A 63-year-old man with a 20-year history of diabetes mellitus, peripheral vascular disease and hypertension presented with a non-healing ulcer of left foot. Approximately 18 months prior, the patient developed dry gangrene of his toes of the same foot. He underwent amputation of the 2nd, 3rd, and 4th toes during that period. In addition to the gangrenous toes, a hyperkeratotic, focally ulcerated lesion over the anterior plantar surface was also identified. This was thought to be a callus. He underwent multiple debridement of the plantar lesion followed by regular wound care over this period. The lesion recurred and grew much larger with central ulceration. Subsequently, a distal amputation of the foot was performed.
On gross examination, the left distal foot measured 9.0x8.0x4.0 cm. There were only two toes (small and great) attached with the left foot. There was one somewhat ill-defined, markedly hyperkeratotic and centrally ulcerated lesion measuring 3.0 x 1.7 on the plantar surface of the left foot (Figure 1). The lesion was separated from the well-healed sites of the previous toe amputation by normal skin.