Warts (Verrucae): Diagnosis and Management

00:01 The clinical presentation.

00:03 So the non-genital cutaneous wart variants, there are several different varieties, typically different subtypes of the HPV virus with different sites where they predominate.

00:16 So there's the common household wart Verruca vulgaris.

00:20 And that's the one that will typically occur on hands or in other locations.

00:24 You can get plantar warts on the sole of the foot, the verruca plantaris.

00:29 And that's a different set of subtypes, or flat warts, which will typically appear on the face.

00:35 And those are called verruca plana.

00:37 Different subset of the subtypes of the human papillomavirus and genital warts are also called Condyloma acuminatum, and it's going to be those subtypes that are responsible for targeting the skin in that area.

00:56 So the common wart is, as you can probably describe as well as I can soft tan colored has kind of cauliflower like papules, basically, as we'll see in a moment.

01:06 Histologically it's an exaggeration of the normal skin architecture.

01:10 They can be very small up to a centimeter in size.

01:13 They can be rough and scaly.

01:15 They can be multiple or single.

01:18 They are mostly asymptomatic.

01:20 Unless you're like me and you can't leave the darn thing alone, and you scrape it and you rub it and you break it off and you know it can bleed.

01:26 It's a benign proliferation.

01:28 You can't say that often enough, and it has virtually no malignant potential.

01:33 The plantar wart on the soles and of the foot, it can also occur on the ankles, can be quite large because you're putting pressure on them all the time.

01:43 They can be quite painful because you are.

01:45 They're big things, they're indurated and you're pushing on nerves that are underneath.

01:49 They also tend to be quite difficult to treat they because of the relatively dense stratum corneum. It's hard to get rid of all the virus that's in the vicinity.

02:00 The flat wart, as I say, is mostly on the face.

02:03 They're small, they're slightly raised warts, they're millimeters. So they tend to be much smaller. They're light brown, and they can occur on the hands and the lower arms.

02:13 Trigger warning the next image is not pleasant.

02:16 You may want to avert your eyes or not anogenital warts.

02:21 So Condyloma acuminatum they are again benign.

02:25 They grow outwards. They can get to be pretty impressive in terms of size and will involve the external genitalia and the perianal region.

02:33 Those virus subtypes just have a predilection for that particular epithelium.

02:40 So what does it look like if we look down the microscope? What is the histopathology? It's an exaggeration, as I've already said, of the normal skin architecture. So we have very thickened epidermis with very prominent papillary projections. That is the proliferation of the keratinocytes being driven by the viral proteins blocking or destroying p53 and retinoblastoma protein.

03:09 On top of that you will have very accentuated stratum corneum.

03:13 So the very thick layer on top of that, that accentuation of the total architecture grossly will look like kind of a cauliflower.

03:22 You're basically seeing the little papillary projections of normal skin now writ large.

03:28 So acanthosis and hyperkeratosis.

03:31 Yes, we will also see when we look in the epithelium, evidence of viral proliferation within the cells.

03:38 There's clearing of each of the individual keratinocytes Tenocytes those cells within the stratum spinosum. That clearing represents fibril proliferation.

03:49 We have little viral factories in each one of those cells, and as they expand, you are seeing kind of a clearing that's called koilocytes ptosis.

03:59 How do we diagnose this? Well, you know, if you've seen it once, you've seen them all and you can pretty much diagnose these in your sleep however you may if there's some question, for example, the the planar lesions, the verruca plana that occur on the face, you may think, gee, could this be lichen planus or something else? Then you may want to do a biopsy.

04:23 And if you really want to like nail it but spend a lot of money, you can do HPV DNA testing.

04:29 That actually becomes important not so much in cutaneous lesions, but in cervical lesions to know whether we're dealing with one of those HPVs that tend to drive the epithelium into malignancy, how do we manage these? Pretty easily. So observation.

04:48 What? Well, yeah, many of these will go away spontaneously.

04:52 And that's because the immune system finally wakes up and goes, oh, there's a virus infection going on here.

04:58 And we throw in cytotoxic T cells or natural killer cells.

05:02 And we can remove the proliferating cells.

05:05 If you can't wait that long then you can put on salicylic acid that causes exfoliation of the keratinocytes. And in most cases you will exfoliate all the way down to the basal layer. And you will get rid of all the virus, and all the residual cells will grow back in.

05:21 They won't have any virus in them and voila, a cure.

05:24 You can also do surgical treatments.

05:26 So cryotherapy you can you can put a liquid nitrogen on top of them.

05:32 You can laser them. You can do a variety of other things, including formal excision.

05:38 And with that, we've really nailed the discussion on the common household wart verruca.