2013.1-11.Piezogenic

                                                                                                                            article in PDF  
Our Dermatol Online.  2013; 4(1): 61-63
DOI:.  10.7241/ourd.20131.11
Date of submission:  23.07.2012 / acceptance: 18.09.2012
Conflicts of interest: None
 

PIEZOGENIC PEDAL NODULES OF YOUNG CHILDREN AND THEIR PARENTS

Piotr Brzezinski1, Karol Kołatka2, Ahmad Thabit Sinjab3, Marta Bury4

1Dermatological Clinic, 6th Military Support Unit, Ustka, Poland
2Orthopaedic Clinic, 6th Military Support Unit, Ustka, Poland
3Department of General Surgery, District Hospital in Wyrzysk a Limited Liability Company, Wyrzysk, Poland
4Hospital in Jelenia Gora, Internal Medicine Ward, Jelenia Gora, Poland
 

Corresponding author:  Piotr Brzezinski, MD PhD    e-mail: brzezoo77@yahoo.com


 

Abstract
Introduction: Skin of atlets foot is open on constant effect of disadvantageous outword factors, which could be reason of illnesses in this area. Very ofen incidence disease is Piezogenic Foot Nodules (PN) These papules represent herniations of subcutaneous fat through the collagen matrix of the reticular dermis. Suggests that as many as 10% to 20% of the population may be affected with both symptomatic and asymptomatic lesions. Painful piezogenic papules are reported more frequently in women than in man. Among athletes they appear mainly at the marathon runners and valleybol players. Trauma may also initiate the formation of pedal papules. These are soft, skin collored, typically asymptomatic, medial heel papules and nodules, appear on the side of the heel, ussualy the medial aspect, when the subject is standing and disappear when weight is taken off the foot. Papules may be painful when there is herniation of fat into the dermis with a resultant reduction in dermal thickness. They could concern one or both feet. Ussually there are plural changes. There is no satisfactory medical or surgical treatment.
Aim: The aim of work is presentation family occurrence of PN.
Material and methods: Research concerned 50 children (girls and boys) in age about 5,5 years.
Results: Incidence of PN observed at 16 % children and 22.06% in check up group (5 children). In children and parents group 100% changes concerned heels. Pain reportered only 4 parents (5,88%).
Conclusions: Appearance skin changes during fat ill on Piezogenic Nodules is connected with doing more activity. Painful papules can limit participation in sports and may affect occupational activity.
 
Key words:  skin diseases; children; foot

 

Introduction
Skin plays many functions that are important for human organizm. It takes part in its defense mechanisms. When it comes to dermatoses, in certain cases skin is the only organ involved – in others skin changes are one of many symptoms preceding or accompanying various entities and illness syndromes. Sometimes, due to characteristic features, skin changes can be a clue facilitating correct diagnosis. Cutaneous eruptions, both on child’s skin and on adult man’ s skin, can often be a significant track leading to the origin of a disease. Changes on the skin can be restricted and therefore characteristic for specific localization, e.g. foot – the most peripheral part of a lower limb in human anatomy. Its structure is characteristic only for human being due to his vertical posture. Foot skin injuries are often observed in groups of physically active people. Therefore, the sportsmen are more affected by them than any other working group. What is more, certain entities are specific only for particular sport disciplines [1-3]. Piezogenic Pedal Nodules (PPN) – cutaneous herniae described in 1968 by Shelley and Rawnsley are not such uncommon entities [4]. Changes are manifested as nodules or papules and localized most often along the sole of the feet. They are flesh-coloured or yellowish. Their size oscillates between 0,5 and 1,5 cm. Other less frequent localizations are: wrists or thenar. PN occurs very often. We can distinguish two forms: 1) asymptomatic, observed in 10-20% of population [2] 2) painful one, observed mainly among the sportsmen or patients with diagnosed connective tissue diseases [5]. Having painful forms of PPN is also characteristic for the people with the injuries of the foot area. PN appear when a patient is in a vertical position. They disappear once he or she is in horizontal one. Moreover, patients can very often feel pain during standing or walking [2]. Changes may affect one or both feet. Nevertheless, the appearance on both sides is more frequent [6]. Usually changes are multiple. Singh et all observed a 22-year old men with 22 nodules and pustules on one foot and 17 on the other [7]. The main cause of PN changes is penetrating epiderma propria by subcutaneous fatty tissue on feet edges during the moment of increased weight [6,8]. Cutaneous herniae created in that way are related to resistance or genetic reduction of the number of septi in fatty tissue. PPN – like changes can occur at any age. In differential diagnosis lipomas, connective tissue mole/ stigma or neurofibroma are considered. The most affected group of people consists of sportsmen, esp. athletes. The aim of this work was to present the appearance of PPN on feet in the family.
 
Material and Methods
The research involved 50 children, girls and boys of 1-10 years (average: 5,5 years old) and their parents-68 people, men and women aged from 25 to 46 years (average age: 35,5). All of the parents, currently or in the past were members of sport clubs: 15 people played basketball, 29-volleyball, 18-football and 6 were athletes. The diagnosis was made on the basis of characteristic clinical symptoms. An interview regarding the incidence of connective tissue diseases as well as feet injuries in the past of the family or the interviewee was held.
 
