|Year : 2015 | Volume
| Issue : 1 | Page : 54-56
Talon noir: A mirage of melanoma
Subramaniam Keerthi, Sankar Madhavi, Kaliaperumal Karthikeyan
Department of Dermatology, Venereology and Leprology, Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Puducherry, India
|Date of Web Publication||26-Jun-2015|
Department of Dermatology, Venereology and Leprology, Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Puducherry - 605 107
Source of Support: None, Conflict of Interest: None
A 45-year-old female patient presented with two black plaques over her toes for the past 3 months that were persistent without any changes in the color, size or surface. Histopathology showed epidermal hyperplasia with corneal collection of fibrinous proteinaceous material and hemosiderin-laden macrophages and fibrinous exudate. We report this case to highlight the importance of proper diagnosis by means of dermoscopy and paring, of any black patch over acral regions in order to exclude the more concerning acral lentiginous melanoma.
Keywords: Hematoma, melanoma, mimic, talon noir
|How to cite this article:|
Keerthi S, Madhavi S, Karthikeyan K. Talon noir: A mirage of melanoma. Pigment Int 2015;2:54-6
| Introduction|| |
Melanoma is a malignancy of melanocytes, associated with high mortality. Growing awareness and suspicion have resulted in early diagnosis and treatment. Certain conditions closely mimic melanoma and cause a clinical diagnostic dilemma. One such condition is talon noir. It is proposed to be caused due to the rupture of dermal papillary capillaries, caused by shearing forces.  post- traumatic intraepidermal hemorrhage is a harmless, self-healing process that is a major cause for concern owing to its dark black color.  Our case is unique as this entity closely mimics acral lentiginous melanoma, which makes a thorough dermoscopic diagnosis and early intervention a necessity.
| Case Report|| |
A 45-year-old lady, a farmer by occupation, came to our out-patient department with complaints of an asymptomatic dark flat patch on the tips of her toes for the past few months, which appeared spontaneously and did not show any increase in size or change in morphology over a period of 3 months. She had no history of preceding trauma, pain or ulceration over the surface. She had not taken any drugs prior to the onset of lesions. On examination, there were two well-defined, hyperpigmented, dark brown to black plaques measuring 0.5 cm × 1 cm and 2 cm × 2 cm each with smooth surface, regular margins present over the tips of the first and second phalanges of her left foot [Figure 1]. The pigmentation of the larger patch varied between black and light brown in some areas. A skin biopsy was then performed to rule out the possibility of an acral lentiginous melanoma. The excised tissue was found to be sticky and uniformly pigmented. Histopathology of the excised lesion showed hyperkeratosis and epidermal hyperplasia. The corneal layer showed a central collection of degenerated old hemorrhage with hemosiderin-laden macrophages and fibrin exudate. Dermis was normal. A sample of separated black mass alone showed fibrinous proteinaceous material with degenerated old hemorrhage [Figure 2] and scattered hemosiderin-laden macrophages. This confirmed the diagnosis of hematoma/talon noir.
|Figure 1: Well-defined, hyperpigmented plaque with a smooth surface and regular margins, measuring 1 cm × 1 cm and irregular margins measuring 0.5 cm × 0.5 cm seen over the tips of first two toes, respectively|
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|Figure 2: Hyperkeratotic stratum corneum showing a degenerated hematoma (H and E, ×10)|
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| Discussion|| |
Talon noir was first described by Crissey and Peachey in 1961 as calcaneal petechiae. Since then, there have been several monikers and debates on a proper nomenclature. A strong association to sports was found and so, adolescents and young adults comprise the majority of patients with this entity. On the other hand, elderly patients with palm or sole injuries can produce similar lesions. A viral etiology has also been reported. 
There occurs a leakage of blood into the epidermis subsequent to trauma and hemoglobin resides in the stratum corneum, away from phagocytic cells, thereby maintaining the intact structure of hemoglobin  [Flow Diagram 1 [Additional file 1] ].
Most of the lesions are asymptomatic, violet-black macules either isolated or in clusters. Some rarer patterns described are linear or horizontal arrays. Most lesions are bilateral and located on the heels. Other sites reported are the metatarsal heads,  palms, ocular conjunctiva, and fingers. 
Diagnosis is of importance since it is one of the closest mimics of melanoma. Other possible diagnoses are chilblains, vasculitis, emboli, fixed drug eruption, pigmented basal cell carcinoma, seborrheic keratosis, solitary angiokeratoma  or pagetoid spitz nevus.  Dermoscopy is of importance in the recent noninvasive diagnosis of this entity. The Legrand du Saulle ecchymotic spectrum is helpful in the diagnosis based on the development of the lesion over days  [Table 1].
Since melanoma has a grave prognosis, a thorough investigation for its mimics should be conducted. Following clinical examination, paring should be the first minimally invasive investigative procedure to be conducted. Scarification by paring reveals puncta of the black pigment of extravasated red cells. This confirms the diagnosis of talon noir and excludes other mimics such as melanoma or hemorrhagic viral wart, especially in the absence of a history of trauma.
Next, a dermoscopic examination can be conducted wherein subcorneal hematoma shows pigmentation that is lighter than expected with a melanoma and also reveals a reddish hue. The overall pattern is homogeneous or globular or rarely distributed along the crests and ridges, giving it a parallel appearance simulating acral lentiginous melanoma. However, the color of the lesion based on the ecchymotic spectrum can provide diagnostic clues. Histopathology reveals a well-developed intraepidermal hematoma that stains positive for hemosiderin.
In our patient, the site and long duration of the lesion made us suspect melanoma, but the appearance of the lesion post- excision [Figure 3] and subsequent histopathology was diagnostic. Talon noir is a relatively benign condition that can mimic a melanoma and cause a diagnostic dilemma.
|Figure 3: Plaque over tip toe postexcision showing uninvolved margins and base|
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| References|| |
Wilkinson DS. Black heel a minor hazard of sport. Cutis 1977;20:393-6.
Cole MB, Smith ML. Environmental and sports-related skin diseases. In: Bolognia J, Schaffer J, Duncan K, Co C, editors. Dermatology Essentials. 3 rd
ed. Spain: Mosby; 2009. p. 1501-2.
Sardana K, Sagar V. Black heel (talon noir) associated with a viral exanthem. Indian Pediatr 2013;50:982.
Urbina F, León L, Sudy E. Black heel, talon noir or calcaneal petechiae? Australas J Dermatol 2008;49:148-51.
Eiland G, Ridley D. Dermatological problems in the athlete. J Orthop Sports Phys Ther 1996;23:388-402.
Periciamedicalegal.com.br. Importância Forense do Espectro Equimótico Parte 1 PeríciaMédica Legal; 2012. Available from: http://www.periciamedicalegal.com.br/?p=6. [Last cited on 2015 Feb 03].
Habif TP, Campbell JL, Chapman SM, Dinulos JG, Zug KA. Melanoma mimics. In: Skin Disease Diagnosis and Treatment. 3 rd
ed. China: Elsevier; 2011. p. 871.
Harris K, Florell SR, Papenfuss J, Kohlmann W, Jahromi M, Schiffman JD, et al.
Melanoma mimic: A case of multiple pagetoid Spitz nevi. Arch Dermatol 2012;148:370-4.
Herrera LM, Serra M, Fernandes C. Violence against children and adolescents: The importance of knowledge of the spectrum of bruise colors in its diagnosis. Rev Sul Bras Odontol 2013;10:378-85.
[Figure 1], [Figure 2], [Figure 3]