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Hyperpigmented lesion on left palm
A 17-year-old high school baseball player presented to a sports medicine clinic for left anterior knee pain. During the exam, a hyperpigmented lesion was incidentally noted on his left palm. The patient, who also played basketball and football, was unsure of how long he’d had the lesion, and he did not recall having any prior lesions on his hand. He denied any discomfort or significant past medical history. There was no known family history of skin cancers, but the patient did report that his brother, also an athlete, had a similar lesion on his hand.
On closer examination, scattered black dots were noted within a 2 × 1–cm thickened keratotic plaque at the hypothenar eminence of the patient’s left hand (Figure). There was no tenderness, erythema, warmth, or disruption of normal skin architecture or drainage.
WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?
Diagnosis: Posttraumatic tache noir
Posttraumatic tache noir (also known as talon noir on the volar aspect of the feet) is a subcorneal hematoma. The diagnosis is made clinically.
Our patient was a competitive baseball player, and he noted that the knob of his baseball bat rubbed the hypothenar eminence of his nondominant hand when he took a swing. The sheer force of the knob led to the subcorneal hematoma. Tache noir was high on the differential due to the author’s clinical experience with similar cases.
Tache noir occurs predominantly in people ages 12 to 24 years, without regard to gender.1 The condition is commonly found in athletes who participate in baseball, cricket, racquet sports, weightlifting, and rock climbing.1-3 Talon noir occurs most commonly in athletes who are frequently jumping, turning, and pivoting, as in football, basketball, tennis, and lacrosse. One should have a high index of suspicion for this diagnosis in patients who participate in any sport that might lead to shearing forces involving the volar aspect of the hands or feet.
Confirmation is obtained through a simple procedure. Dermoscopic evaluation of tache/talon noir will reveal “pebbles on a ridge” or “satellite globules.” Confirmation of tache/talon noir can be made by paring the corneum with a #15 blade, which will reveal blood in the shavings and punctate lesions.4
Other lesions may havea similar appearance
Tache noir can be differentiated from other conditions by the presence of preserved architecture of the skin surface and punctate capillaries beneath the stratum corneum. The differential diagnosis includes verruca vulgaris, acral melanoma, and a traumatic tattoo.
Continue to: Verruca vulgaris
Verruca vulgaris similarly contains puncta but typically appears as a raised lesion with a disruption of the stratum corneum.5
Acral melanoma can be distinguished from tache/talon noir by dermoscopic evaluation and/or paring of the corneum. On dermoscopic evaluation, both acral melanoma and tache/talon noir will reveal parallel ridge patterns; this finding has an 86% sensitivity and 96% specificity for early acral melanoma.6 What differentiates the 2 is the “satellite globules” or “pebbles on a ridge” that are seen with a subcorneal hematoma. Furthermore, paring the corneum would demonstrate an absence of blood within the ridges of the skin shavings, pointing away from tache/talon noir as the diagnosis.1-3,5-7
Traumatic tattoo can also mimic tache/talon noir, due to foreign-material deposits in the skin (gunpowder, carbon, lead, dirt, and asphalt). A history of penetrating trauma should help to narrow the differential. Attempts at paring with traumatic tattoo may or may not help with differentiation.1
In this case, time does heal all wounds
Talon/tache noir are benign conditions that do not require treatment and do not affect sports performance. The lesion will usually self-resolve within a matter of weeks from onset or can even be gently scraped with a sterile needle or blade, which can partially or completely remove the pigmentation from within the parallel ridges.3,5,8
Our patient was advised that the lesion would resolve on its own. His knee pain was determined to be a simple case of patellofemoral syndrome or “runner’s knee” and he opted to complete a home exercise program to obtain relief.
1. Burkhart C, Nguyen N. Talon noire. Dermatology Advisor. Accessed October 19, 2021. www.dermatologyadvisor.com/home/decision-support-in-medicine/dermatology/talon-noire-black-heel-calcaneal-petechiae-runners-heel-basketball-heel-tennis-heel-hyperkeratosis-hemorrhagica-pseudochromhidrosis-plantaris-chromidrose-plantaire-eccrine-intracorne/
2. Talon noir. Primary Care Dermatology Society. Updated August 1, 2021. Accessed October 19, 2021. www.pcds.org.uk/clinical-guidance/talon-noir
3. Birrer RB, Griesemer BA, Cataletto MB, eds. Pediatric Sports Medicine for Primary Care. Lippincott Williams & Wilkins; 2002.
