Can you identify these flesh-colored swellings?

THE CASE: A 13-year-old athletic boy is concerned about the nonpainful flesh-colored swellings on the lateral aspects of both his feet. He first noticed the lesions about a month earlier. He is otherwise well, and the remaining physical examination findings are normal.

What are these lesions?

A. Xanthomas

B. Skeletal abnormalities

C. Tophi

D. Piezogenic papules

The correct answer is D., Piezogenic Papules.

Discussion: Often called “painful” fat herniations, piezogenic papules are more commonly asymptomatic. The papules result from herniation of the subcutaneous fat through the dermis. They are typically multiple, soft, compressible, and most apparent when the patient is standing.¹ The lesions are frequently located on the lateral aspect of the heel or lateral midfoot, although they have been described on the wrists.² They can occur in healthy persons of any age, race, or sex.³

Piezogenic pedal papules tend to be benign lesions induced by pressure. However, painful piezogenic pedal papules have been associated with Ehlers-Danlos syndrome⁴ and with obesity and occupational or sports activities that require excessive weight-bearing or standing. The pain can limit participation in sports and may affect occupational activity.⁵

Infantile pedal papules, xanthomas, tophi, and skeletal abnormalities can mimic piezogenic pedal papules. These conditions can usually be ruled out through clinical evaluation.

Case and image courtesy of Michael W. Cater, MD, of Tustin, Calif.

1. Weston WL, Lane AT, Morelli JG. Color Textbook of Pediatric Dermatology. 2nd ed. St Louis: Mosby; 1996:199.

2. Laing VB, Fleischer AB Jr. Piezogenic wrist papules: a common and asymptomatic finding. J Am Acad Dermatol. 1991;24:415-417.

3. Hurwitz S. Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. 2nd ed. Philadelphia: WB Saunders Co; 1993:181.

4. Kahana M, Feinstein A, Tabachnic E, et al. Painful piezogenic pedal papules in patients with Ehlers-Danlos syndrome. J Am Acad Dermatol. 1987;17(2 pt 1):205-209.

5. Wolf A, Gruber F, Jackac D. Painful piezogenic pedal papules and physical activity [In German].Derm Beruf Umwelt. 1986;34:106-107.

6. Doukas, DJ, Holmes J, Leonard JA. A nonsurgical approach to painful piezogenic pedal papules.Cutis. 2004;73:339-340, 346.

RELATED CONTENT:

1. Rubenstein E, Combs A. Piezogenic pedal papules. Consultant. 2010;50:184.

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