06/08/2013    Name Withheld (MS)

Recurring Skin Lesions

I initially saw this healthy 51 years old patient
in 2011. Her only medical issue is being treated
with Lexapro, Wellbutrin and Xanax by a local
psychiatrist. She has no family history of
associated problems.

History of problem: Approximately 5 years before
I saw her, another local podiatrist performed
surgery on this patient’s 3rd toes (arthroplasty
PIPJ, removal of skin lesion, and flexor
tenotomy). She had (and still has) painful single
punctate hyperkeratosis on the plantar aspect of
both 3rd toes at the level of the PIPJ, third toe
only. There are no other grossly similar lesions
on the feet or hands and the patient claims no
other lesions anywhere on her body. The pathology
report from the original surgery did not mention
skin, only bone fragments. In January 2012, I
performed a bipedicle flap to cover her left
lesion and a direct closure to close her right. I
also modified the previous arthroplasty which had
some hypertrophic bone and scar tissue and
fixated it with an axial K-wire. The pathology
came back as “clavi (two)”. Healing was
uneventful.

In October 2012, she returned with a mild
recurrence of skin lesions on the flap, as well
as the direct closure toes (both) although much
smaller. At that time, I used loupes to examine
her entire foot and hands and saw very small,
isolated <1mm plaque-like hyperkeratosis 4-5 on
her feet and only 1 on her hand. They were
dramatically different in appearance from the
painful hyperkeratotic lesions on her digits I am
still unsure if there is a direct relationship.
On a functional exam with “C” arm I felt as
though the distal end of her proximal phalanx
stump was plantarflexed and could be contributing
to the problem.

Of course, padding was attempted and did give
temporary relief of symptoms. Given the bilateral
symmetry and the fact that these developed years
before-- I began to look at the flexor digitorum
brevis at a possible contributor to the
plantarflexion of the proximal phalanx and
resulting plantar lesion –which would admittedly
be rare bilaterally. Ultimately it was my belief
that a tight or abnormally functioning FDB to
both 3rd toes was the mechanical contributing
factor.

After much discussion and explanation with the
patient, we decided to remove the lesions again,
which were smaller at this time, and lengthen the
FDB as well as attempt to fuse the PIPJ. This was
done at the end of October, 2012. Healing was
without problem, but she did develop a stable non-
painful non-union at both PIPJs with a digital
implant.

I saw her last week and the skin lesions are back
and very similar to the original lesions that I
saw in early 2012. Note the proximal phalanx is
slightly dorsiflexed due to the FDB lengthening.
My inclination is that this is a primary skin
issue. After three failed attempts to resolve
this problem, the patient wants to try again. I
have suggested referral and second opinions – but
honestly, there is no one locally (even at the
University-derm or plastics) that has come up
with a novel idea except amputation, which the
patient refuses. Comments welcome!

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