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 81-year-old white female patient had had a painful tumor at the lateral malleolus of\nthe right ankle for three years. Physical examination revealed an erythematous tumor\nwith a small central ulceration on the right lateral malleolus ( and ). The\nfollowing hypotheses were formulated: cutaneous annex tumor, fibrosarcoma, schwannoma,\ncutaneous lymphoma, basal cell carcinoma and squamous cell carcinoma. Next, a lesion\nbiopsy was performed.\nHistopathology showed epidermis-derived, intertwined epithelial cords, ending in thin\nprojections. Some of these projections had a typical 'crab claw' appearance. Between\nthese cords, a rich fibrovascular stroma is present (). Light formations of the eccrine ducts were identified within some\nof the cords ().\nThe patient was referred to the plastic surgery service, where surgical excision and\nreconstruction by a reverse-flow supramalleolar flap were done (). Three months postoperatively, the patient was completely\nrecovered ().