Derma _ Verruca Plana and Vulgaris

Dermatology Case 2

Abigail RamirezEileen Jill Ramos

Joanna Marie Rayos del Sol

Chief Complaint and History

• A 54 year old Japanese sushi cook • Chief Complaint: Multiple keratotic papules

over his 3rd, 4th, and 5th finger of his right hand. • HPI: 6 months prior to consult, patient noted 2

to 3 skin colored hard intraepidermal papule which slowly enlarged in time

RAMIREZ, Abigail P.

Physical Examination

• There are several 1x1 to 1.5x1.5 cm grey colored rough surfaced papules with hemorrhagic dots found over the sides of the 3rd, 4th, and 5th finger of the right hand.

• He also has a few flat topped slightly pink non-scaly papule over the right hand, some forming a linear line over the right forearm.

RAMIREZ, Abigail P.

Salient Features Pertinent Positives

• Japanese Sushi Cook• Chief complaint of multiple

keratotic papules over the 3rd, 4th, and 5th finger of his right hand.

– 6 months PTA: Skin colored hard intraepidermal papule which slowly enlarged in time

– PE : several 1x1 to 1.5x1.5 cm grey colored rough surfaced papules with hemorrhagic dots

– PE: few flat topped slightly pink non-scaly papule over the right hand, some forming a linear line over the right forearm

Pertinent Negatives

RAMIREZ, Abigail P.

Clinical Impression

• Verruca Vulgaris (common wart)• Verruca Plana (flat wart)

RAMIREZ, Abigail P.

Differential DiagnosisPatient

ManifestationsVerruca Vulgaris Verruca Plana Molluscum

Contagiosum

Sites Sides of the 3rd, 4th, 5th fingers of the right hand

Hands – favors the fingers and palms

Forehead, cheeks, nose, around the mouth, backs of the hands.

In adults, lower abdomen, upper thighs, penile shaft in men

Lesion 1x1 to 1.5x1.5 cm grey colored rough surfaced papules with hemorrhagic dots

Pinpoint to >1cm, average about 5mm. Presents as elevated, rounded papules with a rough grayish surface

2-4mm flat topped papules that are slightly erythematous or brown on pale skin and hyperpigmented on dark skin

Smooth-Surfaced , dome-shaped, pearly papules; average of 3-5mm in diameter

Useful Finding

Papules with hemorrhagic dots

Black dots may be visible at the surface of wart

Tendency of warts to Koebnerize, forming linear, slightly raised, papular lesions

Central umbilication

RAMIREZ, Abigail P.

Differential DiagnosisPatient

ManifestationsVerruca Vulgaris Verruca Plana Molluscum

Contagiosum

Sites Right hand and right forearm

Hands – favors the fingers and palms

Forehead, cheeks, nose, around the mouth, backs of the hands.

In adults, lower abdomen, upper thighs, penile shaft in men

Lesion flat topped slightly pink non-scaly papule

Pinpoint to >1cm, averagea about 5mm. Presents as elevated, rounded papules with a rough grayish surface

2-4mm flat topped papules that are slightly erythematous or brown on pale skin and hyperpigmented on dark skin

Smooth-Surfaced , dome-shaped, pearly papules; average of 3-5mm in diameter

Useful Finding

Some forming a linear line over the right forearm

Black dots may be visible at the surface of wart

Tendency of warts to Koebnerize, forming linear, slightly raised, papular lesions

Central umbilication

RAMIREZ, Abigail P.

Diagnosis

• Verruca Vulgaris (common wart)• Verruca Plana (flat wart)

RAMIREZ, Abigail P.

Verruca Vulgaris (Common warts)

Andrews’ Diseases of the Skin: Clinical Dermatology 10th edition.

RAMOS, Eileen Jill


RAMOS, Eileen Jill

Verruca Plana (Flat Warts)


RAMOS, Eileen Jill


RAMOS, Eileen Jill

Management• Many warts give no trouble, need no treatment and go away

by themselves. – Up to 30% of common warts tend to spontaneously regress and disappear

within 6 months– Up to 75% will disappear in three years

• They rarely recur but can be re-infected. • To prevent re-infection, the source of infection should also

be treated.

