Answer: A

Verruca vulgaris (VV), or the common wart, is a benign growth of the skin or mucous membranes. VV lesions present as firm, hyperkeratotic, raised lesions with a rough or cauliflower-like surface. They generally occur on the skin of the hands and feet, although unusual locations such as the tongue and larynx have been reported.6-9

VV is an ancient condition, reported in the literature since Hippocrates in 400 BC. Although it was once believed that a person could contract VV by touching toads, it is now recognized that human papillomavirus (HPV) is the cause of the common wart.8 The virus infects epithelial basal keratinocytes through breaks in the skin, resulting in plaque or nodule formation.7,9

Spread of HPV can occur either through direct contact (touching an infected person) or indirect contact (touching fomites).7-9 The virus also can spread to secondary sites on an individual by auto-inoculation of the virus via scratching.9 HPV infection can cause a singular growth, multiply to cause numerous lesions, or spontaneously resolve without clinical symptoms.7-9 VV on the extremities is most commonly associated with HPV types 1, 2, 4, 27, 40, and 57. Multiple strains often co-infect an individual and can demonstrate synergistic or antagonistic effects on disease manifestation.9


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Although VV can occur at any age, it most commonly occurs in 12 to 16-year-olds, affecting as many as 20% of school-aged children.7 Most people are affected at some point in their lifetime.10 Whites are twice as likely to have VV than Blacks or people of Asian descent. There is no predilection for a particular sex. Skin exposure to moisture and trauma increases an individual’s risk for acquiring a VV. Using public showers or swimming pools and handling raw meat (these are aptly named “Butcher’s warts”) are known activities that carry risk for VV. Systemic disease and malignant transformation into verrucous carcinoma are very rare but more common in immunosuppressed patients.7

Histopathologically, granular layer cells from VV lesions contain keratohyalin vacuoles and raisin-like nuclei; these koilocytic changes are diagnostic of an HPV infection. Other findings include hypergranulosis, tortuous capillaries within the dermal papillae, papillomatosis, acanthosis, and digitated epidermal hyperplasia.7

Clinically, VV does not cause severe pain, but it can become an irritant or lead to psychological stress.9 The lesions can limit joint range of motion, become tender after traumatic contact, or bleed. Typically, bothersome lesions occur on plantar surface of the foot; they may become so large or numerous that they limit patients’ activities of daily living.7

Diagnosis typically is made clinically; VV is common and the lesions generally have a homogenous appearance. Characteristic brown or red dots, best visualized via dermatoscope, represent thrombosed dermal papilla capillary loops and are indicative of VV.The differential diagnosis includes molluscum contagiosum, lichen planus, digital mucous cyst, seborrheic keratosis, and keratoacanthoma.

If the lesion cannot be diagnosed by history and physical examination, certain laboratory tests can be used. Identification of viral DNA identification via Southern blot hybridization or polymerase chain reaction can confirm an epidermal HPV infection. These tests are more likely to be positive in newer rather than older lesions. A biopsy of the lesion also can be obtained to rule-out other diagnoses, although typically this is not required.7

A large number of cases of VV resolve without treatment: 23% within 2 months, 65% after 3 months, and 78% after 2 years; thus a reasonable treatment plan may be observation7,9

There are many treatment options available, and several may be indicated to yield a definitive cure. Filing down the VV with a scalpel blade, known as paring, can be used to allow for better penetration of treatments.10 Cryotherapy can be performed in a provider’s office, typically in several sessions, to freeze the wart.7-10 Injection of a Candida antigen can encourage the immune system to identify and fight off the HPV infection.8,10 At home, patients can use over-the-counter treatments that are applied after soaking and filing the lesion.10 Retinoids, compounded wart treatments containing ingredients such as salicylic acid or 5-fluorouracil, or systemic treatment with oral cimetidine are other potential treatments for VV lesions.7,8,10

Prognosis is good for VV patients. . Patients should be counseled that the lesions almost always are benign, that most resolve without treatment and leave no residual scarring  and that if they chose treatment, many rounds may be required before lesion resolution.7,9 Thus, the decision to pursue treatment, which may lead to monetary cost, pain, scarring, and adverse effects, should be considered carefully.

Patient education is essential to prevent future lesions and limit the spread of disease. Butchers should wear gloves at work, swimmers should wear footwear around the pool, and cosmetic tools such as nail files and pumice stones should not be shared.

Our patient was treated with cryotherapy in the office. At his follow up appointment, there was mild improvement and he received a second round of cryotherapy after paring and was instructed to use an over-the-counter treatment as well. At his third follow up visit, the wart had resolved.

Table. Digital Mucous Cyst vs Verruca Vulgaris

Cynthia Truong, BS, and Yelena Dokic, BSA, are medical students at Baylor College of Medicine, and Christopher Rizk, MD, is a certified dermatologist at Elite Dermatology in Houston, Texas.

References

  1. Li K, Barankin B. Digital mucous cysts. J Cutan Med Surg. 2010;14(5):199-206.
  2. Kim EJ, Huh JW, Park HJ. Digital mucous cyst: a clinical-surgical study. Ann Dermatol. 2017;29(1):69-73.
  3. Jabbour S, Kechichian E, Haber R, Tomb R, Nasr M. Management of digital mucous cysts: a systematic review and treatment algorithm. Int J Dermatol. 2017;56(7):701-708.
  4. Elder DE, Johnson BL, Elenitsas R, eds. Lever’s Histopathology of the Skin. 9th ed. Lippincott Williams & Wilkins; 2004;1003-1004.
  5. De Berker DA, Lawrence CM. Treatment of myxoid cysts. Dermatol Surg. 2001;27(3):296-299.
  6. Topdag M, Erdogan S, Kara A, Derin S. Laryngeal verruca vulgaris. BMJ Case Rep.2015:bcr2014207773.
  7. Al Aboud AM, Nigam PK. Wart (plantar, verruca vulgaris, verrucae). In: StatPearls. StatPearls Publishing; 2020.
  8. Bope ET, Kellerman RD. Conn’s Current Therapy 2012.Elsevier Health Sciences; 2011:275.
  9. Ural A, Arslan S, Ersoz S, Deger B. Verruca vulgaris of the tongue: a case report with a literature review. Bosn J Basic Med Sci. 2014;14(3):136-138.
  10. Patient perspectives: Warts (verruca vulgaris) and what to do about them. Pediatr Dermatol. 2015;32(6):e322-e323.