4-49
“reddish-black seeds” (thrombosed capillary loops).
Verruca plana: Appear predominately as smooth, esh-colored to slightly tan, elevated papules, 2 to 5 mm
in diameter, with a round or polygonal base on the face, neck, arms, and legs. In the bearded area of men
and on the legs and axilla of women, irritation from shaving tends to cause the warts to spread in linear
arrays (Koebner effect)
Verruca plantaris: Appear initially as small, shiny, skin colored, sharply marginated papules that evolve to
plaques with a rough hyperkeratotic surface. They commonly present over the weight bearing points of the
foot and therefore are commonly tender to palpation. They may be distinguished from calluses by noting the
loss of the normal dermography (skin lines) that calluses usually retain. (see Podiatry: Plantar Warts).
Venereal Wart / Condyloma Acuminatum: Appear initially as tiny, pinpoint, esh-toned, papules that may grow
rapidly to cauliower-like masses in any region of the anogenital area and the oral mucosa.
Assessment:
Differential Diagnosis See appropriate sections in this book for most conditions listed.
Verruca vulgaris - seborrheic keratosis, lichen planus, simple callus, molluscum contagiosum, carcinoma with
verrucous (wart-like) appearance
Verruca plana - simple callus, foreign body, lichen planus, carcinoma with verrucous (wart-like) appearance
Venereal warts - condyloma lata (syphilis), intraepithelial neoplasm (Bowen’s disease), invasive squamous cell
skin cancer, molluscum contagiosum, lichen planus, skin tag
Plan:
Treatment
Verruca vulgaris: Trim warts; apply liquid nitrogen to the lesion (for 5 seconds, slowly thaw, repeat x 1); or
apply 40% salicylic acid to area once daily after trimming lesions; apply duct tape if unable to keep acid on
lesion; may need to treat for weeks until dermography (skin lines) returns.
Verruca plana: Trim warts; apply liquid nitrogen to the lesion for 5 seconds, slowly thaw, repeat x 1; or apply
40% salicylic acid, retinoic acid, or cimetidine to the lesions as described above
Venereal Warts: Apply podophyllin (10-25%), imiquimod cream to the lesions as described above; or apply
liquid nitrogen as above.
Follow-up Actions
Return Evaluation: Consider alternate treatment or diagnosis, or refer for biopsy to rule out cancer.
Evacuation/Consultation Criteria: Evacuation not indicated, unless venereal warts cannot be treated and are
large enough to interfere with mission. Consult dermatologist as needed.
Superficial Fungal Infections
Skin: Dermatophyte (Tinea) Infections
MAJ Daniel Schissel, MC, USARingworm - Tinea corporis Jock itch - Tinea cruris
Athlete’s foot - Tinea pedis Some Dandruff - Tinea capitis
Finger/Toenails - Tinea unguium Dandruff of Beard - Tinea barbae/faciale
Palms and Soles - Tinea manuum
Introduction: Dermatophyte infections are superficial, caused by fungi that invade only dead outer layers of
the skin or its appendages (stratum corneum, nails, hair). Microsporum, Trichophyton and Epidermophyton
are the genera most commonly involved. Some dermatophytes produce only mild or no inflammation. In
such cases the organism may persist indefinitely, causing intermittent remissions and exacerbations of a
gradually extending lesion with a scaling, slightly raised border. In other cases an acute infection may occur,
typically causing a sudden, vesicular and bullous reaction of the feet or an inflamed, boggy lesion of the scalp
(kerion) due to a strong immunologic reaction to the fungus. Transmission of dermatophyte infections may