Slow-growing papule with no pain or itching


  • Verruca vulgaris_0312 Derm Look 2

A woman aged 85 years presented for evaluation of a slowly growing bump on her neck. The patient explained that the lesion first appeared three months earlier and had grown slowly in the interim to its present size. Although no itching or pain was associated with the lesion, the woman reported bleeding when it got caught on her necklace.

Physical exam revealed a flesh-colored 6-mm verrucous papule on the left lateral neck. On gentle paring, the lesion showed pinpoint black dots.
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Verruca vulgaris refers to the common wart, a benign neoplasm that is caused by infection with the human papillomavirus (HPV). Verruca vulgaris, as opposed to genital warts, are usually caused by the HPV 1, 2, 4, 27, 57, and 63...

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Verruca vulgaris refers to the common wart, a benign neoplasm that is caused by infection with the human papillomavirus (HPV). Verruca vulgaris, as opposed to genital warts, are usually caused by the HPV 1, 2, 4, 27, 57, and 63 strains, which are spread through skin-to-skin contact or via fomites.

Warts usually occur during the school-age and young-adult years, but they can appear at any age. Although healthy patients are commonly affected, immunosuppression predisposes to the occurrence of multiple and resistant warts. In addition, adults who handle meat and fish as part of their job or who frequently immerse their hands in water have a higher incidence of common warts.

Warts are usually found on the dorsal hands, fingers and palms. Periungual lesions may cause significant pain and/or paronychia. People who bite their fingernails often present with spread of warts to the vermillion and cutaneous lip, presenting a treatment challenge.

Diagnosis of a verruca is almost always clinical. Classically, a wart presents as a rounded papule with a rough grayish surface — this texture is referred to as “verrucous.” Thickening of the infected epidermis and prominence of the dermal papillae cause the verrucous appearance.

Flat warts have a more subtle appearance, and the verrucous texture may be difficult to appreciate. The average size of the common wart is 5 mm, but lesions range in size from pinpoint to larger than 1 cm. More than one wart is usually present, and there is often one large wart and several smaller ones grouped nearby. A linear arrangement of warts typically results from autoinoculation, demonstrating the Koebner phenomenon.

Verrucae may be difficult to distinguish from seborrheic keratoses, benign lesions seen in the elderly, and palmar or plantar calluses. If the diagnosis is unclear, gentle paring with a surgical blade can remove the verrucous surface keratin painlessly and reveal pinpoint black or purple dots, representing thrombosed capillaries. A wart will also interrupt normal dermatoglyphics, whereas a callus retains the skin lines. More concerning, squamous cell carcinoma and amelanotic melanoma must be ruled out in atypical-appearing lesions.

Treatment of warts is often frustrating for both the clinician and the patient. The goal of treatment is resolution of the lesions along with acceptable cosmetic outcome (i.e. minimal or no scarring).

Prior to initiating treatment, inform the patient that resolution of a wart does not eradicate the causative virus, which remains latent within the affected squamous epithelial cells, making recurrence common. Also explain that no single treatment method is guaranteed to successfully resolve the warts.

Patients should be advised that many warts spontaneously resolve. Literature suggests a 30% clearance rate at three months, 65% to 78% at two years, and 90% over five years.1 As a result, benign neglect is an acceptable option for warts that are not bothersome to patients and for those that do not interfere with a patient’s social activities. More often, concern regarding the spread of warts prompts many patients — and more commonly, parents of affected children — to request treatment.

Physical treatment modalities include cryotherapy, shave removal, electrodessication and curettage and laser treatment. Cryotherapy with liquid nitrogen is generally considered the first-line treatment option, as this procedure is highly effective and the pain is of short duration.2

Inform the patient that two or three treatments scheduled at two to four weeks’ duration are frequently necessary for eradication. After treatment, the wart will progress to scabbing, crusting, and sometimes blistering. Vigorous treatment may result in scarring. Surgical removal and laser therapy are generally more painful and have a higher likelihood of scarring.

Several chemotherapeutic treatment options exist. OTC salicylic acid is an inexpensive albeit time-consuming choice. At-home treatment involves nightly application of the acid. Once the acid has dried, duct tape is applied to occlude the surface of the wart. Removal of the tape the next morning accomplishes gradual and painless debridement. This method may take anywhere from two to 12 weeks for cure.

For in-office treatment, cantharidin (Canthacur), a strong blistering agent extracted from the blister beetle, or chloroacetic acid may be carefully applied. Because of their painless application, these are usually the treatments of choice in children. As with cryotherapy, these also result in blister formation and may require two or three treatments.

Imiquimod cream (Aldara) is a biologic agent approved for treatment of external genital warts, but many practitioners prescribe it for daily use in the treatment of common warts. This cream may be used in conjunction with physical destructive techniques. Advise patients of potentially irritating effects, and cease application if any erythema or skin breakdown occurs. Similarly, 5-fluorouracil cream (Efudex) has been shown to be safe and effective for treatment of verruca vulgaris.3

The oral immunomodulating agents cimetidine (Tagamet) and levamisole (Ergamisol), used alone or in combination, have been shown to be effective for recalcitrant warts; however, there is no FDA indication for this use.4 Intralesional injection of bleomycin (Blenoxane) and interferon alfa-2a (Roferon) is reserved for warts resistant to all other standard treatments.

The woman described in this case was treated with two rounds of cryotherapy three weeks apart, leading to complete resolution of the lesion.

Esther Stern, NP-C, is a family nurse practitioner at Advanced Dermatology & Skin Surgery, P.C., in Lakewood, N.J. The author has no relationhsips to discolse relating to the content of this article.


1. James WD, Berger TG, Elston DM. Viral diseases. In: Andrews’ Diseases of the Skin: Clinical Dermatology. 10th ed. Philadelphia, PA.: Saunders-Elsevier; 2006:404.

2. Lipke MM. “An armamentarium of wart treatments.” Clin Med Res. 2006;4:273-293.

3. Gladsjo JA, Alió Sáenz AB, Bergman J, et al. 5% 5-Fluorouracil cream for treatment of verruca vulgaris in children. Pediatr Dermatol. 2009;26:279-285.

4. Parsad D, Pandhi R, Juneja A, Negi KS. Cimetidine and levamisole versus cimetidine alone for recalcitrant warts in children. Pediatr Dermatol. 2001;18:349-352.

All electronic documents accessed March 8, 2012

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