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Black Heel (Calcaneal Petechiae): Differential Diagnoses & Workup

Author: Christine Malcolm, MD, Resident Physician in Dermatology, Department of Internal Medicine, University of Toronto Faculty of Medicine
Coauthor(s): Joel G DeKoven, MD, FRCPC, Associate Professor, Division of Dermatology, Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre and St Michael's Hospital, Canada; Scott Richard Albert Walsh, MD, PhD, Assistant Professor, Program Director, Department of Dermatology, University of Toronto, Sunnybrook Health Sciences Centre
Contributor Information and Disclosures

Updated: Sep 23, 2009

Differential Diagnoses

Lentigo
Malignant Melanoma
Nevi, Melanocytic
Tattoo Reactions
Warts, Nongenital

Other Problems to Be Considered

Traumatic tattoo

Workup

Laboratory Studies

  • The most important goal is to differentiate black heel (calcaneal petechiae) from melanoma. No specific workup is necessary to make the diagnosis of black heel.

Imaging Studies

  • Epiluminescence techniques, such as dermatoscopy and video macroscopy, can be used to aid in the differentiation of melanoma from black heel.4,5 Under the dermatoscope, black-reddish globules on the ridges (resembling pebbles) are characteristic.6 If doubt persists, rapidly process the shaved fragments of keratin with commonly available screening tests used for detection of occult blood.

Procedures

  • The diagnosis of black heel (calcaneal petechiae) is clinical and can be aided by paring down the lesion with a surgical blade. Melanocytic lesions will not lose their pigmentation with paring, while black heel may clear completely after the stratum corneum is removed.
  • A biopsy is indicated if the diagnosis remains in doubt, but this is seldom necessary.

Histologic Findings

Hyperkeratotic stratum corneum typical of acral skin is seen; parakeratosis is common. Extravasated erythrocytes in the dermal papillae are characteristic. Often, biopsy is only performed to the stratum corneum and the hemorrhage can be identified as loculated serum and degenerated erythrocytes.7

Phagocytosis of extravascular RBCs and subsequent degradation of hemoglobin to hemosiderin does not occur; therefore, traditional iron stains do not work and histochemical stains must be directed toward hemoglobin. Benzidine stain reveals brown homogenous clusters of hemoglobin.8,9

More on Black Heel (Calcaneal Petechiae)

Overview: Black Heel (Calcaneal Petechiae)
Differential Diagnoses & Workup: Black Heel (Calcaneal Petechiae)
Treatment & Medication: Black Heel (Calcaneal Petechiae)
Follow-up: Black Heel (Calcaneal Petechiae)
Multimedia: Black Heel (Calcaneal Petechiae)
References
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References

  1. Crissey JT, Peachy JC. Calcaneal petechiae. Arch Dermatol. Mar 1961;83:501. [Medline].

  2. Rufli T. Hyperkeratosis haemorrhagica. Hautarzt. Nov 1980;31(11):606-9. [Medline].

  3. Mailler-Savage EA, Adams BB. Skin manifestations of running. J Am Acad Dermatol. Aug 2006;55(2):290-301. [Medline].

  4. Akasu R, Sugiyama H, Araki M, Ohtake N, Furue M, Tamaki K. Dermatoscopic and videomicroscopic features of melanocytic plantar nevi. Am J Dermatopathol. Feb 1996;18(1):10-8. [Medline].

  5. Saida T, Oguchi S, Ishihara Y. In vivo observation of magnified features of pigmented lesions on volar skin using video macroscope. Usefulness of epiluminescence techniques in clinical diagnosis. Arch Dermatol. Mar 1995;131(3):298-304. [Medline].

  6. Malvehy J, Puig S, Braun RP, Marghoob AA, Kopf AW. Handbook of Dermoscopy. United Kingdom: Informa UK Ltd; 2006:70.

  7. Elder DE. Lever's Histopathology of the Skin. 9th ed. Lippincott Williams & Wilkins; 2005:367.

  8. Hafner J, Haenseler E, Ossent P, Burg G, Panizzon RG. Benzidine stain for the histochemical detection of hemoglobin in splinter hemorrhage (subungual hematoma) and black heel. Am J Dermatopathol. Aug 1995;17(4):362-7. [Medline].

  9. Weedon D. Skin Pathology. 2nd ed. Elsevier Limited; 2002:595.

  10. Adams BB. Dermatologic disorders of the athlete. Sports Med. 2002;32(5):309-21. [Medline].

  11. Cho KH, Kim YG, Seo KI, Suh DH. Black heel with atypical melanocytic hyperplasia. Clin Exp Dermatol. Sep 1993;18(5):437-40. [Medline].

  12. Garcia-Doval I, de la Torre C, Losada A, Cruces MJ. Disseminated punctate intraepidermal haemorrhage: a widespread counterpart of black heel. Acta Derm Venereol. Sep 1999;79(5):403. [Medline].

  13. Levine N. Dermatologic aspects of sports medicine. J Am Acad Dermatol. Oct 1980;3(4):415-24. [Medline].

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Further Reading

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Keywords

black heel, calcaneal petechiae, talon noir, tennis heel, hyperkeratosis haemorrhagica, pseudochromhidrosis plantaris

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Contributor Information and Disclosures

Author

Christine Malcolm, MD, Resident Physician in Dermatology, Department of Internal Medicine, University of Toronto Faculty of Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Joel G DeKoven, MD, FRCPC, Associate Professor, Division of Dermatology, Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre and St Michael's Hospital, Canada
Joel G DeKoven, MD, FRCPC is a member of the following medical societies: American Academy of Dermatology, American Contact Dermatitis Society, Canadian Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Scott Richard Albert Walsh, MD, PhD, Assistant Professor, Program Director, Department of Dermatology, University of Toronto, Sunnybrook Health Sciences Centre
Scott Richard Albert Walsh, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Canadian Dermatology Association, International Society of Dermatology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Medical Editor

Donald Belsito, MD, Clinical Professor, Department of Internal Medicine, Division of Dermatology, University of Missouri at Kansas City; Private Practice, American Dermatology Associates, LLC
Donald Belsito, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, Dermatology Foundation, Kansas Medical Society, Noah Worcester Dermatological Society, Phi Beta Kappa, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Edward F Chan, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine
Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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