What are those white bumps on your heels that you only see when you stand?

Answer 1

A 25-year-old white female was referred to the dermatology clinic by her primary care provider for evaluation of bumps on her heels. The patient reported that the bumps had been on her heels, unchanged and asymptomatic, for "as long as I can remember." The bumps were visible when she stood up and put weight on her heels but immediately disappeared when she sat down. They had not been clinically evaluated before our examination and no treatments had been attempted.

The patient was otherwise in good health. She had no other skin complaints. She did not take any medications regularly and denied alcohol or tobacco use.

Physical examination revealed 10 to 15 smooth papules and nodules ranging in size from 2 to 7 mm (see Figure1). The lesions were evenly distributed on the medial aspects of both of the patient's heels and visible only with weight bearing. The flesh-colored, palpable lesions were soft and compressible but nonmobile. There was no associated erythema, edema, or scale. The examination of the patient's remaining skin was unremarkable except for the presense of mild nummular eczema and seborrheic dermatitis seen on her trunk and scalp.

WHAT IS YOUR DIAGNOSIS?• Cysts

• Verruca vulgaris

• Piezogenic pedal papules

• Lipomas

DISCUSSIONThis patient has piezogenic pedal papules. A common condition, piezogenic pedal papules are caused by fat herniations through defects in the dermis.

The diagnosis is not likely to be cysts because of the location of the papules. The heel is a highly unlikely location for cysts to appear. Furthermore, cysts would be firmer and would not be elicited by weight bearing.

Verruca vulgaris, or warts, is not a likely diagnosis because the smooth lesions observed here lack the rough surface seen with warts. Verucca vulgaris also would not be induced by weight bearing.

Although lipoma should be considered in the differential diagnosis, it is not the correct diagnosis for this patient. Lipomas are discrete, rubbery papules or nodules that would not be generated by weight bearing. They are not likely to occur in multiples and very rarely appear on the feet.

TREATMENT Piezogenic pedal papules can occur on the medial or lateral heel. The lesions are generally asymptomatic, and most patients do not require treatment. However, some patients will experience pain, especially when standing for extended periods of time. Obese people or those who suffer repeated trauma to the heels also may experience pain. Weight loss and avoidance of standing for prolonged periods of time may relieve the pain in some patients. Other possible treatment options include plastic heel cups or surgical excision.

Piezogenic pedal papules are often misdiagnosed because they are common and can have a possible symptomatic course. Clinicians must be able to accurately diagnose these papules to determine potential treatment options. JAAPA