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A papule arising in a skin graft – To biopsy or not to biopsy?
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e229ee230
CORRESPONDENCE AND COMMUNICATION
A papule arising in a skin graft e To biopsy or not to biopsy? We report the case of an 80-year-old man who presented with an enlarging nodule on his left heel. Histology showed an acral lentiginous melanoma, Breslow thickness 2.3 mm, with no ulceration and no angiolymphatic or perineural invasion. He was treated with a 2 cm margin wide excision and split skin grafting, and placed on a 3-monthly followup. Eight months post-surgery, he presented with a painless papule on his heel in the middle of the skin graft, which had developed since his previous review. On examination there was a soft, 1 cm flesh-coloured papule in the centre of the skin graft (Figure 1). The papule increased in size on weight bearing (Figure 2), and was reducible on application of digital pressure. This was consistent with a diagnosis of a piezogenic pedal papule. The patient was advised to manage the condition conservatively by wearing a heel pad. At follow-up 3 months later, the papule remained unchanged. Piezogenic pedal papules were first described by Shelley and Rawnsley1 in 1968, who postulated that they are pressure-induced herniations of the subcutaneous fat through tears or weaknesses in the fascial lining of the heel, into
Figure 1 Reducible flesh-coloured papule, left heel, non-weight bearing.
smaller chambers in the reticular dermis. Multiple asymptomatic papules are frequently found in healthy individuals, and associations with physical activity2 and connective tissue disorders such as Ehlers-Danlos syndrome3 have been found. Occasionally, piezogenic pedal papules may be painful, and it has been suggested that pain is due to ischaemia secondary to the protrusion into the dermis of encapsulated adipose tissue with its vasculature and associated nerves, when pressure is applied on the foot. Piezogenic pedal papules may resemble cutaneous tumours including plantar fibroma, adnexal neoplasms, amelanotic melanoma or a melanoma recurrence. Although the diagnosis of a piezogenic pedal papule is made on clinical grounds, imaging may be considered if there is diagnostic uncertainty, and MRI has been used to demonstrate a piezogenic pedal papule as a capsulated fatty lesion.4 In the case of suspected melanoma, high-frequency ultrasound has been shown to successfully differentiate between melanoma and benign skin lesions, and accuracy can be further improved with the addition of colour Doppler to detect vasculature of the lesions.5 To the best of our knowledge, this is the first reported case of a piezogenic pedal papule developing at the site of a split skin graft. This diagnosis should be considered when papules develop at sites of previous acral surgery, and careful examination can differentiate a piezogenic pedal papule from cutaneous tumours. In our patient, the classical
Figure 2 Prominent non-reducible flesh-coloured papule, left heel, weight bearing.
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.03.020
e230 examination finding of a soft flesh-coloured papule that was reducible when not weight bearing, and firm and prominent on weight bearing, allowed us to confidently make the diagnosis of a piezogenic pedal papule. This precluded the need for a biopsy, which can exacerbate the condition. If any diagnostic doubt remains following this simple examination process, a biopsy should be performed.
Correspondence and communication 2. Kohn SR, Blasi JM. Piezogenic pedal papules. Arch Dermatol 1972;106:597e8. 3. Kahana M, Feinstein A, Tabachnic E, et al. Painful piezogenic pedal papules in patients with Ehlers-Danlos syndrome. J Am Acad Dermatol 1987;17:205e9. 4. Bo ¨ni R, Dummer R. Compression therapy in painful piezogenic pedal papules. Arch Dermatol 1996;132:127e8. 5. Dancey AL, Mahon BS, Rayat SS. A review of diagnostic imaging in melanoma. J Plast Reconstr Aesthet Surg 2008;61:1275e83.
Conflicts of interest None declared.
Funding None declared.
References 1. Shelley WB, Rawnsley JM. Painful feet due to herniation of fat. JAMA 1968;205:308e9.
