A 42-year-old man presented with slowly progressive asymptomatic red plaques on the left foot which developed over 4 years. He was treated by topical corticosteroids with minimal improvement. He had no weight loss, prolonged fever, or night sweat. There was no family history of similar lesions. He had a 7-year history of type 2 diabetes mellitus which was treated with oral metformin and insulin injections. He had undergone amputation of the 1st, 2nd, and 3rd toe of the left foot due to neuropathic arthropathy 5 years earlier.\nPhysical examination revealed two discrete, well-defined, moist, macerated, erythematous, verrucous plaques on a background of diffuse red-brown discoloration on the left foot (fig. , fig. ). Peripheral arterial pulses on both legs were normal and regular. There was no fever, lymphadenopathy, or hepatosplenomegaly. Other physical examinations were within normal limits. A 4-mm punch biopsy specimen was obtained from the lesion for routine histological examination.\nHistopathological results showed multiple foci of thin anastomosing strands of uniform cuboidal cells emanating from the epidermis. The epithelial strands showed ductal differentiation, embedded within fibrovascular stroma (fig. , fig. ). Doppler ultrasound of the left leg showed evidence of severe degree of venous reflux involving the left saphenofemoral junction and common femoral vein.\nIn this case, a complete excision with flap or graft was offered but the patient refused surgery. He was treated with monthly cryotherapy using liquid nitrogen spray and attended follow-ups with surveillance for malignant change. Venous stripping was performed as the treatment for severe venous reflux, which resulted in partial improvement of the lesion.
A 90-year-old Japanese woman presented with a 4-year history of hyperkeratotic lesions on her left heel that had not been improved by topical treatment with salicylic acid petrolatum ointment or 10% urea cream. There was no history of trauma, but she gradually found it hard to walk because of her left heel pain. The patient had been taking clopidogrel, aspirin, azosemide, metformin hydrochloride, and alogliptin benzoate for the treatment of chronic heart failure, angina, and diabetes mellitus, and all of these symptoms had been well controlled. At the first visit, a clinical examination revealed an erythematous plaque with multiple brown macules, ulcer, and hyperkeratosis ().\nDermoscopy demonstrated glomerular vessels with regular arrangement in the ulcer area () and red-black homogeneous areas in the erythematous area (). She had no particular family history. Although we recommended that she undergo a skin biopsy to diagnose the skin lesion, the patient and her family expressed a strong desire to treat the lesion through a single surgical operation because she was at an advanced age, and the possibility of squamous cell carcinoma could not be completely excluded. Therefore, the skin lesion was totally excised.\nThe histopathological examination revealed hyperkeratosis and thin anastomosing strands of cuboidal cells extending from the epidermis to the upper dermis (). Small ductal structures and cystic changes were observed within the interconnected strands of cells. Hematomas were found in the intracorneal region and upper dermis (). No mitotic or dysplastic cells were observed. The cells of the ductal and cystic structures were positive for carcinoembryonic antigen (CEA) (Figures and ). Based on these findings, the lesion was diagnosed as a reactive ESFA.