Wearing shoes became difficult and painful when a lesion manifested on this 56-year-old woman's foot, about 19 years ago. But the idea of removal scared her more than the lesion did, so she left it alone (aside from unsuccessful OTC treatment attempts) until a friend finally convinced her that it needed to be removed.
The patient looks at least 15 years older than her stated age and coughs throughout the examination. She denies any history of similar lesions and at first denies any serious health problems. On further questioning, however, she admits to having COPD, diabetes, a 30-pack-year history of smoking, and severe atopy.
A 4-cm floriform, warty plaque is seen on the dorsum of her left foot. Its surface is quite rough and firm but nontender. The lesion is obviously a wart, albeit one of huge size and odd morphology.
In addition, a flaky red rash is seen around the entire rim of the foot; the patient says it itches little if at all. The great toenail is dystrophic and yellowed. No such changes are seen on the other foot, which has good pulses.