I would like to tell you a tale, not one of mystery and intrigue, but of frustration and pain. No, this is not the first chapter of my next murder mystery, but an everyday occurrence, a scenario that takes place frequently in exam rooms across the country. Someone presents with a small painful callus on the bottom of the foot. The health care provider performs a cursory exam and provides treatment. An important question here that should come to mind: was an accurate diagnosis made before treating?

This is the story of Brian, a fairly average bloke, a hard-working fellow, employed as a maintenance worker, spending long hours on his feet, performing physical work. When Brian experienced a sharp pain emanating from the bottom of his right foot while working one day, he thought nothing of it. He had had this job for years, so some foot pain was to be expected. He spent ninety-five percent of his work day on concrete surfaces, doing hard labor. The conclusion he had reached, as do so many people, was that foot pain was a natural product of hard work. Plain and simple, his feet were supposed to hurt.

I hear this so often, too often, for my tastes. It’s a widely held belief: foot pain is normal if you perform physical work. But think about it…..if this were true, everyone who worked hard would have foot pain. I can assure you this is not the case. Certainly, more physical activities do indeed stress the many structures that support us, skin included. Especially the feet. Another example of nature’s amazing engineering, the feet do experience tremendous amounts of stress, of which there are many types.

Sheer forces occur with every step, defined as a sort of twisting action exerted on certain areas of the bottom surface. These twisting and pulling forces experienced by our body’s “envelope” can produce a great variety of skin problems. The consequences can instigate all manner of cellular and molecular changes, from thickening of the skin (your basic callus), to skin cancer (a possibility that devoted readers will be familiar with).

But let’s get back to Brian, our intrepid laborer, dealing with a gradually worsening problem. Whereas initially, the pain from the ball of his left foot was experienced but rarely, it had progressed to the point it was a daily problem. Early on, the sore area of his foot revealed only some superficial callusing. But over the years, the pain became sharper and the callus better defined. He tried the usual, home-spun methods, the latest innersole, the finest callus cream. As you have likely predicted, these attempts were unsuccessful.

Time to seek professional help; Lisa, the x-ray technician who lived next door. Although this may come as a surprise, radiology technician’s school is not heavy on the pedal dermatology. She peeked, primarily in horror, at his foot but was unable to arrive at a definitive diagnosis. But Lisa’s mother was the Romanian equivalent of a gypsy witch doctor. Her recommended treatment involved the application of certain food products. Finally, Brian’s primary care physician thought it might be a wart, and proceeded to freeze it with some form of cryotherapy. It hurt for a while, then it felt better, and then it hurt again. Just like it always did.

Has anyone wondered at the specific diagnosis responsible for this gentleman’s pain? Many health care providers will be asking this question, even after examining Brian’s foot. Arriving at a diagnosis is often a difficult task with plantar skin lesions (ie skin problems on the bottom of the foot). The tremendous pressures experienced by the skin of this area will cause any type of growth to be forced inward, into the foot, rather than grow out. Thus, identification is noticeably more difficult if only because you can’t actually see much of it. Another factor in this diagnostic challenge is a lack of familiarity. A health care provider who has not specialized in this tissue type or region of the body may not be properly acquainted with the problems originating here.

The skin of the human body is possessed of many different structures other than actual skin cells. One of the most common are oil and sweat glands, especially the skin of the plantar surface of the foot. Excessive pressure to one specific area of the foot, over time, can lead to a problem with these particular glands. The normal physiology of these cells is disrupted, leading to an inability to release the substance produced. The gland becomes plugged up, resulting in a “scarring in” of the gland. This plugged gland puts pressure on the local skin cells, and callus is produced. This is because any area of skin receiving excessive pressure and irritation over time will build callus tissue. The technical term for this lesion is porokeratosis plantaris discreta, or simply porokeratosis. And these lesions are not rarities, but an extremely common, and frustrating, occurrence. Many people have some variant of a porokeratosis and have not received the correct diagnosis, or they haven’t yet experienced the level of symptomatology requiring attention.

These lesions appear as a small, rounded callus with well-defined borders, whitish in color, often located at the ball of the foot, although they can be found elsewhere. Far too often, they are misdiagnosed as a wart, which is a viral infection of the skin. But porokeratoses are not due to an infection. Still, treating them as one would a wart can occasionally lead to eradication, although the success rate is poor. Padding, properly applied, can also give some relief by reducing the amount of pressure exerted on the area, but then, one still has the lesion.

This is a resistant problem, primarily due to the location of the gland, deeper than the many layers of skin. Often, sufferers will use various over-the-counter products, only to find the lesion comes back after some time. I have found one of the most successful methods to be the use of an agent that causes the gland to physically shrink up, eventually disappearing. Another excellent technique utilizes high-intensity radiowaves, vaporizing the cells of the gland. This method has a very good success rate and leads to resolution, usually after just one or two treatments.

These are just a few of the many techniques that can lead to relief. Sometimes, seeing a specialist is the quickest way to resolve some problem, since a physician treating only that type of pathology (foot problems being only one example) will be more familiar with the various pathologies responsible. An accurate diagnosis is a critical step leading to a cure, since, as should be logical, specific knowledge of the cause is important in developing a successful treatment plan.

The more we learn about medicine and the human body, the more there is to know. The evolution of modern medicine has been a process occurring over hundreds of years, meaning we know now more than we ever have. This abundance of information cannot be properly absorbed and utilized by one type of doctor, instead requiring many, each concentrating on a particular topic. Thus, the years have led to a proliferation in the number of medical specialties. It can pay off in the diagnosis and treatment of a painful porokeratosis, as it can for many problems.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.