagus, cervix, vagina, prostate, lungs and the mouth. Unlike basal cell carcinoma, squamous cell carcinoma can metastasize. Often, this skin cancer can be present in scars.
Amelanotic malignant melanoma. This is the most serious condition that one needs to rule out. Just because the lesion is devoid of dark pigmentation, contrary to most melanomas, that does not mean it is not melanoma. Of all the skin cancers, amelanotic malignant melanoma has a high potential to metastasize and potentially cause death if it is not caught in time.
Hemangiomas. The appearance of the hemangioma, a large group of blood vessel tumors, is dependent upon the location. Since the tumors are made of blood vessels, the mass may look blue, purple or red. When the hemangioma is on the surface of the skin, it can have a strawberry-like appearance.