When A Patient Presents With A Skin Growth On The Heel

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Key Questions To Consider


1. Is there any pain?

2. Has there been any recent skin trauma such as a puncture wound?

3. Does the patient have a history of cancer?

4. Has the skin lesion been growing fast or slow?

5. Does the skin lesion have any variability in color or border?






Answering The Key Diagnostic Questions


1. Pain is uncommon in pyogenic granuloma and cancerous skin lesions. Eccrine poromas can be painful and glomus tumors are very painful.

2. Pyogenic granulomas are frequently caused by trauma to the skin.

3. Cutaneous lesions that bleed or ulcerate can be primary cancers such as amelanotic melanoma or metastatic cancer spread from the lungs or kidneys.

4. Pyogenic granuloma is generally a fast growing skin lesion within a one- to three-month period whereas other skin lesions such as carcinomas are slow growing.

5. Skin cancer, especially melanoma, is characterized by asymmetry of color and border.





29
Author(s): 
William Fishco, DPM, FACFAS

   Kaposi’s sarcoma. This is a cancer of blood vessels that is endemic to elderly men with a Mediterranean descent. Since the 1980s, the incidence of Kaposi’s sarcoma has increased due to HIV infection as a causative condition. The clinical appearance of the skin lesion is quite variable. It may be red to purple and may be flat or raised. These lesions can ulcerate and become painful.

   Glomus tumors. These benign vascular tumors are histologically venous malformations. The glomus body plays a role in regulation of skin temperature. These tumors are easy to identify because they are very painful, unlike the other vascular skin tumors. These tumors are most common under the nail plate on fingers and toes.

   Metastatic carcinoma. This condition is rare. The most common organs to produce cutaneous metastasis include the breast, lungs, uterus, large intestine and kidneys (renal cell carcinoma). Most cutaneous carcinomas occur in close proximity to the primary cancer tumor. The clinical presentation is typically non-tender nodules that are usually flesh-colored.

   Breast cancer is the most common source of metastatic cutaneous carcinoma. Generally, lesions are present on the chest and abdomen. Due to the abundant vascularity of renal cell carcinomas, cutaneous carcinomas derived from the kidney may appear hemangioma-like with the clinical appearance similar to pyogenic granuloma.

Pertinent Insights On Eccrine Poroma

   Clinically, the lesion looks like pyogenic granuloma. However, the patient did have a one-year history of a slow growing lesion, which is not typical in pyogenic granuloma. The mass was painful with shoe irritation, which is also atypical in pyogenic granuloma and carcinomas.

   The patient does live in Arizona, which has a higher incidence of skin cancers due to higher sun exposure. Certainly, the lesion required a biopsy for confirmatory diagnosis.

   An excisional biopsy of the lesion revealed it was an eccrine poroma.

   The lesion did not recur after a one-year follow up. Eccrine poroma is a benign adnexal neoplasm of eccrine sweat glands.

   Clinical appearance of the eccrine poroma is usually a flesh-colored nodule. Rarely do these lesions exceed 2 cm in diameter. Occasionally, the eccrine poroma may be pigmented or have a vascular appearance as illustrated with this patient. Clinically, this lesion looked similar to a pyogenic granuloma.

Dr. Fishco is board-certified in foot surgery and reconstructive rearfoot and ankle surgery by the American Board of Podiatric Surgery. He is in private practice in Phoenix. Dr. Fishco is also a faculty member of the Podiatry Institute.

Editor’s note: For related articles, see “Identifying Skin Malignancies On The Distal Lower Extremity” in the September 2003 issue of Podiatry Today or “Differentiating Non-Pigmented Tumors In The Lower Extremity” in the December 2009 issue.




References:

Suggested Reading
1. Requena L, Sangueza OP. Cutaneous vascular proliferation. Part II. Hyperplasias and benign neoplasms. J Am Acad Dermatol 1997 Dec; 37(6):887-919.
2. Requena L, Sangueza OP. Cutaneous vascular proliferations. Part III. Malignant neoplasms, other cutaneous neoplasms with significant vascular component, and disorders erroneously considered as vascular neoplasms. J Am Acad Dermatol 1998 Feb; 38(2 Pt 1):143-75.
3. Wong MW, Tse GM. Eccrine poroma: a differential diagnosis in chronic foot lesions. Foot Ankle Int 2003 Oct; 24(10):789-92.
4. Lemont H, Brady J. Amelanotic melanoma masquerading as an ingrown toenail. J Am Podiatr Med Assoc 2002 May; 92(5):306-7.
5. Betti R, Facchetti M, Menni S, Crosti C. Basal cell carcinoma of the sole. J Dermatol 2005 Jun; 32(6):450-3.
6. Cahill S, Cryer JR, Otter SJ, Ramesar K. An amelanotic melanoma masquerading as hypergranulation tissue. Foot Ankle Surg 2009; 15(3):158-60.





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