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Right 1st Painful lesion

Discussion in 'General Issues and Discussion Forum' started by cheese14, Aug 17, 2015.

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  1. cheese14

    cheese14 Welcome New Poster


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    HI All,

    Would love some help regarding a patient who I am having difficulty with currently.

    41 YR Old man

    History of anxiety and depression

    Low Social economic

    Low limb Blood flow and nerve conduction WNL

    Referral from GP saying "painful corn Right 1st"

    Presents with approx 6 month history of painful lesion on Right 1st medial MTPJ.
    Worsened to point of appointment him unable to wear shoes or touch the lesion.

    Lesion was very vascular with peri- wound tissue very firm. Pain on medial lateral compression and direct compression. More so on direct

    1st consult offload with with Semi compressed felt and PPT and ordered US to rule out foreign body and see how it responded to offloading. Couldn't touch it as too painful.

    2nd appointment- Ultrasound results discussed, offloading not successful. LA gel used and lesion lanced with purulent discharge. Painful but patient managed

    3rd appointment- symptoms were reduced for 3-4 days. Returned to similar levels pre lancing of lesion. LA gel used again and lesion lanced and very superficial curretted. Patient didn't want LA injected. Upon very superficial curettage I noticed lesion had break in skin striations but wasn't typical wart tissue.

    Reviewed patient 4 days post lesion currette and it is still bubbling away not as sore as previously but now has a whitey kind of scab overlying.

    2 other podiatrists in house have looked at the lesion and we're all stumped. My best guess is a ganglion with underlying bursitis, gouty trophy.

    US results and pic of lesion attached at first consult. Will get another pic upon review later this week.

    Cheers

    Joe
     

    Attached Files:

  2. LeonW

    LeonW Active Member

    Looks like cutting helped. What do u think of cutting it out? Why would u not cut it out? Mabe it will heal without u needing to take it all out?
     
  3. cheese14

    cheese14 Welcome New Poster

    I was thinking of cutting it out but I've never completed anything like this before and was wondering the procedure/ possible complications.

    Cheers

    Joe
     
  4. W J Liggins

    W J Liggins Well-Known Member

    Notwithstanding the US report, I would ellipse it out with a wide margin and send for report to the histopathology dept. It may be malignant

    Bill Liggins
     
  5. osheajm

    osheajm Welcome New Poster

    options:
    1 cut it out as previously suggested. He may not have the $$ for histopathogy & you haven't really done it before, but largely most of whatever it is is gone
    2. Refer to gp & get them to remove it, the histo will be bulk billed, & they cut things out all the time, & you'll get a definitive diagnosis of what it is,( if you wanted to get the gp to supervise you cutting it out, that could be good for cpd)
    3. Cryotherapy may do the job as well but you won't find out what it is.

    All the best, good luck
     
  6. Ros Kidd

    Ros Kidd Active Member

    Could turn out to be sinister and not something I would be handling myself. Personally I would refer to a dermatologist, it certainly does need removing, this may involve a plastics person. As the referral came from a GP and is clearly not a corn, possibly someone more qualified that the GP is needed for its removal. Love to know what the Histology report says.
    Regards
    Ros
     
  7. jhgilmartin

    jhgilmartin Welcome New Poster

    Hi Joe
    I agree with the comment above - it could be something more sinister and could therefore be out of our depth and therefore probably not appropriate for you to go chopping out. Tissue sampling? MRI? I would refer back to GP for referral onto dermatologist and continue with offloading for pain management while waiting for further intervention.

    Good luck! look forward to hearing the outcome.
     
  8. W J Liggins

    W J Liggins Well-Known Member

    Can I just gently suggest that this is a foot lesion, and therefore definitely within our purview? It is very reasonable for an individual practitioner to feel uncomfortable with a particular presentation but surely the correct response is to refer to a colleague who does deal with such matters (letting the GP know, of course)?

    I think it unlikely that an MRI would be a great deal more helpful than US in this case. I still maintain that histopathological examination after excision is the correct, and ethical course to follow.

    Bill Liggins
     
  9. Lab Guy

    Lab Guy Well-Known Member

    I agree with your thoughts Bill, but to me, there is only one way to treat a lesion if you suspect it may be malignant. Take a 2 mm punch biopsy first. The histopathological report will then provide you the next course of action. This way, if it is not malignant, you can excise the lesion without taking a wide margin of tissue to avoid excessive tension on the skin and possible symptomatic scar. If it is malignant, referral to an oncologist and partial amputation may also be necessary.

    If the patient cannot afford a biopsy, then do not treat the patient. Do not lower your standards based on what your patient can afford. Let the patient go elsewhere for treatment. It does not serve your patient nor your best interest to hope the lesion is not malignant when the consequences can be devastating.
     
  10. Greg Fyfe

    Greg Fyfe Active Member

    What are peoples thoughts on the role of dermoscopy in this case when considering the alternate options suggested so far i.e. excision and biopsy, punch biopsy, referral to others, MRI.

    http://www.dermnetnz.org/doctors/dermoscopy-course/


    http://www.dermnetnz.org/doctors/dermoscopy-course/dermatoscopic-histology.html#9
    includes a a section on dermatoscopic histologic correlaton of non pigmented lesions.


    I don't have a view myself,at the moment, but thought it was a worthwhile query.

    Regards
    Greg
     
    Last edited: Aug 24, 2015
  11. Lab Guy

    Lab Guy Well-Known Member

    If you remain suspicious of a malignancy after doing a dermatoscope, you still have to biopsy the lesion. I believe a biopsy will always be the definitive gold standard for diagnosis.



    Steven
     
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