4. Googe AB, Schulmeier JS, Jackson AR, et al. Talon noir: paring can eliminate the need for biopsy. Postgrad Med J. 2014;90:730-731. doi: 10.1136/postgradmedj-2014-132996
5. Lao M, Weissler A, Siegfried E. Talon noir. J Pediatr. 2013;163:919. doi: 10.1016/j.jpeds.2013.03.079
6. Saida T, Koga H, Uhara H. Key points in dermoscopic differentiation between early acral melanoma and acral nevus. J Dermatol. 2011;38:25-34. doi: 10.1111/j.1346-8138.2010.01174.x
7. Emer J, Sivek R, Marciniak B. Sports dermatology: part 1 of 2 traumatic or mechanical injuries, inflammatory condition, and exacerbations of pre-existing conditions. J Clin Aesthet Dermatol. 2015;8:31-43.
8. Kaminska-Winciorek G, Spiewak R. Tips and tricks in the dermoscopy of pigmented lesions. BMC Dermatol. 2012;12:14. doi: 10.1186/1471-5945-12-14
A 17-year-old high school baseball player presented to a sports medicine clinic for left anterior knee pain. During the exam, a hyperpigmented lesion was incidentally noted on his left palm. The patient, who also played basketball and football, was unsure of how long he’d had the lesion, and he did not recall having any prior lesions on his hand. He denied any discomfort or significant past medical history. There was no known family history of skin cancers, but the patient did report that his brother, also an athlete, had a similar lesion on his hand.
On closer examination, scattered black dots were noted within a 2 × 1–cm thickened keratotic plaque at the hypothenar eminence of the patient’s left hand (Figure). There was no tenderness, erythema, warmth, or disruption of normal skin architecture or drainage.
WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?
Diagnosis: Posttraumatic tache noir
Posttraumatic tache noir (also known as talon noir on the volar aspect of the feet) is a subcorneal hematoma. The diagnosis is made clinically.
Our patient was a competitive baseball player, and he noted that the knob of his baseball bat rubbed the hypothenar eminence of his nondominant hand when he took a swing. The sheer force of the knob led to the subcorneal hematoma. Tache noir was high on the differential due to the author’s clinical experience with similar cases.
Tache noir occurs predominantly in people ages 12 to 24 years, without regard to gender.1 The condition is commonly found in athletes who participate in baseball, cricket, racquet sports, weightlifting, and rock climbing.1-3 Talon noir occurs most commonly in athletes who are frequently jumping, turning, and pivoting, as in football, basketball, tennis, and lacrosse. One should have a high index of suspicion for this diagnosis in patients who participate in any sport that might lead to shearing forces involving the volar aspect of the hands or feet.
Confirmation is obtained through a simple procedure. Dermoscopic evaluation of tache/talon noir will reveal “pebbles on a ridge” or “satellite globules.” Confirmation of tache/talon noir can be made by paring the corneum with a #15 blade, which will reveal blood in the shavings and punctate lesions.4
Other lesions may havea similar appearance
Tache noir can be differentiated from other conditions by the presence of preserved architecture of the skin surface and punctate capillaries beneath the stratum corneum. The differential diagnosis includes verruca vulgaris, acral melanoma, and a traumatic tattoo.
