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A 13-year-old boy presents with a black lesion on his heel
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A 13-year-old boy presented to the pediatric dermatology clinic for evaluation of a black lesion on the back of his right heel that had been present for at least the past couple of weeks. Parents are concerned that it may have been present longer but has gone unnoticed. The lesion is asymptomatic to the patient, and he has continued his normal regimen of basketball practice three times per week.
Jenna L. Streicher
Marissa J. Perman
Parents deny that the lesion has significantly changed in size since presentation. The patient is otherwise healthy with no significant past medical history. The mother noted that she tried to clean the area, but that the spots remained. She is very concerned as she has a personal history of melanoma.
On exam, the patient has violaceous-to-black, punctate macules on the posterior edge of the left plantar surface of the heel. The skin lines are uninterrupted.
Figure 1. Violaceous to black, punctate macules on the posterior, medial edge of the left plantar heel.
Source: Streicher JL
Click the image to enlarge.
Case Discussion:
Talon noir (D) — French for “black heel” — is caused by shearing forces due to physical activities. The condition goes by many names including “calcaneal petechiae” and “posttraumatic punctate intraepidermal hemorrhage.” These forces cause rupture of intradermal blood vessels, which eventually deposit as punctate hemorrhages in the stratum corneum. This condition is commonly seen in adolescents and young adult athletes who are quickly changing directions, as seen in basketball, lacrosse, tennis or soccer.
The lesions most commonly present on the heel due to this area being more susceptible to trauma and are usually unilateral. When found on the hands, the entity is called “tache noir.” Talon noir is asymptomatic and therefore often goes unrecognized. While the diagnosis is usually made clinically, it can be confirmed by using a #15 blade to pare the lesion, which often results in resolution. A hemoccult test can also be used to confirm the diagnosis, but is rarely necessary. The lesions will spontaneously resolve with time.
The differential diagnosis of a dark lesion on the plantar surface of the heel includes a wart, dysplastic nevus, melanoma and tinea nigra.
Due to the location on the plantar surface, a wart could be considered. Warts often have central black dots, which are dilated and thrombosed capillaries, and could be confused with talon noir. Warts, however, have a more verrucous surface change rather than the flat macules of talon noir. Warts also disrupt the skin lines.
An acral nevus is also on the differential of a dark lesion on the foot. The concern for melanoma or atypical nevus is a common reason for presentation of talon noir to a physician, as in this case, due to its dark black color. Unlike talon noir, a melanocytic process would not resolve with paring of the lesion.
Tinea nigra is a rare fungal infection caused by Hortaea werneckii that can present as brown-to-black macules commonly on the palmar or plantar surfaces. The fungus produces its own melanin-like pigment that leads to the characteristic brown appearance. This fungal infection is usually due to contamination from an environmental source such as soil or wood, but is uncommon in the United States. The lesions are asymptomatic and can be diagnosed by a potassium hydroxide scraping that reveals pigmented hyphae and oval spores.
Another consideration could include traumatic implantation of a foreign material. However, this is more likely to be symptomatic. If concerned about foreign material, paring and a hemoccult test could be used, which would be negative.
Talon noir presents commonly in athletes with black or violet-black macules located on the posterior plantar surface of the heels. Practitioners should be aware of this diagnosis in order to reassure parents that this is a benign process that does not require further work-up and will spontaneously resolve with time.
- References:
- Bolognia JL, et al. Dermatology. 3rd ed. Philadelphia, PA; Elsevier Saunders; 2012.
- James WD, et al. Andrews’ Diseases of the Skin: Clinical Dermatology. 11th ed. London; Saunders/Elsevier; 2011.
- Lao M, et al. J Pediatr. 2013;doi:10.1016/j.jpeds.2013.03.079.
Disclosures: Streicher and Perman report no relevant financial disclosures.