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Fig. 4.42 This subungual lesion, shown 1 week following biopsy, was a squamous cell carcinoma.

Fig. 4.41 This girl pulled skin off her foot and caused an ulcer which remained open for 3 years. It healed in 3 weeks when a tamper-free total-contact cast was applied.

clinicians who are not aware of what is going on. Many of these patients are profoundly hypochondriac and only feel safe and in control when they are causing the foot problem.

We have also seen a 41-year-old patient with 'brittle' type 1 diabetes mellitus of 24 years' duration, who had numerous hospital admissions for infected ulcers of the feet and legs. On one occasion his leg ulcers were grafted using split-skin grafts and the evening before his proposed discharge from hospital, the dressings were removed and the skin grafts scratched off. On two occasions during that admission, glass was broken on the ward and found in his foot ulcers. He was discharged, attended another hospital, and underwent bilateral below-knee amputations within 6 months.

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