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Piezogenic Pedal Papules

Piezogenic pedal papules are lesions that appear on the feet and wrists. These can either be accompanied by pain or be asymptomatic and they usually take the form of papules. It seems that they appear when fat herniates through the dermis, having a characteristic popular appearance. This is a common medical condition and generally asymptomatic in the majority of people. It is not genetically inherited and it is not related in general to connective tissue disease (in certain cases, it might be associated with such conditions but this is not a direct cause). As for the actual papules, these become obvious when the person stands up, distributing the entire body weight on the heels.

Symptoms of Piezogenic Pedal Papules

These are the most common symptoms of the piezogenic pedal papules:

Skin lesions in the form of papules appear on the feet and wrists
Pale to skin-colored
Obvious when weight is distributed on the feet (standing up), disappear when the person sits down and the weight is reduced
Bilateral involvement
Most often affects the heel of the foot, including the medial, posterior and lateral side
In the wrist, the volar surface is the one most affected (because of the pressure)
Pain might accompany the papules, preventing the person from performing certain activities
The papules present on the feet or wrists can be easily compressed

What are the Causes of Piezogenic Pedal Papules?

These are the most common causes associated with the appearance of the piezogenic pedal papules:

Excessive weight – obese patients have more weight to bear on their feet and this is why they present an increased risk for fat to herniate through the dermis layer of the skin
Occupation
- Standing for prolonged periods of time
- Constant pressure applied to the wrist
Associated with Ehlers-Danlos syndrome (collagen disorder)
Idiopathic (unknown cause)
Orthopedic problems
- Flat feet
Can occur in newborns (no predisposition)
Excessive weight bearing (physical exercise or other vigorous physical activity)
Repetitive pressure force on the said areas

Diagnosis

These are the most common methods used for the diagnosis of piezogenic pedal papules:

Clinical examination
- Identification of fat herniating through the dermis
No laboratory analysis
No imaging studies
Differential diagnosis – this can be made with the following medical conditions:
- Infantile pedal papules (bilateral congenital adipose plantar nodules/precalcaneal congenital fibrolipomatous hamartomas/pedal papules) – appear in newborns
- Xanthomas – painful lesion that occurs most often on the buttocks but can affect other areas of the body as well
- Tophi – appear in patients with gout, being represented by solid urate that deposits in the connective tissue.

Treatment

These are the most common treatment courses and recommendations made for people diagnosed with piezogenic pedal papules:

No oral or topical medication available or necessary
Orthotics and other devices are recommended in patients who exhibit symptoms
- Supportive external pressure device
- Heel taping
- Compression stockings
- Foam rubber foot pads
- Foam-fitting plastic heel cups
Rest and elevation might help with the symptoms (temporary relief)
Non-surgical approach
- Injections with betamethasone and bupivacaine – these are recommended for patients who have been diagnosed with Ehlers-Danlos syndrome, reducing the painful symptoms. Repeated injections are necessary for complete pain relief.
No surgery has proven to be effective for the treatment of piezogenic pedal papules but the surgical approach can be recommended for a skin lesion that is persistent and intensely painful.
Avoiding periods of prolonged standing, walking or running can help if the papules are painful (practically, the patient is recommended avoid any kind of physical activity that might involve excessive or prolonged weight bearing)
In case of excessive weight, patients are recommended to follow a weight loss program
Recent studies recommend electro-acupuncture as treatment for this medical condition.