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Non-healing ulcer on the toe

BMJ 2008; 337 doi: (Published 27 November 2008) Cite this as: BMJ 2008;337:a2460
  1. E E Craythorne, specialist registrar,
  2. A W P du Vivier, consultant
  1. 1Department of Dermatology, King’s College Hospital, London SE5 9RS
  1. Correspondence to: E E Craythorne emma_craythorne{at}

    A 59 year old Somalian woman went to her podiatrist for treatment of a lesion on her right great toe, which followed an injury eight months before. At that time radiography showed soft tissue swelling only. She was referred to an orthopaedic surgeon and admitted for intravenous antibiotics and wound debridement. However, the lesion continued to be painful and to bleed spontaneously. Despite regular dressings the wound failed to heal and she was referred to a dermatologist.

    On examination she had a pigmented ulcerated lesion on the distal right great toe, measuring 3×2 cm, which had replaced the nail and had extended over both lateral and distal borders (figure). The lesion was more macular at the periphery and an area of depigmentation was seen. General examination revealed lymphadenopathy in the right groin.

    Pigmented ulcerated lesion on the distal right great toe

    A biopsy was taken to confirm the diagnosis. Positron emission tomography showed deposits in the right groin.


    • 1 What is the diagnosis?

    • 2 How should it be managed?

    • 3 What are the risk factors for this diagnosis?

    • 4 What is the prognosis?


    Short answers

    • 1 Acral lentiginous melanoma—a distinct variant of cutaneous melanoma. This variant is the most common type of melanoma found in people with dark skin (Fitzpatrick type VI). It is relatively rare in white people.

    • 2 The diagnosis must be considered carefully—acral lentiginous melanoma is misdiagnosed in about a third of cases. She should be referred to a …

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