Case report 
aser, 
tfeatment 
Piezogenic pedal papules 
Painful piezogenic pedal papuks -
succ~eful low level lnser theraw 
B. Mijailovic, D. Karadaglic, T. Mladenovic, L. Popovic, R. D. Zečevic and M. D. Pavlovic 
SuMMARY 
Painful piezogenic pedal papules may be very difficult to treat. We describe two patients with this condi-
tion successfully treated with a low-level laser. A two-week treatment protocol induced a relatively long-
lasting pain relief without any side effects. 
Introduction 
Piezogenic pedal papules, first described by Shelley 
and Rawnsley (1), represent painless or painful pap-
ules, which appear on the side of the heel, usually on 
its medial aspect, when the patient is standing, and dis-
appear on sitting or lying. The condition, if painful, may 
be very distressing and recalcitrant to treatment. I-Ierein 
we have presented two patients with painful piezogenic 
pedal papules successfully treated with low leve! laser 
irradiation, which may be added to a rather long list of 
therapeutic modalities for this condition. 
Case reports 
Two patients, a 64-year-old man and a 63-year-old 
woman, presented with skin-colored, firm, painful pap-
ules and nodules distributecl over lateral and medial 
aspects of their heels, which croppecl up on stancling 
or walking and disappearecl on sitting or lying. Both 
patients had noted the papules severa! months earlier 
but they had been completely painless ancl asymptom-
atic until a few weeks before the referral to our depart-
ment. The number of lesions and their tenderness in-
creased graclually. 
Physical examination revealed a number of firm, 
skin-colorecl papules , 4-8 mm in diameter, while the 
patients were in an upright position and disappearecl 
on sitting (Figure 1). In a recumbent position, at sites of 
larger papules , hollow depressions conlcl be palpated. 
The female patient was biopsied. Histologic examina-
tion showed moclerate acanthosis, marked hyperkera-
tosis and orthokeratosis. There were numerous perivas-
cular spaces fillecl with fat tissue, mostly degenerated 
and acellular, without seconclary deposition of connec-
Acta Dermatoven APA Vol 10, 2001, No 3 - ---------- - ---------- --- ----- ----- 99 
Piezogenic pedal papules 
tive tissue fibers . The dermis was composed of mature 
coll agen fibers with a decreased number of elastic fi-
bers and without acidic and basic mucopolysaccharides. 
Standard measures usually used to alleviate the con-
dition, like foam mbber footpads or foam-fitting plastic 
heel cups in conjunction with avoidance of prolonged 
standing or walking were not sufficient to help the pa-
tients. Literature data suggest other treatment options 
like surgical removal of individual papules or compres-
sion therapy using foot-and-ankle stockings. However, 
as patients refused to undergo surgery and were not 
able to provicle aclequate stockings, low lever laser 
therapy was triecl asa means to eliminate the pain. They 
were treated with a pulsed diode soft laser (Ga-As, MID-
LASER, Irradia, Sweden) with a wavelength of 904 nm, 
the average power output of 60 mW, ancl freq uencies 
of 50 Hz (for pain) and 700 Hz (for swelling) at a dose 
of 1 J/cm2 per treatment. There were 10 treatment ses-
sions, the first five treatments once daily, and the next 
five applied every second day. The treatment produced 
a marked improvement in symptoms enabling the pa-
tients to resume their everyday activities. The firs t pa-
tient has been followecl up for more than a year ancl 
only over the last few weeks the pain has begun to re-
appear on standing. He has asked for further laser treat-
ments. The second patient has been followed up for 6 
months and she is stili without significant complaints. 
Discussion 
Piezogenic pedal papules are skin-colored and hard 
papules measuring 3-8 mm in diameter, and may be 
painless or painful. The pain may be persistent and more 
intense on standing (2) . If painless, they may go unno-
ticed and the persons may overlook their presence for 
a long tirne . 
Piezogenic pedal papules are usually seen in sub-
jects older than 40 years, mostly in women (3) . Shelley 
ancl Rawnsley (1) have assumed that piezogenic pedal 
papules represent pressure-induced herniations of the 
subcutaneous fat through acquired or inherited clefects 
in the connective tissue of the heel. The pain is then 
caused by resulting ischaemia. However, the cause is 
not known although the lesions are thought to be in-
duced by physical activity C 4) , repeated pressure in pre-
disposed indivicluals (2), hereditary factors (5) or col-
lagen defects in patients with Ehlers-Danlos syndrome 
(6). The condition is relatively infrequently seen in der-
matologic practice although some authors claim that it 
can be found in almost every person, if properly exam-
ined (3) . However, in the vast majority of persons they 
are not painfu l and hence go unnoticed. 
100 
Figure 1. Multiple firm, skin-colored papules 
distributed over the medial side of both feet 
while the patient is standing. 
