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A 65-year-old woman presents with numerous lesions on the feet below the level of the ankle joint. She indicates that the lesions have been present for several years and do not cause pain or itching. Her concern is primarily cosmetic. Examination reveals asymmetric, scattered lesions on both feet that are variable in size and appear as well-circumscribed, flesh-colored papules. No tenderness to palpation is noted, and no similar lesions are present elsewhere.
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Pedal papules, also known as piezogenic papules, are herniations of the subcutaneous fat of the plantar foot through the adjacent dermal tissue. These lesions often are flesh-colored and occur as a direct result of weight-bearing.1 Populations at highest risk for piezogenic papules include obese, flat-footed individuals or those who work in jobs that require long periods of standing or axial loading.2 There is also a well-described link between Ehlers-Danlos syndrome and other connective tissue diseases. It is theorized that impaired collagen synthesis in these patients can lead to characteristic connective tissue weakness and, consequently, tissue herniation.3
Piezogenic papules may present with or without pain. Painless lesions typically are only a cosmetic concern for patients and often can be managed conservatively using compression stockings, taping, orthotics, and electroacupuncture.4 If the lesions are painful or bothersome, the following treatment options can be considered: avoidance of long periods of weight-bearing or high-impact activities, weight loss, use of compression stockings and/or heel cups, acupuncture, or corticosteroid injections. Surgical management of these patients should be considered last for recalcitrant cases.5
Nelson Maniscalco, DPM, is a podiatric-dermatology fellow under the aegis of St. Luke’s Medical Center and the DermDox Centers for Dermatology, and Stephen Schleicher, MD, is director of the DermDox Center for Dermatology, as well as an associate professor of medicine at Commonwealth Medical College and a clinical instructor of dermatology at Arcadia University and Kings College.
References
- Altin C, Askin U, Gezmis E, Muderrisoglu H. Piezogenic pedal papules with mitral valve prolapse. Indian J Dermatol. 2016;61(2):234.
- Brown F, Cook C. Piezogenic pedal papule. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2019.
- Poppe H, Hamm H. Piezogenic papules in Ehlers-Danlos syndrome. J Pediatr. 2013;163(6):1788.
- Doukas DJ, Holmes J, Leonard JA. A nonsurgical approach to painful piezogenic pedal papules. Cutis. 2004;73(5):339-340.
- Ma DL, Vano-Galvan S. Piezogenic pedal papules. CMAJ. 2013;185(18):E847.
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