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A 4-month-old girl presents with papules on her heels
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A 4-month-old female was seen in the clinic for evaluation of papules on her heels that had been present since birth. The lesions were symmetrically located on both heels and appeared to be asymptomatic, according to the parents. The lesions had not changed over the past few months, and the child was otherwise healthy. The child’s medical record noted that she was born full-term via spontaneous vaginal delivery.
On exam, the bilateral medial heels had prominent symmetric, skin-colored, firm papules. The papules were visible when the child was sitting up as well as while she was lying down.
Figure 1. Infant presents with bilateral, symmetric, skin-colored papules over the heels.
Image: Perman MJ
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Case Discussion
Infantile pedal papules (C) are asymptomatic, skin-colored papules located on the medial aspect of the foot and often extend onto the heel. These papules have been described by many different names, including congenital pedal papules, congenital piezogenic-like papules, bilateral congenital fatty heel pads, plantar fibromatosis of the heel, precalcaneal congenital fibrolipomatous hamartoma, and bilateral congenital adipose plantar nodules. Distribution is usually bilateral and symmetric.
Piezogenic pedal papules have a similar appearance; however, these lesions occur on the lateral and posterior surface of the feet in older children and adults. Compared with piezogenic pedal papules, infantile pedal papules usually do not accentuate with standing. The etiology is unknown, but many authors have hypothesized that the papules are due to congenital herniation of fat tissue through the muscle. Another hypothesis is that these are hamartomatous lesions of normal fetal tissue that has incompletely regressed. These lesions typically resolve spontaneously by the time the child is aged 2 to 3 years.
The differential diagnosis in an infant with papular or nodular lesions on the plantar surface of the heels includes calcinosis cutis, infantile digital fibromatosis, scabies and plantar warts. Calcinosis cutis usually presents with a tiny white papule that gradually enlarges over time to become nodular; generally, the lesion is unilateral and not multifocal. Calcinosis cutis is most commonly seen in infants who received multiple heel sticks and, in this location, is referred to as “heel stick calcinosis.” Similar to pedal papules, these lesions usually spontaneously resolve with time.
One could consider the diagnosis of infantile digital fibromatosis with the appearance of nodules on the foot of an infant; however, these lesions are usually present on the extensor or lateral aspects of the fingers or toes rather than the plantar surface. Infantile digital fibromatosis usually spontaneously regresses over a few years.
Scabies also should be on the differential when an infant is noted to have nodular lesions on the plantar surface of the heels. However, the presentation would be very different than this case as infants with nodular scabies are extremely itchy and should present with cutaneous findings on other areas of their body — such as wrists, hands, axillae and genitalia — which are not involved here.
Due to the location on the plantar surface, the differential could include warts. However, warts should have a verrucous surface rather than the smooth surface seen in this case, are less likely to be symmetric, and would be unlikely to be present at birth or in an infant.
Infantile pedal papules present as bilateral, symmetric, skin-colored papules over the medial foot and heels of an infant. Practitioners should be aware of this diagnosis in order to reassure parents that these are benign, asymptomatic lesions that will spontaneously involute over time.
- References:
- Greenberg S, et al. J Am Acad Dermatol. 2005;doi:10.1016/j.jaad.2005.02.035.
- Paller AS, et al. Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. 4th ed. Philadelphia, PA; Elsevier Saunders; 2011.
- For more information:
- Jenna L. Streicher, MD, is a pediatric dermatology fellow at The Children’s Hospital of Philadelphia. She can be reached at streicherj@email.chop.edu.
- Marissa J. Perman, MD, is an attending physician at The Children’s Hospital of Philadelphia.
Disclosures: Streicher and Perman report no relevant financial disclosures.