Verruca vulgaris (common warts)
Common warts; verrucae; viral warts; HPV-induced cutaneous warts; periungual warts; subungual warts
Verruca vulgaris is one of the commonest cutaneous infections, caused by epidermotropic strains of human papillomavirus (HPV-1, -2, -4, -27, -57 most common cutaneous types). It presents as firm hyperkeratotic papules with characteristic punctate haemorrhages from thrombosed dermal capillaries on dermoscopy. Skin-oncology relevance is twofold — persistent verrucous lesions, especially periungual / subungual / chronic plantar, can be biopsied as suspected cSCC or keratoacanthoma, and chronic warts in immunosuppressed patients (organ-transplant recipients, HIV, chemotherapy) raise concern for HPV-driven cSCC particularly at digital and anogenital sites.
Clinical features
- Firm, hyperkeratotic, rough-surfaced papule with central punctate haemorrhages.
- Common sites — hands (dorsa, fingers), periungual, plantar surface, knees.
- Multiple in immunosuppressed (transplant recipients, HIV, chemotherapy) and children.
- Filiform variant — thread-like projections on the face, eyelids, neck.
- Mosaic variant — confluent plaque of multiple warts on the plantar surface.
- Spontaneous resolution within 2 years in 65% of children.
Dermoscopy
- Multiple punctate haemorrhages corresponding to thrombosed papillary dermal capillaries — pathognomonic for verruca.
- Hyperkeratotic surface; disruption of dermatoglyphics on the palm / sole.
- White background with capillary loops on dermoscopy.
- Absence of pigment network, polymorphous vessels, atypical structures.
- Distinguishes from plantar callus (no capillaries; preserved dermatoglyphics) and amelanotic acral melanoma.
Differential
- cSCC — persistent verrucous lesion, especially periungual / digital, particularly in immunosuppressed.
- Subungual SCC — chronic nail dystrophy / paronychia; HPV-16 association.
- Bowenoid papulosis — pigmented HPV-driven anogenital papules; HPV-16/18.
- Seborrhoeic keratosis — stuck-on appearance, fingerprint pigmentation.
- Plantar callus — physiological hyperkeratosis without capillaries.
- Acquired digital fibrokeratoma.
- Lichen planus — flat-topped, violaceous, polygonal.
Management
- Most warts self-resolve — observation is reasonable, particularly in children.
- Topical salicylic acid 12–17% with occlusion / paring; 12-week courses.
- Cryotherapy with liquid nitrogen — every 2–3 weeks for 4–6 cycles.
- Cantharidin, podophyllotoxin, fluorouracil 5% topical, imiquimod 5% — alternatives.
- Pulsed-dye laser, CO₂ laser, electrocautery — for refractory.
- Bleomycin intralesional, immunotherapy with squaric acid dibutyl ester (SADBE) or diphencyprone (DCP) — specialist option.
- Biopsy any verrucous lesion that is: persistent > 6 months despite treatment, in an immunosuppressed patient, at a site with HPV-driven malignancy risk (anogenital, periungual), or with atypical clinical features. Histology to exclude cSCC / Bowen disease.
- HPV vaccination relevant for OTRs and HPV-driven cancer risk.
References
- Sterling JC, Gibbs S, Haque Hussain SS, Mohd Mustapa MF, Handfield-Jones SE. British Association of Dermatologists' guidelines for the management of cutaneous warts 2014. Br J Dermatol. 2014;171(4):696-712.
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