Beyond the Nail Care Visit: Early Detection of Lower Extremity Squamous Cell Carcinoma in Podiatric Practice
My medical assistant rushed into my office in the middle of a chaotic morning clinic. “He’s just here for nail care. His blood sugar is elevated again this morning, but he’s due for repeat hemoglobin A1c next week when he sees his primary care physician. He is not using his ciclopirox and his legs are swollen again today.”
We have all experienced these scenarios; patients with type 2 diabetes and high blood sugar, don’t check their glucose levels daily, and who may have peripheral arterial disease, neuropathy, or chronic venous insufficiency. These are the patients who may not wear compression stockings because they are too difficult to put on. These are the patients who truly do qualify for at-risk foot care of their fungal toenails via Medicare class findings, because they are at high risk for diabetic foot ulcers and amputations. However, even though these clinical situations arise often in podiatric practice, each case deserves targeted consideration, as the case below demonstrates.
When a Diabetic Foot Examination Reveals More Than Expected
The patient was an 81-year-old male presenting for at-risk foot care. He had a past medical history of type 2 diabetes, hypertension, hypercholesterolemia, venous insufficiency, coronary artery disease, and peripheral vascular disease. He lives at home with his wife with no smoking history. His HbA1c was 10.3% approximately 7 months prior. His visit felt typical and familiar, with the same conversation about self-care and managing his treatment course to the best of his ability. During the physical exam, I noted a bandage on the back of his right calf. He told me that he scraped his leg against the chair approximately 1 week prior and that, “it was nothing.” Under the bandage was what initially appeared to be a small venous stasis ulcer. It had a granular base, was oval-shaped and measured approximately 0.9 x 0.7 x 0.2 cm with mild serous drainage and with no signs of infection. Based on the clinical findings, its appearance was more suggestive of a venous stasis ulcer over a traumatic ulcer. He agreed to elevate his legs, perform the prescribed dressing changes, and return in 2 weeks.
He did indeed return 2 weeks later with improved leg edema, but with minimal change to the ulceration other than more irregularity of the edges. At this visit, the interval change in appearance raised the index of suspicion away from traumatic or venous etiology and more towards a pathologic or neoplastic process. After a long discussion, he agreed to allow me to perform punch biopsies to the site. Two punch biopsies, each 3 mm, were obtained from the ulceration. The first biopsy took place at the central portion of the ulceration and the second was at the proximal-most margin, under local anesthesia at chairside, and were not closed. The post-biopsy dressing consisted of antibiotic ointment, a nonadherent layer, gauze pads, and soft gauze roll.
Pathology results returned the same morning that he returned to clinic, 7 days later. The biopsy from the central portion of the ulceration returned as stasis dermatitis, with a histologic profile of hyperkeratosis, parakeratosis, and mild spongiosis, along with extravasated erythrocytes with hemosiderin deposits present.
The proximal edge biopsy specimen pathology report noted the diagnosis as microinvasive squamous cell carcinoma. The pathology comment noted “superficial or microinvasive squamous cell carcinoma is arising from overlying intraepidermal atypical squamous epithelia proliferation. Very early penetration of supper inflamed elastic dermal connective tissue is identified.”
Upon his follow-up, biopsied areas were healing well with no pain, and with no signs of bacterial infection. However, we had to formulate a plan for further treatment. I placed a referral to a Mohs surgeon in the dermatology department. I discussed the pathology results with the patient, along with the need for further excision of the area and full malignancy work-up. Since the dermatology department at our institution has a well-respected Mohs surgeon who works closely with the oncology department, the patient and I agreed on the referral. We prepared records to assure continuity of care and deferred to the Mohs surgeon on necessity of a positron emission tomography (PET) scan. The patient was able to secure an evaluation 4 days later.
