Photo Quiz

Pink-Colored Papule on the Dorsal Foot



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Am Fam Physician. 2008 May 15;77(10):1449-1450.

A 64-year-old man presented with a lesion on his right foot. Over the preceding three years, the lesion had slowly increased in size. The patient denied pruritus, pain, bleeding, or ulceration of the lesion.

On physical examination, a pink, fleshy, dome-shaped papule, 9 mm in diameter, was noted at the dorsal base of the right second toe (see accompanying figure). A shave biopsy was performed.

Question

Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?

A. Acquired digital fibrokeratoma.

B. Digital mucinous cyst.

C. Fibroepithelioma of Pinkus.

D. Intradermal nevus.

E. Pyogenic granuloma.

Discussion

The correct answer is C: fibroepithelioma of Pinkus. Pathologic evaluation of the biopsy specimen revealed an intricate, net-like proliferation of thin, branching, anastomosing strands of basaloid cells embedded in a loose, dermal, fibrovascular stroma. This histologic pattern is consistent with fibroepithelioma of Pinkus. Fibroplasia of the dermal stroma and solar elastosis were also noted.

In 1953, Hermann Pinkus originally described the condition as a premalignant fibroepithelial skin tumor that may develop into basal cell carcinoma.1 The lesion usually appears as a flesh- to pink-colored, dome-shaped, sessile papule; however, there has been at least one report of a pigmented lesion.2

There is controversy regarding the appropriate pathologic classification of fibroepithelioma of Pinkus. Although the condition has traditionally been considered a rare variant of basal cell carcinoma, more recently it has been classified as a benign, follicular neoplasm called a trichoblastoma.3,4

Regardless of the pathologic classification, the clinical behavior of fibroepithelioma of Pinkus differs from that of basal cell carcinoma. Classic basal cell carcinoma appears as an erythematous patch (superficial variant) or a pearly, translucent papule with adjacent vascular dilatation (nodular variant). In addition, basal cell carcinoma locally invades surrounding tissue, resulting in bleeding, local extension, and ulceration. In contrast, fibroepithelioma of Pinkus is papular without a pearly appearance and does not lead to telangiectasias. Fibroepithelioma of Pinkus has a much more indolent and less aggressive clinical course.5,6 Basal cell carcinoma typically occurs on sun-exposed areas of the head and neck, whereas fibroepithelioma of Pinkus typically occurs on the trunk.4

Treatment of fibroepithelioma of Pinkus is similar to that of other variants of basal cell carcinoma. Simple excision with 4-mm margins is usually adequate, although Mohs' surgery is an alternative.6 Curettage and electrodesiccation, cryosurgery, and radiation are less favorable treatment modalities.

Acquired digital fibrokeratomas are nodular, isolated, flesh-colored growths that typically occur on the hands and feet. The growths are pedunculated or sessile and have been associated with trauma of the affected area.7

Digital mucinous cysts are mucin collections that appear as soft, pink-white to translucent growths on the dorsal surface of a distal phalanx. They most commonly occur in middle-age and older adults.8

Intradermal nevi may lose pigmentation over time and can transition from brown hues to a light-pink color. Dome-shaped lesions are common, although verrucous, polypoid, or pedunculated lesions also may occur.8

Pyogenic granulomas are acquired vascular lesions of the skin and mucous membranes. The rapidly growing lesions are bright red, glistening, and dome shaped. They are more common in children and young adults and are triggered by trauma or hormonal factors.8

Selected Differential Diagnosis of a Flesh- to Pink-Colored Papule on the Foot

Condition Characteristics

Acquired digital fibrokeratoma

Isolated, flesh-colored, pedunculated or sessile nodule; collarette of scale surrounding the lesion

Digital mucinous cyst

Soft, pink-white to translucent, solitary, dome-shaped nodule

Fibroepithelioma of Pinkus

Pink- to flesh-colored, solitary, dome-shaped, sessile papule

Intradermal nevus

Brown- to pink-colored lesion; dome-shaped, pedunculated or sessile papule

Pyogenic granuloma

Bright red, glistening lesion; eruptive, rapid growth; friable; bleeding and ulceration are common; polypoid nodule or papule

Selected Differential Diagnosis of a Flesh- to Pink-Colored Papule on the Foot

View Table

Selected Differential Diagnosis of a Flesh- to Pink-Colored Papule on the Foot

Condition Characteristics

Acquired digital fibrokeratoma

Isolated, flesh-colored, pedunculated or sessile nodule; collarette of scale surrounding the lesion

Digital mucinous cyst

Soft, pink-white to translucent, solitary, dome-shaped nodule

Fibroepithelioma of Pinkus

Pink- to flesh-colored, solitary, dome-shaped, sessile papule

Intradermal nevus

Brown- to pink-colored lesion; dome-shaped, pedunculated or sessile papule

Pyogenic granuloma

Bright red, glistening lesion; eruptive, rapid growth; friable; bleeding and ulceration are common; polypoid nodule or papule

Address correspondence to Brett Summey, MD, at summey@alumni.unc.edu. Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

1. Pinkus H. Premalignant fibroepithelial tumors of skin. Lancet Neurol. 1953;67(6):598–615.

2. Strauss RM, Edwards S, Stables GI. Pigmented fibroepithelioma of Pinkus. Lancet Neurol. 2004;150(6):1208–1209.

3. Ackerman AB, Gottlieb GJ. Fibroepithelial tumor of Pinkus is trichoblastic (basal-cell) carcinoma. Lancet Neurol. 2005;27(2):155–159.

4. Bowen AR, LeBoit PE. Fibroepithelioma of Pinkus is a fenestrated trichoblastoma. Lancet Neurol. 2005;27(2):149–154.

5. Saldanha G, Fletcher A, Slater DN. Basal cell carcinoma: a dermatopathological and molecular biological update. Lancet Neurol. 2003;148(2):195–202.

6. Su MW, Fromer E, Fung MA. Fibroepithelioma of Pinkus. Lancet Neurol. 2006;12(5):2.

7. Vinson RP, Angeloni VL. Acquired digital fibrokeratoma. Lancet Neurol. 1995;52(5):1365–1367.

8. Habif TB. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 4th ed. New York, NY: Mosby; 2004.

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