Two approaches:1. Based on destruction of the wart: slowly or quickly2. Based on induction of local immune reactions (immunotherapy)

RAYOS DEL SOL, Joanna Marie

Management: Home Application• First Line: Salicylic Acid

– Salicylic Acid 17% (OTC)• Apply daily to wart• As effective as Cryotherapy

– Occlusal (17% salicylic acid)

• Second line Keratolytic Agents– Cantharidin– Retin A (Tretinoin) 0.05% cream applied qhs to warts


Management: Clinic Procedures• First line therapy

– Cryotherapy (50% efficacy)

• Second line therapy– Wart Immune Therapy

• Imiquimod Cream 5%• Intralesional Candida Injection• Cimetidine Wart Therapy (No more effective than Placebo)

• Other measures that have been used– Curattage electrodessication– Topical 5-FU


Management:

Advanced Dermatologic Procedures• Pulse dye laser• CO2 Laser • Intralesional Bleomycin


• Cryotherapy – freezing with liquid nitrogen or CO2 spray– Complications:

• Hypopigmentation (Melanocytes are very cold sensitive)• Hyperpigmentation (in darker skinned individuals)• Atrophy in skin areas directly over bone• Neuropathy where nerves are superficial

N.B. Patients with cryoglobulinemia, poor peripheral circulation, and Reynaud’s may develop blisters.

• 10-20% salycylic lactic acid• The normal moisture of the body draws the active chemical into the wart, the acid dissolves

the bonds between the skin cells, and the wart tissue crumbles apart as a result.

• Keratolytics: Retinoids• ability to alter keratinization and accelerate the clearing of warts by inducing an irritant

dermatitis• disrupt intercellular adhesion structures• May produce “doughnut wart”

TreatmentRAYOS DEL SOL, Joanna Marie

Treatment

• Cimetidine Wart Therapy⁻ H2 receptor antagonist that employs the ability of the immune system to

recognize certain viral and fungal antigens. ⁻ enhances delayed-type hypersensitivity reaction that block H2 receptor

stimulation of T-cells.

• Candida injection (Intralesional Wart Therapy)⁻ believed that the delayed-type hypersensitivity reaction induced by these

antigens increases the ability of the immune system to recognize and clear HPV⁻ most common side effect was itching at the injection site. Other side effects:

influenza-like illness that lasted less than 24 hours and improved with nonsteroidal anti-inflammatory drugs.

⁻ Intralesional immunotherapy is a promising treatment that warrants more clinical trials to further evaluate its effectiveness


Treatment

• Imiquimod Cream 5%• imidazoquinolin heterocyclic, an immune response modifier that increases local cytokine

production, with a subsequent activation of both the innate (rapid, nonspecific) and adaptive (specific, cellular, and humoral) immune systems

• induces peripheral monocytes and macrophages to release interferon α and interleukin (IL)-12. Both cytokines promote a cell-mediated immune response led by CD8+ cytotoxic T cells and natural killer cells.

• Bleomycin• a chemotherapeutic agent, inhibits DNA synthesis in cells and viruses. • Disadvantages:– Severe pain– Hemorrhagic eschar– digital necrosis – nail dystrophy– Risk of scarring– High cost


• Surgical ablation: • Curattage electrodessication– Risk for painful scars– Lesions larger than 1 cm should be excised instead

• CO2 Laser destruction– Slow healing– Risk of painful scars– Special equipment and Training– Very Expensive

• Pulsed dye laser therapy- selectively target hemoglobin contained in blood vessels within the wart. As the hemoglobin heats up, thermal energy is dissipated to surrounding tissues, leading to cauterization of blood vessels. The result is a necrotic wart that eventually sloughs off.


HPV infection First-line therapy Second-line therapy Third-line therapyCommon warts(Verruca vulgaris)

Salicylic acid, cryotherapy

Cantharidin* Bleomycin, intralesional immunotherapy, pulsed dye laser therapy

Flat warts(Verruca plana)

Salicylic acid, imiquimod cream

Cryotherapy, retinoids Intralesional immunotherapy, pulsed dye laser therapy

Plantar warts(Verruca plantaris)

Salicylic acid Cryotherapy, intralesional immunotherapy, pulsed dye laser therapy

Bleomycin, surgical excision

Treatment Considerations for Nongenital Cutaneous Warts


THANK YOU!

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Derma _ Verruca Plana and Vulgaris