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.
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.
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