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CORRESPONDENCE |
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| Year : 2016 | Volume
: 61
| Issue : 2 | Page : 227-228 |
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| Pedal poppers: Soles to hold |
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Balkrishna Nikam, Harsimran Kaur, Varsha Jamale, Mohan Kale
Department of Dermatology, Krishna Institute of Medical Sciences, Karad, Maharashtra, India
| Date of Web Publication | 1-Mar-2016 |
Correspondence Address:
Balkrishna Nikam
Department of Dermatology, Krishna Institute of Medical Sciences, Karad, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0019-5154.177763
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How to cite this article:
Nikam B, Kaur H, Jamale V, Kale M. Pedal poppers: Soles to hold. Indian J Dermatol 2016;61:227-8 |
Sir,
Piezogenic (Peizo – pressure, genic – giving rise to) pedal papules, usually present as skin colored painless bumps on the heel. These result from herniation of subcutaneous fat through connective tissue defects into the dermis. However, if painful, they can be distressing and difficult to treat.
A 20-year-old girl presented with painful lesions on both heels since 15 days. There was a history of aggravation of pain on walking or standing for long periods. Clinical examination revealed multiple skin-colored papules on the medial aspect of heels giving it a cobblestone appearance. The papules were approximately 8–10 in number on each heel, 3–8 mm in diameter, soft in consistency and became prominent on standing or applying pressure [Figure 1]a and disappeared on lifting the foot off ground and lying down [Figure 1]b. Skin biopsy from a papule suggested fragmentation of dermal elastic fibers with herniation of subcutaneous fat into the dermis [Figure 1]c and [Figure 1]d. On the basis of clinical and histopathological findings, a diagnosis of painful piezogenic pedal papules was made. The possibility of any associated hereditary connective tissue disease was ruled out clinically. No orthopedic abnormality was found on imaging. The patient was counseled to avoid prolonged standing and was provided satisfactory symptomatic management with “Micro-Cellular Rubber (MCR) insoles with a heel raise” [Figure 2]. | Figure 1: (a) Lesions become prominent on pressure (b) lesions disappear on lifting the foot off ground (c) fragmentation of elastic fibers (H and E, ×10) (d) herniation of subcutaneous fat in dermis (H and E, ×40)
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Painless piezogenic pedal papules often go unnoticed as they are symptomless. They represent normal peripheral fat chambers of the heel. They become painful only when there is entrapment of fat and its neurovasculature resulting in ischemia and anoxia. Though most often idiopathic, common associations of this entity include obesity, flat feet, excessive weight bearing, trauma, and collagen defect disorders such as Ehler–Danlos syndrome.[1] Xanthomas, tophi, and infantile pedal papules comprise the frequent clinical differentials.[2]
Painful piezogenic pedal papules are a therapeutic hurdle for the dermatologist. Conservative treatment measures include weight loss, avoiding standing for long periods, and reducing foot trauma. Various case reports suggest the use of compression stockings,[3] foam-fitted plastic heel cups,[3] local electroacupuncture,[3] combination of a steroid and anesthetic injections,[4] low-level laser light therapy [1] and even surgical excision [5] with variable success. However, we were able to manage this recalcitrant condition both successfully and conservatively with “MCR insoles with a heel raise.” The therapeutic aim is to prevent the excessive trauma caused with a hard sole and to redistribute the weight to the anterior part of the foot by increasing the thickness of the insole over the heel area. This will prevent herniation and resultant entrapment of fat. MCR footwear and insoles can be looked upon as a cheap and effective therapeutic option for institutional management of painful piezogenic pedal papules.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 References | |  |
| 1. | Karadaglic D, Mijailovic B. Painful piezogenic pedal papules – Successful low level laser therapy. Acta Dermatovenerol APA 2001;10:99-101.  |
| 2. | Greenberg S, Krafchik BR. Infantile pedal papules. J Am Acad Dermatol 2005;53:333-4. |
| 3. | Ma DL, Vano-Galvan S. Piezogenic pedal papules. CMAJ 2013;185:E847. [ PUBMED] |
| 4. | Doukas DJ, Holmes J, Leonard JA. A nonsurgical approach to painful piezogenic pedal papules. Cutis 2004;73:339-40, 346. |
| 5. | Karadag AS, Bilgili SG, Guner S, Yilmaz D. A cases series of piezogenic pedal papules. Indian Dermatol Online J 2013;4:369-71. [ PUBMED]  |
[Figure 1], [Figure 2] |
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