Histologically, especially in older lesions , there is 
thickening of the dermis, with a loss of the usual small 
fat compartments in the lower dermis and subcutis (7). 
Among the homogenized collagen there may be areas 
of necrosis with hemorrhage at the borcler of dermis 
and subcutaneous tissue (2). In the subcutaneous tis-
sue, thin fibrous septa are degenerated, scarce or com-
pletely absent. There may also be protrusion of these 
enlarged fat lobules into the dermis (8,9). 
Treatment options for piezogenic pedal papules 
comprise electro-acupuncture , compressive therapy, 
and surgical removal of inclividual large papules (3, 10). 
To the best of our knowledge, there have not been re-
ports on the use of a low-level laser to treat piezogenic 
pedal papules . In our two patients, the low leve! laser 
treatment led to a significant improvement in their con-
dition. At present, the mode of action of the lasers is 
not known. However, the irradiation enhances the re-
generative capacities of tissues , suppresses inflamma-
tion and pain sensation (11). The analgesic effect of the 
low-level laser might be related to changes in nerve 
excitability (12) . In addition , it aids in resorption of 
edema fluid and favors lymphatic and blood vascular 
regeneration (13 , 14) . 
Case report 
Acta Dermatoven APA Vol 10, 2001, No 3 
Ca se r e port Piezogenic pedal papules 
R E FE R E N C E S l. Shelley WB, Rawnsley HM. Painful feet due to herniation of fat. JAMA 1968; 205: 308-9. 
AUTHORS' 
ADDRESSES 
2. Schlappner OL, Wood MG, Gerstein W, Gross PR. Painful and nonpainful piezogenic pedal papules. 
Arch Dermatol 1972; 106: 729-33. 
3. Boni R, Dummer R. Compression therapy in painful piezogenic pedal papules. Arch Dermatol 1996; 
132: 127-8. 
4. Kahn SR, Blasi JM. Piezogenic pedal papules. Arch Dermatol 1972; 106: 597-8. 
5. Lebovits PE, Kouskoukis CE, Wedman AI. Piezogenic pedal papules. Cutis. 1982; 29: 276-7. 
6. Kahana M, Feistein A, Tabachnic E, Schewach-Millet M, Engelbarg S. Painful piezogenic pedal papules 
in patients with Ehlers-Danlos syndrome. J Am Acad Dermatol 1987; 17: 105-9. 
7. Dokery GL, Diana JL. Painful piezogenic papules. J Am Podiatr Med Assoc 1978; 10: 703. 
8. Plewig G, Braun-Falco O. Piezogene Knotchen. Druckbedingte Fersen - und Handkantenknotchen. 
Hautarzt 1973; 24: 114 - 18. 
9. Harman RR, Mathews NAJ. Painful piezogenic pedal papules. Br J Dermatol 1974; 90: 573 - 4. 
10. Woodrow SL, Bereton-Smith G, Handfiled-Jones S. Painful piezogenic pedal papules: response to 
local electro-acupunture. Br J Dermatol 1997; 136: 628 - 30. 
11. Konstatinovic LJ, Antonie M, Brdareski Z. Osnovi biološkog delovanja lasera niske snage. Vojnosanit 
Pregl 1998; 55: 61 - 7. 
12. Khullar SM, Brodin P, Barkovoll A, Haanaes HR. Preliminaiy study of low leve! laser far treatment of 
longstanding senso1y aberrations in inferior alveolar nerve. J Oral Maxillofac Surg 1996; 54: 2 - 7. 
13. Schindl A, Schincll M, Schindl L, Jurecka W, Honigsmann I-I , Breier F. Increased dermal angiogenesis 
after low-intensity laser therapy far a chronic radiation ulcer determined by a video measuring system. J 
Am Acad Dermatol 1999; 40: 481-4. 
14. I-Ionmura A, Yanase M, O bata J, Haruki E. Therapeutic effect of Ga-Al-As diode laser irradiation on 
experimentally induced inflammation in rats. Lasers Surg Med 1992; 12: 441-9. 
Branimir MijailovicMD, dermatovenereologist, Department oj 
Dermatology and Venereology, Military MedicalAcademy, Crnotravska 7, 
YU-11002 Belgrade, Yugoslavia 
Dordije Karadaglic MD, DSc, projessor oj dermatovenereology and 
chairman, same address 
Tomislav Mladenovic MD, dermatovenereologist, same address 
Miloš D. Pavlovic MD, PhD, associate projessor oj dermatovenereology, 
same address 
Radoš D. Zečevic MD MSc, assistant projessor oj dermatovenereology, 
same address 
Lidija Popovic MD, dermatopathologist, Institute oj Pathology and 
Forensic Medicine, Military MedicalAcademy, Crnotravska 17, YU-11002 
Belgrade, Yugoslavia 
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