Results
PN appeared in the group of 8 children (16%) (Fig. 1), (aged 4-10 years old): 25% were boys, 75%-girls. In the group of adults PPN was diagnosed in 15 cases (22,06%) (Fig. 2): 10-female (66,67%), 5-male (33,34%). None of the children complained about pain, whereas in the adult group 4 people (5,88%) suffered from pain. The interview regarding past feet` injuries was positive among 2 children with PPN. Other 2 children have positive interview related to connective tissue diseases (one of these children’s parents suffered from Morphea, the second from RZS). In the group of children with PPN the following changes were observed: – 1 child (12,5%) – only one foot affected, – The rest of children (87,5%) – changes appeared on both feet. The changes were localized on children’s heels. Among adults proportions were almost identical: – whole skin changes were linked to heel localization, – in 80% of cases changes appeared on one foot, – in 20% of cases on both feet.
 
Figure 1. Piezogenic Pedal Nodules in children
Figure 2. Piezogenic Pedal Nodules in an adult
 
Discussion
PN are observed in 10-20% of the the society [2]. In the population of our research (126 people) PPN were diagnosed in 23 cases (18,25%). PN can appear at any age. Greenberg and Krafchik noted incidence of PPN in 5,9% of examined newborns and in 39,45% infants from Canada [9]. Lorralde de Luna et all described 4 PPN cases among newborns from Argentina [10]. There is significant correlation between PPN and physical activity: PPN is often described in the group of people taking up different sport disciplines. This is the factor that can trigger changes among people of genetical predisposition (reduction of the number of septi in fatty tissue or their resistance) [11]. In our group this correlation reached 22,06%. Intensiveness of pain can differ. Laing in his group described pain syptoms in 86% cases of herniae [12]. In the male group analyzed by us pain appeared in 5,88%. Pain accompanies PPN in cases of connective tissue disease or past feet injuries. Doukas believed that the major causative factor of PPN is either positive feet injury history or genetically inhabited connective tissue diseases [13]. Kahana et all described PPN incidence among more than 34,5% patients with Ehlers- Danlos Syndrome [5]. Family incidence of PPN was also described [14]. In our research familial occurance was expressed in 8 cases, in 4 cases changes correlated with injuries and connective tissue diseases. Treating in case of asymptomatic changes is not needed. In other cases painfull nodules and papules can be excised surgically [15]. It is recommended to reduce body weight (especially for overweight people) and to avoid long staying in standing positions [2]. Doukas et all suggested non-surgical approach towards treatment. They injected betametazone and bupivacaine in equal parts (1-2ml/injection), in 3 doses, in 1-3-5 –month intervals. The last 3rd injection resulted in pain vanishing. Moreover, they also tried using electroacupuncture [16]. Pantious et all used special orthopedic coverings for heels in cases characterized by intense pain [17].
 
Conclusion
The appearance of changes in the course of PPN is significantly related to the intensiveness of physical activity. Training is a factor that can trigger changes in people with genetic predisposition. There is a possibility of the incidence of PPN among family, especially if one of the parents was physically active and trained a lot in the past.
 
REFERENCES
1. Bender TW: Cutaneous manifestations of disease in athletes. Skinmed. 2003;2:34-40. 2. Mailler-Savage EA, Adams BB: Skin manifestations of running. J Am Acad Dermatol. 2006;55:290-301. 3. Caputo R, De Boulle K, Del Rosso J, Nowicki R: Prevalence of superficial infections among sports-active individuals: results from the Achilles survey, a review of the literature. J Eur Acad Dermatol Venereol. 2001;15:312-6. 4. Shelley WB, Rawnsley HM: Painful feet due to herniation of fat. JAMA. 1968;205:308-9. 5. Kahana M, Feinstein A, Tabachnic E: Painful piezogenic pedal papules in- patients with Ehlers-Danlos syndrome. J Am Acad Dermatol. 1987;17:205-9. 6. Zaidi Z, Jafri N, Noori B, Thawerani H: Piezogenic papules a study of 100 cases. J Pak Med Assoc. 1995;45:93-4. 7. Singh S, Kalla G, Jain VK: Painful piezogenic pedal nodules. Indian J Dermatol Venereol Leprol. 1992;58:271-2. 8. Hassan I, Sajad P: Piezogenic pedal papules in a young female. Our Dermatol Online. 2012;3:358. 9. Greenberg S, Krafchik BR: Infantile pedalpapules. J Am Acad Dermatol. 2005;53:333-4. 10. Lorralde de Luna M, Ruizleon J, Cabera HN: Pedal papules in newborn infants. Med Cutan Ibero Lat Am. 1990;18:9-12. 11. Berger-Czop B, Brzezińska-Wcisło L, Trzmiel D: Bolesne grudki pizogeniczne-opis przypadku. Post Dermatol i Alergol. 2007;5:238-40. 12. Laing VB, Fleischer AB Jr: Piezogenic wrist papules: a common and asymptomatic finding. J Am Acad Dermatol. 1991;24:415-7. 13. Doukas DJ, Holmes J, Leonard JA: A nonsurgical approach to painful piezogenic pedal papules. Cutis. 2004;73:339-40,346. 14. Gibney MD, Glaber DA: Piezogenic pedal papules in two family members. Cutis. 1996;57:260-2. 15. Leslie KS, Grattan CE: Piezogenic pedal and palmar papulosis. Eur J Dermatol. 2002;4:369. 16: Woodrow SL, Brereton-Smith G, Handfield-Jones S: Painful piezogenic pedal papules: response to local electro-acupuncture. Br J Dermatol. 1997;136:628-30. 17. Pontious J, Lasday S, Male R: Pizogenic pedal papules extending into the arch. Case eport and discussion. J Am Pediatr Med Assoc. 1990;80:444-5.


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