1. A 22-year-old woman dropped an iron on her toe yesterday. Today, the toe is painful at rest and worse with movement.
Diagnosis: The patient was diagnosed with a subungual hematoma and a possible fracture of the distal phalanx. In this case, the clinician offered to drain the hematoma but did not have access to an electrocautery unit. The patient consented to any procedure that would relieve the pain. An open paperclip, held in a hemostat and heated with a torch, was used to pierce the patient’s nail plate and drain the blood, providing immediate relief. Citing lack of insurance, the patient declined an x-ray, despite the possible fracture. The toe was bandaged, and the patient was instructed to keep it elevated and avoid weight-bearing activity. Her toe healed well, and no radiographs were taken.
For more information, see “ Painful toe .” J Fam Pract . 2011;60(12).
2. For the past month, a man in his 50s has had a discolored right foot with increasing tenderness, as well as livedo reticularis on the sole and lateral aspect. He has a history of right-arm arterial thrombosis, multiple deep vein thromboses of the legs, ischemic stroke, atrial fibrillation, peripheral arterial disease, and long-term warfarin treatment. Pulses are palpable on exam.
Diagnosis: The patient was diagnosed with antiphospholipid syndrome. He remained on inpatient anticoagulation therapy with fondaparinux and was treated with pulse-dose IV corticosteroids followed by a slow oral taper: daily plasmapheresis for one week, three doses of IV immunoglobulin (0.5 g/kg), and four weekly doses of rituximab (375 mg/m 2). His cutaneous findings slowly improved over the next several weeks.
For more information, see “ Cyanosis of the Foot .” Cutis. 2017;100(4):206, 209-210.
3. A 35-year-old woman presents in January with purplish toes that are markedly tender to pressure. Recurrent over three successive winters, the initial symptom is an itchy, burning sensation in her toes. The discoloration and other symptoms are constant, not episodic. The condition resolves each year in late spring. Her distal pulses are normal.
Diagnosis: Pernio—also called perniosis or chilblains—is a common dermatologic condition associated with a cold, humid climate. The inflammatory lesions of pernio may be pruritic, painful, erythematous to violaceous plaques, papules, or nodules, which may have overlying blisters or ulcerations. The condition is frequently misdiagnosed; proper diagnosis relies on patient history and clinical picture. Histologic examination is typically not needed or definitive. This patient had moderately disabling pernio, which responded promptly to therapy with a calcium channel blocker.
For more information, see “ Erythrocyanotic Discoloration of the Toes .” Cutis. 2000;65(4):223-226.
4. For three days, a 63-year-old man has had severe, sudden-onset pain in the right hallux and fifth toe. The patient has hypertension and hyperlipidemia and has not undergone any vascular procedures. Physical exam reveals cyanotic change with remarkable coldness on the affected toes and livedo reticularis on the underside of the toes. Pulses are palpable. A biopsy of the fifth toe reveals thrombotic arterioles with cholesterol clefts.
Diagnosis: There are a variety of causes for blue toe syndrome , including embolism, thrombosis, vasoconstrictive disorders, infectious and noninfectious inflammation, extensive venous thrombosis, and abnormal blood circulation. Among them, only emboli from atherosclerotic plaques give rise to cholesterol clefts on biopsy. Such atheroemboli are often an iatrogenic complication, especially those caused by invasive percutaneous procedures or damage to the arterial walls from vascular surgery. However, spontaneous plaque hemorrhage or shearing forces of the circulating blood can disrupt atheromatous plaques and cause embolization of cholesterol crystals—which was likely the case with this patient, since no preceding events were noted.