Derm Dx: White lumps on the heel when standing - Clinical Advisor

Derm Dx: White lumps on the heel when standing

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  • Piezogenic 1_0712 Derm Dx

  • Piezogenic 2_0712 Derm Dx

  • Piezogenic 3_0712 Derm Dx

A 55-year-old man presents complaining of asymptomatic lumps on the sides of his heels that appear when he is standing up, but seem to disappear when sitting.

The patient has a history of gout, having experienced two gouty attacks in his left large toe in the past 20 years. He takes hydrochlorothiazide for hypertension. His father died of melanoma, and his mother died of ovarian cancer. On exam, the patient has normal vitals signs. A full-body skin exam is significant only for soft, skin-colored papules on the side heels when weight-bearing. The papules largely disappear when he lifts his foot off the ground. The lumps are asymptomatic, but the patient is anxious for the diagnosis.

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Piezogenic pedal papules are small skin-colored papulonodules on the sides of the heels that represent herniation of fat through connective tissue. The word piezogenic is defined as "resulting from pressure." The pressure generated while bearing weight leads to fat herniation,...

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Piezogenic pedal papules are small skin-colored papulonodules on the sides of the heels that represent herniation of fat through connective tissue.

The word piezogenic is defined as “resulting from pressure.” The pressure generated while bearing weight leads to fat herniation, which causes the piezogenic pedal papules. Because of this the papules disappear when the leg is lifted.

Piezogenic pedal papules are so common in the general population that they can be considered a normal variant. They may be more frequently noted in athletic individuals. In general, piezogenic pedal papules are asymptomatic. Occasionally, long distance runners and other endurance competitors complain of pain. 

Piezogenic pedal papules have been reported in association with Ehlers-Danlos and Prader-Willi syndrome. There are also case reports of a non-weight-bearing variant in infants. 

Diagnosis   

Piezogenic pedal papules diagnosis is based on the physical exam finding of skin colored papules on the sides of the heels, which are more prominent with weight bearing and less noticeable when the leg is raised. 

Classically, gout is an acute monoarthritis of the large toe or knee caused by deposits of monosodium urate crystals. Clinically, this appears as a sudden attack of pain in the joint with swelling, redness and warmth.  

Soft corns occur most commonly between the fourth and fifth toes. They are painful, macerated keratoses caused by repetitive trauma.

Xanthelasma is the most common form of xanthoma, a condition in which lipid deposition occurs under skin. It is characterized by yellowish oblong papules near the inner canthi of the upper eyelids.  

Treatment and prognosis

Usually, no treatment is required since piezogenic pedal papules are largely asymptomatic. If a patient complains of pain, treatment options include avoiding prolonged weight-bearing activities, using a compression stocking, taping the heel, or using heel cups or orthotics to help prevent the herniation. Surgical excision is rarely required. 

Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine in Houston.

    References

    1. Bolognia J, Jorizzo JL and Rapini RP. Dermatology. St. Louis, Mo.: Mosby/Elsevier, 2008.
    2. James WD, Berger TG, Elston DM et al. Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunders Elsevier, 2006.
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