Continue to: Verruca vulgaris
Verruca vulgaris similarly contains puncta but typically appears as a raised lesion with a disruption of the stratum corneum.5
Acral melanoma can be distinguished from tache/talon noir by dermoscopic evaluation and/or paring of the corneum. On dermoscopic evaluation, both acral melanoma and tache/talon noir will reveal parallel ridge patterns; this finding has an 86% sensitivity and 96% specificity for early acral melanoma.6 What differentiates the 2 is the “satellite globules” or “pebbles on a ridge” that are seen with a subcorneal hematoma. Furthermore, paring the corneum would demonstrate an absence of blood within the ridges of the skin shavings, pointing away from tache/talon noir as the diagnosis.1-3,5-7
Traumatic tattoo can also mimic tache/talon noir, due to foreign-material deposits in the skin (gunpowder, carbon, lead, dirt, and asphalt). A history of penetrating trauma should help to narrow the differential. Attempts at paring with traumatic tattoo may or may not help with differentiation.1
In this case, time does heal all wounds
Talon/tache noir are benign conditions that do not require treatment and do not affect sports performance. The lesion will usually self-resolve within a matter of weeks from onset or can even be gently scraped with a sterile needle or blade, which can partially or completely remove the pigmentation from within the parallel ridges.3,5,8
Our patient was advised that the lesion would resolve on its own. His knee pain was determined to be a simple case of patellofemoral syndrome or “runner’s knee” and he opted to complete a home exercise program to obtain relief.
A 17-year-old high school baseball player presented to a sports medicine clinic for left anterior knee pain. During the exam, a hyperpigmented lesion was incidentally noted on his left palm. The patient, who also played basketball and football, was unsure of how long he’d had the lesion, and he did not recall having any prior lesions on his hand. He denied any discomfort or significant past medical history. There was no known family history of skin cancers, but the patient did report that his brother, also an athlete, had a similar lesion on his hand.
On closer examination, scattered black dots were noted within a 2 × 1–cm thickened keratotic plaque at the hypothenar eminence of the patient’s left hand (Figure). There was no tenderness, erythema, warmth, or disruption of normal skin architecture or drainage.
WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?
Diagnosis: Posttraumatic tache noir
Posttraumatic tache noir (also known as talon noir on the volar aspect of the feet) is a subcorneal hematoma. The diagnosis is made clinically.
Our patient was a competitive baseball player, and he noted that the knob of his baseball bat rubbed the hypothenar eminence of his nondominant hand when he took a swing. The sheer force of the knob led to the subcorneal hematoma. Tache noir was high on the differential due to the author’s clinical experience with similar cases.
Tache noir occurs predominantly in people ages 12 to 24 years, without regard to gender.1 The condition is commonly found in athletes who participate in baseball, cricket, racquet sports, weightlifting, and rock climbing.1-3 Talon noir occurs most commonly in athletes who are frequently jumping, turning, and pivoting, as in football, basketball, tennis, and lacrosse. One should have a high index of suspicion for this diagnosis in patients who participate in any sport that might lead to shearing forces involving the volar aspect of the hands or feet.
Confirmation is obtained through a simple procedure. Dermoscopic evaluation of tache/talon noir will reveal “pebbles on a ridge” or “satellite globules.” Confirmation of tache/talon noir can be made by paring the corneum with a #15 blade, which will reveal blood in the shavings and punctate lesions.4
Other lesions may havea similar appearance
Tache noir can be differentiated from other conditions by the presence of preserved architecture of the skin surface and punctate capillaries beneath the stratum corneum. The differential diagnosis includes verruca vulgaris, acral melanoma, and a traumatic tattoo.
Continue to: Verruca vulgaris
Verruca vulgaris similarly contains puncta but typically appears as a raised lesion with a disruption of the stratum corneum.5
Acral melanoma can be distinguished from tache/talon noir by dermoscopic evaluation and/or paring of the corneum. On dermoscopic evaluation, both acral melanoma and tache/talon noir will reveal parallel ridge patterns; this finding has an 86% sensitivity and 96% specificity for early acral melanoma.6 What differentiates the 2 is the “satellite globules” or “pebbles on a ridge” that are seen with a subcorneal hematoma. Furthermore, paring the corneum would demonstrate an absence of blood within the ridges of the skin shavings, pointing away from tache/talon noir as the diagnosis.1-3,5-7
Traumatic tattoo can also mimic tache/talon noir, due to foreign-material deposits in the skin (gunpowder, carbon, lead, dirt, and asphalt). A history of penetrating trauma should help to narrow the differential. Attempts at paring with traumatic tattoo may or may not help with differentiation.1
In this case, time does heal all wounds
Talon/tache noir are benign conditions that do not require treatment and do not affect sports performance. The lesion will usually self-resolve within a matter of weeks from onset or can even be gently scraped with a sterile needle or blade, which can partially or completely remove the pigmentation from within the parallel ridges.3,5,8
Our patient was advised that the lesion would resolve on its own. His knee pain was determined to be a simple case of patellofemoral syndrome or “runner’s knee” and he opted to complete a home exercise program to obtain relief.
