Welcome to the Podiatry Arena forums, for communication between foot health professionals about podiatry and related topics.
You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members (PM), upload content, view attachments, receive a weekly email update of new discussions, earn CPD points and access many other special features. Registered users do not get displayed the advertisments in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!
If you have any problems with the registration process or your account login, please contact contact us.
A 53-year-old woman was referred to a dermatologist because
of a verrucous nodule on the sole of her right foot (Panels A and B) that had
been treated as a plantar wart for 2 years by a podiatrist. A plantar wart was
diagnosed, and the patient underwent electrocoagulation therapy without histologic
examination. The lesion began to grow, and 6 months later, the patient came
to our clinic. Examination of her right foot revealed an erythematous, partially ulcerated,
nodular lesion, approximately 2 cm in diameter, covered by a thickened corneal
layer. Enlarged right inguinal lymph nodes were also identified. Histopathological
examination of the lesion showed an ulcerated, nodular, amelanotic malignant
melanoma, exceeding 6 mm in thickness (Clark’s level IV). The plantar melanoma
and involved inguinal nodes were excised, and interferon therapy was administered.
Plantar and subungual sites account for two thirds of melanomas of the foot and for
3 to 15% of all cutaneous melanomas. Acral melanomas may be misdiagnosed as
warts, calluses, fungal disorders, keratoacanthomas, nonhealing ulcers, foreign bodies,
moles, ingrown toenails, onychomycoses, and subungual hematomas. Six months
after coming to our clinic, the patient was found to have liver metastases, and she died 6 months later.
Earlier I posted this same NEJM article on Jiscmail but there's not much going on there so I'll put my same reply in here too.
I was wondering what others look for that rings alarm bells when dealing with lesions that initially appear to be v.p.
Melignant melonoma would be the most aggressive and important lesion to diff dx i would think but it is not likely to be confused with a verruca. Look for Assymetry, Border irregularity, Colour verigation, Diameter increasing. (ABCD).
I would think the most likely lesions confused with V.P. might be Epithileoma or Verrucous carcinoma and sqamous cell carcinoma as both look very much like v.p. The former is non metastic and the latter can be extremely metastic and can occur as the result of sun burn. Basal cell carcinomas are more common and caused by sun exposure but rarely metatisise. All these and others can look very similar to a v.p. so if I have any doubts I first refer to my trusted book Cutaneous Disorders of the Lower Extremity and if this gives a suspicious indication I will refer to GP or specialist. I did once find a very large epithileoma sub ungual (verified on referral) but this did not resemble a verruca though.
I am always suspicious of long term V.P. ( over two years ) that are increaing in size.
The above article just highlights the need to be on one's guard and not be complacent even in apparently routine treatments.
This links well with another topic in pod arena dealing with a podiatrist cautioned for incompetence.
There but for the grace of God go I eh!
When I was a student on practical assessment, a thirty-something female pt presented with an interdigital lesion that had become painful.
The only thing that made me go hmmmm... was the fact it was in no area of friction.
Luckily I was with a surgeon and (I still look at him starry eyed for this) he just said-'amelanotic melanoma.' Biopsied it and voila! Histo confirmed his immediate diagnosis.
Needless to say I feel sorry for the poor pod who misdiagnosed, it's easy to do.
I think it's more understandable that this pod misdiagnosed, unlike another pt of mine who had been getting cryotherapy for 6 mnths on a very painful heel 'verruca.' when he finally was referred on to me and I debrided the HK-a large splinter of glass came out!!
Isn't it great that we almost know as much about feet as doctors? (A quote from a pt also.)