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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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