In the store-and-forward teledermatology modality, there is a transfer of patient medical information electronically (including history and visual data) obtained in one location to a provider who is in another location (Roman & Jacob, 2015). The construct of the TeleDermViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.
TELEDERMATOLOGY READER REPORT1
History
Chief complaint: tender nodule on the right great toe
History of Present Illness
A 50-year-old man presents with a tender, solitary, dome-shaped nodule on the medial aspect of the right great toe. He denies any recent or previous trauma to the right toe. The growth has been present for at least 4 months. It initially grew rapidly over the first few weeks before slowing its growth rate to a now static size. He denies any other symptoms.
Image Quality Assessment
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT
There is one image provided with this consult (Figure 1). The image shows a skin-colored, firm, hyperkeratotic, pink, well-demarcated, dome-shaped papule on the medial aspect of the right great toe. A surrounding collarette of scale is noted to encircle the base of the lesion.
INTERPRETATION OF IMAGES
Lesion A
Findings
The morphology of the lesions, distribution, and history are characteristic of acquired digital fibrokeratoma (ADFK) or acral fibrokeratoma.
RECOMMENDATIONS
Referral for face-to-face evaluation for skin biopsy.
CLINICAL PEARL
ADFKs are relatively rare, benign, often nodular, fibrous neoplasms with a predisposition for the fingers. As these lesions can also be seen on the toes and feet, they have also been called acral fibrokeratoma or acquired fibrokeratoma. Classically, ADFKs present as skin-colored or pink keratotic nodules that rarely grow more than 1 cm in diameter. Lesions are often asymptomatic when they are discovered by the patient. The etiology of ADFKs is often attributed to chronic repetitive irritation or trauma to the area in question. Staphylococcus aureus infections associated with chronic paronychia have also been reported to incite growth of ADFKs (Shih & Khachemoune, 2019).
On dermatoscopic evaluation, these lesions appear to have a yellow homogenous central area that sometimes is noted to have discrete vascular lacunae. The periphery of the lesion is noted to have more globular vessels and scattered telangiectasias (Shih & Khachemoune, 2019). In addition, a thin, hyperkeratotic, white encircling collarette of scale is a hallmark of this lesion in most cases, as seen in Figure 1.
Initial treatment of a suspected ADFK would be to confirm the diagnosis with shave biopsy or definitive excisional surgery to remove the lesion. Recurrence after excision is a rare finding. Biopsy is an important initial step as common mimickers of ADFK include verrucae vulgaris, superficial acral fibromyxoma, supernumerary digit, Koenen's tumor (angiofibroma), eccrine poroma, pyogenic granuloma, keratoacanthoma and neurofibroma, dermatofibroma, and aggressive papillary digital adenocarcinoma (Shih & Khachemoune, 2019).
NURSING PERSPECTIVE
Nurses are frontline educators who play a considerable role in teaching patients to report new or changing skin lesions. Lesions that become symptomatic or change in appearance, including color, shape, or topographical changes, should be referred to dermatology for evaluation.
REFERENCES