1. Burkhart C, Nguyen N. Talon noire. Dermatology Advisor. Accessed October 19, 2021. www.dermatologyadvisor.com/home/decision-support-in-medicine/dermatology/talon-noire-black-heel-calcaneal-petechiae-runners-heel-basketball-heel-tennis-heel-hyperkeratosis-hemorrhagica-pseudochromhidrosis-plantaris-chromidrose-plantaire-eccrine-intracorne/
2. Talon noir. Primary Care Dermatology Society. Updated August 1, 2021. Accessed October 19, 2021. www.pcds.org.uk/clinical-guidance/talon-noir
3. Birrer RB, Griesemer BA, Cataletto MB, eds. Pediatric Sports Medicine for Primary Care. Lippincott Williams & Wilkins; 2002.
4. Googe AB, Schulmeier JS, Jackson AR, et al. Talon noir: paring can eliminate the need for biopsy. Postgrad Med J. 2014;90:730-731. doi: 10.1136/postgradmedj-2014-132996
5. Lao M, Weissler A, Siegfried E. Talon noir. J Pediatr. 2013;163:919. doi: 10.1016/j.jpeds.2013.03.079
6. Saida T, Koga H, Uhara H. Key points in dermoscopic differentiation between early acral melanoma and acral nevus. J Dermatol. 2011;38:25-34. doi: 10.1111/j.1346-8138.2010.01174.x
7. Emer J, Sivek R, Marciniak B. Sports dermatology: part 1 of 2 traumatic or mechanical injuries, inflammatory condition, and exacerbations of pre-existing conditions. J Clin Aesthet Dermatol. 2015;8:31-43.
8. Kaminska-Winciorek G, Spiewak R. Tips and tricks in the dermoscopy of pigmented lesions. BMC Dermatol. 2012;12:14. doi: 10.1186/1471-5945-12-14
1. Burkhart C, Nguyen N. Talon noire. Dermatology Advisor. Accessed October 19, 2021. www.dermatologyadvisor.com/home/decision-support-in-medicine/dermatology/talon-noire-black-heel-calcaneal-petechiae-runners-heel-basketball-heel-tennis-heel-hyperkeratosis-hemorrhagica-pseudochromhidrosis-plantaris-chromidrose-plantaire-eccrine-intracorne/
2. Talon noir. Primary Care Dermatology Society. Updated August 1, 2021. Accessed October 19, 2021. www.pcds.org.uk/clinical-guidance/talon-noir
3. Birrer RB, Griesemer BA, Cataletto MB, eds. Pediatric Sports Medicine for Primary Care. Lippincott Williams & Wilkins; 2002.
4. Googe AB, Schulmeier JS, Jackson AR, et al. Talon noir: paring can eliminate the need for biopsy. Postgrad Med J. 2014;90:730-731. doi: 10.1136/postgradmedj-2014-132996
5. Lao M, Weissler A, Siegfried E. Talon noir. J Pediatr. 2013;163:919. doi: 10.1016/j.jpeds.2013.03.079
6. Saida T, Koga H, Uhara H. Key points in dermoscopic differentiation between early acral melanoma and acral nevus. J Dermatol. 2011;38:25-34. doi: 10.1111/j.1346-8138.2010.01174.x
7. Emer J, Sivek R, Marciniak B. Sports dermatology: part 1 of 2 traumatic or mechanical injuries, inflammatory condition, and exacerbations of pre-existing conditions. J Clin Aesthet Dermatol. 2015;8:31-43.
8. Kaminska-Winciorek G, Spiewak R. Tips and tricks in the dermoscopy of pigmented lesions. BMC Dermatol. 2012;12:14. doi: 10.1186/1471-5945-12-14
