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Patient Case: Warts (Verrucae)

Patient Case: Warts (Verrucae)

Discussion

A 16-year-old male presents to the dermatology clinic with multiple rough, skin-colored growths on the fingers and palms of his hands. He reports that the lesions started as small bumps several months ago and have gradually increased in size and number. The growths are painless but occasionally catch on objects, causing mild discomfort. He denies itching, bleeding, or systemic symptoms.

On examination, several firm, hyperkeratotic papules with an irregular surface are noted on the fingers and palms. Some lesions display black pinpoint dots, consistent with thrombosed capillaries. The rest of the skin examination is unremarkable.

Given the characteristic appearance and slow progression, a diagnosis of common warts (verruca vulgaris) caused by human papillomavirus (HPV) is made. The patient is educated on treatment options, including cryotherapy and topical salicylic acid, and reassured that many warts resolve spontaneously over time.

Questions
  1. What is the most likely causative agent of the patient’s condition?
    a) Human papillomavirus (HPV)
    b) Herpes simplex virus (HSV)
    c) Staphylococcus aureus
    d) Varicella-zoster virus (VZV)
  2. Which clinical feature is most characteristic of common warts (verruca vulgaris)?
    a) Smooth, dome-shaped lesions with central umbilication
    b) Firm, hyperkeratotic papules with black pinpoint dots
    c) Painful vesicular rash following a dermatomal distribution
    d) Flat, erythematous plaques with silvery scales
  3. Which of the following is the most appropriate first-line treatment for common warts?
    a) Oral antiviral therapy
    b) Cryotherapy or topical salicylic acid
    c) High-dose systemic corticosteroids
    d) Surgical excision in all cases
  4. What is the usual course of untreated common warts in healthy individuals?
    a) They resolve spontaneously over time
    b) They rapidly spread systemically, requiring urgent intervention
    c) They persist indefinitely without any change
    d) They cause severe pain and ulceration in all cases
Reveal answers

Answers

  1. (a) Human papillomavirus (HPV)
    • Warts are caused by various strains of HPV, with verruca vulgaris commonly associated with HPV types 2 and 4.
  2. (b) Firm, hyperkeratotic papules with black pinpoint dots
    • Common warts typically appear as rough, thickened papules with thrombosed capillaries, seen as black dots, which help distinguish them from other skin lesions.
  3. (b) Cryotherapy or topical salicylic acid
    • First-line treatments for common warts include cryotherapy (liquid nitrogen) and keratolytic agents like salicylic acid, which help break down the wart tissue.
  4. (a) They resolve spontaneously over time
    • In many healthy individuals, warts can regress on their own within months to years due to the immune response against HPV, though treatment may be needed for persistent or bothersome lesions.