A. Wiberg Department of Dermatology, The Churchill Hospital, Old Road, Oxford OX3 7LJ, UK E-mail address: [email protected] O. Cassell Department of Plastic Surgery, The John Radcliffe Hospital, Oxford OX3 9DU, UK J. Bowling Department of Dermatology, The Churchill Hospital, Old Road, Oxford OX3 7LJ, UK
CORRESPONDENCE AND COMMUNICATION
A papule arising in a skin graft e To biopsy or not to biopsy? We report the case of an 80-year-old man who presented with an enlarging nodule on his left heel. Histology showed an acral lentiginous melanoma, Breslow thickness 2.3 mm, with no ulceration and no angiolymphatic or perineural invasion. He was treated with a 2 cm margin wide excision and split skin grafting, and placed on a 3-monthly followup. Eight months post-surgery, he presented with a painless papule on his heel in the middle of the skin graft, which had developed since his previous review. On examination there was a soft, 1 cm flesh-coloured papule in the centre of the skin graft (Figure 1). The papule increased in size on weight bearing (Figure 2), and was reducible on application of digital pressure. This was consistent with a diagnosis of a piezogenic pedal papule. The patient was advised to manage the condition conservatively by wearing a heel pad. At follow-up 3 months later, the papule remained unchanged. Piezogenic pedal papules were first described by Shelley and Rawnsley1 in 1968, who postulated that they are pressure-induced herniations of the subcutaneous fat through tears or weaknesses in the fascial lining of the heel, into
Figure 1 Reducible flesh-coloured papule, left heel, non-weight bearing.
smaller chambers in the reticular dermis. Multiple asymptomatic papules are frequently found in healthy individuals, and associations with physical activity2 and connective tissue disorders such as Ehlers-Danlos syndrome3 have been found. Occasionally, piezogenic pedal papules may be painful, and it has been suggested that pain is due to ischaemia secondary to the protrusion into the dermis of encapsulated adipose tissue with its vasculature and associated nerves, when pressure is applied on the foot. Piezogenic pedal papules may resemble cutaneous tumours including plantar fibroma, adnexal neoplasms, amelanotic melanoma or a melanoma recurrence. Although the diagnosis of a piezogenic pedal papule is made on clinical grounds, imaging may be considered if there is diagnostic uncertainty, and MRI has been used to demonstrate a piezogenic pedal papule as a capsulated fatty lesion.4 In the case of suspected melanoma, high-frequency ultrasound has been shown to successfully differentiate between melanoma and benign skin lesions, and accuracy can be further improved with the addition of colour Doppler to detect vasculature of the lesions.5 To the best of our knowledge, this is the first reported case of a piezogenic pedal papule developing at the site of a split skin graft. This diagnosis should be considered when papules develop at sites of previous acral surgery, and careful examination can differentiate a piezogenic pedal papule from cutaneous tumours. In our patient, the classical
Figure 2 Prominent non-reducible flesh-coloured papule, left heel, weight bearing.
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.03.020
e230 examination finding of a soft flesh-coloured papule that was reducible when not weight bearing, and firm and prominent on weight bearing, allowed us to confidently make the diagnosis of a piezogenic pedal papule. This precluded the need for a biopsy, which can exacerbate the condition. If any diagnostic doubt remains following this simple examination process, a biopsy should be performed.
Correspondence and communication 2. Kohn SR, Blasi JM. Piezogenic pedal papules. Arch Dermatol 1972;106:597e8. 3. Kahana M, Feinstein A, Tabachnic E, et al. Painful piezogenic pedal papules in patients with Ehlers-Danlos syndrome. J Am Acad Dermatol 1987;17:205e9. 4. Bo ¨ni R, Dummer R. Compression therapy in painful piezogenic pedal papules. Arch Dermatol 1996;132:127e8. 5. Dancey AL, Mahon BS, Rayat SS. A review of diagnostic imaging in melanoma. J Plast Reconstr Aesthet Surg 2008;61:1275e83.
Conflicts of interest None declared.
Funding None declared.
References 1. Shelley WB, Rawnsley JM. Painful feet due to herniation of fat. JAMA 1968;205:308e9.
A. Wiberg Department of Dermatology, The Churchill Hospital, Old Road, Oxford OX3 7LJ, UK E-mail address: [email protected] O. Cassell Department of Plastic Surgery, The John Radcliffe Hospital, Oxford OX3 9DU, UK J. Bowling Department of Dermatology, The Churchill Hospital, Old Road, Oxford OX3 7LJ, UK