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Basics ⬇

Clinical Variant ⬆ ⬇

Common warts (aka verruca vulgaris) !!navigator!!

  • Hyperkeratotic, exophytic papules that can be found anywhere on body but most often seen on the hands and feet (Figs. 17.1-17.5).

Plantar warts !!navigator!!

  • Hyperkeratotic papules that can coalesce into larger plaques called mosaic warts on the sole of the foot (Figs. 17.6-17.8).

Flat warts !!navigator!!

  • Skin colored to tan flat-topped papules that usually occur in clusters. Often spread by scratching or shaving (Figs. 17.9-17.12).

Filiform warts !!navigator!!

Genital warts (condyloma acuminata) !!navigator!!

Outline

Diagnosis ⬆

  • Warts are usually diagnosed clinically.

  • A biopsy should be performed if the diagnosis is in doubt or if the wart is not responding to conventional treatment, especially if a squamous cell carcinoma is suspected.

Diagnosis-icon.jpg Differential Diagnosis

Common Warts
Molluscum Contagiosum

  • Dome-shaped shiny papules, central umbilication (see below).

Seborrheic keratosis

  • “Stuck-on” appearance.

  • May be clinically indistinguishable from verrucae.

Acrochordon (skin tag)

  • Smooth (not verrucous), small papules.

  • May be clinically indistinguishable from verrucae.

Solar keratosis and cutaneous horn

  • Rough-textured papules in sun-exposed areas.

Squamous cell carcinoma

  • Rough-textured papule, nodules, or ulcers in sun-exposed areas.

  • A solitary squamous cell carcinoma under the nail may easily be misdiagnosed as a subungual wart.

Plantar Warts
Calluses

  • Broad-based hyperkeratotic plaques commonly found on the soles.

  • Distinguished from plantar warts because they reveal an accentuation rather than interruption of skin markings.

Corns (Clavi)

  • Similar to calluses, corns are thickened areas of the skin that develop in response to excessive pressure and friction. Like warts, corns interrupt skin markings.

  • Can be distinguished by the lack of “black dots” and punctate bleeding after paring.

  • Corns are circular and hard, and when pared down, will exhibit a polished or central translucent core, similar to a kernel of corn from which they take their name (Fig. 17.16).

Flat Warts
Molluscum Contagiosum

Disseminated cryptococcosis, toxoplasmosis, and histoplasmosis

  • Noted especially in immunocompromised patients.

Management-icon.jpg Management of Warts (Discussed in Chapter 6: Superficial Viral Infections)

General Principles

  • Warts often prove to be persistent and difficult to eradicate in many adults and in immunocompromised patients.

  • The management of warts is challenging and there is no ideal treatment. The abundance of therapeutic modalities described in Chapter 6: Superficial Viral Infections is a reflection of the fact that none of them is uniformly effective.

  • Adults often opt for more definitive treatment options such as electrocautery and curettage or excision.

  • Before choosing a treatment, consider the patient's pain threshold, the type and size of the wart, the location of the lesion, and its cosmetic or psychological considerations.

Point-Remember-icon.jpg Points to Remember

  • Freezing and other destructive treatment modalities do not kill the virus but merely destroy the “host” cells that harbor HPV.

  • How to avoid getting warts? Never shake hands. Never kiss anyone. Never walk barefoot. Never share towels. Live in a bubble…and there's still a good chance you'll get one. HPV is highly prevalent.

  • Shaving over warts in the beard area or on the legs with a razor blade tends to spread the lesions.

  • A clinical “cure” is achieved when the skin lines are restored to a normal pattern and there is no recurrence.

Important Information About Plantar Warts

  • Melanoma can mimic a plantar wart.

  • Verrucous carcinoma, a slow-growing, locally invasive, well-differentiated squamous cell carcinoma, may also be easily mistaken for a plantar wart.

SEE PATIENT HANDOUT “Warts” IN THE COMPANION eBOOK EDITION.