More on the Patient’s Diagnosis
Squamous cell carcinoma arises from skin cells which are affected by UV exposure. It is the second most common form of skin cancer and predominately affects older male patients.1,6 Approximately one million patients receive a diagnosis of squamous cell carcinoma each year in the United States.2
Squamous cell carcinoma often presents as a firm, red nodule, a non-healing ulcer, or a flat sore with a scaly crust. Diagnosis is often via biopsy, generally punch biopsy of the lesion. Advanced imaging, such as magnetic resonance imaging (MRI) or PET scans can often aid in determining the level of spread. Staging occurs via 2 separate staging systems; the Brigham and Women’s Hospital (BWH) system from Stage T1-T3 and the American Joint Committee on Cancer (AJCC)-8 Staging system.1
Depending on the size of the lesion, treatment can vary between electrodissection (also known as electrodessication) and curettage, laser therapy, phototherapy, or surgical excision via Mohs surgery. If the squamous cell carcinoma is diagnosed late, and has metastasized, then chemotherapy may be necessary to help destroy the cancer cells.1 Survival rate for squamous cell carcinoma varies upon the stage and location of squamous cell carcinoma. For cutaneous squamous cell carcinoma of the foot, assuming there is no spread to lymph nodes or distant sites, the 5-year survival rate is as high as 95%6; however if the cancer has spread to nearby lymph nodes, the 5-year survival rate drops to 45-70%. Additionally, if there is spread to distant organs, the survival rate is a mere 25-35%.1,6 Early diagnosis is crucial to the prognosis. Unfortunately, squamous cell carcinoma in the foot often has a delayed diagnosis, as it is mistaken for chronic wounds, calluses, or a skin rash.
Mohs surgery for squamous cell carcinoma of the foot is the treatment with the lowest recurrence rate, 1 to 5%. This is the preferential treatment for high risk or recurrent squamous cell carcinomas on the foot. Amputation also has a low local recurrence rate, of 5% recurrence, and is often curative if there is no metastasis at diagnosis.5,6
Final Thoughts
I was once told that there is no such thing as “routine nail care.” As podiatrists, we are always evaluating our patients for peripheral arterial disease, neuropathy, areas of preulcerative lesions or open ulcerations, and, every once in a while, we evaluate, diagnose, and treat something that may not just save a limb, but a life. The role of podiatrists in intercepting and swiftly facilitating the treatment of lower extremity cancerous lesions is not to be underestimated. The case presented above underscores the importance of careful evaluation of the lower extremities and thoughtful application of clinical acumen to question initial impressions, arriving at the most accurate conclusion to improve outcomes.
Dr. Suchak is a triple board-certified podiatrist. She is a Fellow of the American College of Foot and Ankle Surgeons, a Diplomate of the American Board of Foot and Ankle Surgery, Certified in Foot Surgery, a Diplomate of the American Board of Podiatric Medicine, and a Certified Wound Specialist by the American Board of Wound Management. She is the Second Vice President for the American Association for Women Podiatrists. She is an Assistant Professor of Podiatry for the Department of Orthopaedics at West Virginia University.
References
1. Hadian Y, Howell JY, Ramsey ML, et al. Cutaneous Squamous Cell Carcinoma. In: StatPearls [Internet]. StatPearls Publishing; 2025. Accessed December 5, 2025.
2. Squamous cell carcinoma. Yale Medicine. Accessed December 5, 2025. https://www.yalemedicine.org/conditions/squamous-cell-carcinoma
3. McGlamry’s Textbook of Foot and Ankle Surgery. Vol 2. 3rd ed. Pages 1325-1326.
4. Dörr S, Lucke-Paulig L, Vollmer C, Lobmann R. Malignant transformation in diabetic foot ulcers: case reports and review of the literature. Geriatrics (Basel). 2019;4(4):62.
5. Holgado RD, Ward SC, Suryaprasad SG. Squamous cell carcinoma of the hallux. J Am Podiatr Med Assoc. 2000;90(6):309-312.
6. Squamous cell carcinoma FAQs. American College of Mohs Surgery. Accessed December 5, 2025. https://www.mohssurgery.org/skin-cancer-faqs/squamous-cell-carcinoma-faqs/
