A 78-year-old man with type 2 diabetes of 5 years' duration was referred with a discharging subungual ulcer on his right hallux which had been present for 8 years. Pedal pulses were palpable. The footwear was narrow and insufficiently roomy, and he was asked to purchase shoes with a deep toe box which would not cause pressure on the nails.
The toe nail was cut back. The patient wore suitable shoes, and the ulcer improved, with less discharge, but
failed to heal completely. An X-ray showed no signs of osteomyelitis.
When the foot failed to heal after 3 months, the patient was referred to dermatology for an opinion (Fig. 4.43). Although the dermatologists were not really suspicious that there was any neoplasia present because the area was not elevated, they felt that it would be wise to check, and a biopsy was arranged. A malignant melanoma was diagnosed and the toe was amputated. The patient is alive and well 3 years later and has regular follow-up appointments with the dermatologists.
• Ulcers which fail to heal after full treatment should be regarded as suspicious lesions and referred to the dermatologists for biopsy
• Malignant melanomas may be amelanotic
• Malignant lesions may not be elevated.
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