A 55-Year-Old Man With a Painful Rash on the Sole of His Foot

Abstract

A 55-year-old man with hypertension and hypercholesterolemia presented to the clinic with a 6-day history of a painful rash on the sole of his right foot. He described the pain as akin to stepping on a sharp object and characterized it as moderately intense, sharp, continuous, and without radiation. After first noticing the pain, he had examined the inside of his boot but did not identify anything that would account for the tenderness. He reported no fevers, chills, or malaise. He denied history of human immunodeficiency virus (HIV), hepatitis, chickenpox, or recurrent infections. His medications included amlodipine, hydrochlorothiazide, and ezetimibe. He worked outdoors for an oil drilling company. He denied recent travel out of the country. Physical examination revealed 2-to 3-mm grouped vesicles on an erythematous base in a discrete area of the sole of the right foot (Figure ) and no additional rashes elsewhere on the body. Vesicular fluid was sent for analysis. Figure. Left, Grouped vesicles on sole of patient's right foot. Right, Closer view of vesicles. WHAT WOULD YOU DO NEXT? A. Obtain blood cultures B. Initiate antiviral therapy with valacyclovir C. Prescribe an oral antihistamine agent D. Prescribe a topical corticosteroid cream Clinical Review & Education JAMA Clinical Challenge