4-48
Subjective: Symptoms
Asymptomatic, slow growing papules; commonly irritated by trauma or scratching, which can cause local
spreading and/or secondary infection.
Objective: Signs
Using Basic Tools: Sharply circumscribed single or multiple superficial, pearly, dome-shaped papules with
a characteristic umbilication seen easily with a hand-held lens. They initially present as pinpoint papules,
increase slowly to 2-3 mm in size (see Color Plates Picture 11), and are often found in the genital region.
Assessment:
Differential Diagnosis See these topics in Dermatology Chapter.
Flat warts (Verruca Plana), condylomata acuminata (venereal warts), squamous cell or basal cell skin cancers,
sebaceous gland hyperplasia (seen in elderly), epidermal inclusion cyst (on CD-ROM).
Plan:
Treatment
Primary: Treatment depends on location on body. Facial lesions should be treated less aggressively to
decrease the risk of scarring. Retinoid gel 0.01%-0.25% applied to affected area q hs will cause a minor
irritation to the lesion and works well for the face, as does potassium hydroxide topically. Apply to lesion
daily until cleared.
Alternative: Curettage, followed by imiquimod 5% cream applied to the lesion each day until cleared.
Patient Education
General: Patient will likely continue to develop new lesions (in or around the area of old ones) that are not
clinically visible at the initial visit. Return for additional treatment as needed
Medication: Avoid sun exposure when using retinoid gel.
Prevention: Keep all skin surfaces well hydrated/emolliated to avoid spread of the lesions.
Follow-up Actions
Return Evaluation: Consider alternate treatment or diagnosis, or refer for biopsy to rule out cancer.
Evacuation/Consultation Criteria: Evacuation not usually necessary. If not responding to appropriate therapy,
refer to dermatologist or primary care physician for biopsy to rule out cancer.
Skin: Warts (including Venereal Warts)
MAJ Daniel Schissel, MC, USAIntroduction: The common wart is a benign growth in the epidermis seen in 7-10 % of the population. It is
caused by the human papilloma virus (HPV) and commonly presents as papules and plaques in school age
children. Some HPV strains have been associated with malignant transformation.
Subjective: Symptoms
Usually slow growing; commonly irritated with minor trauma or excoriations
Objective: Signs
Verruca vulgaris: Appear predominately on the dorsal aspect of the hands and periungual region of the nail,
but may occur anywhere. They vary from solitary isolated lesions to vast numbers in any given individual.
The normal progression of the primary lesion is from a small, round, discrete, esh colored papule to a larger
yellowish tan to black lesion that measures from several millimeters to a couple centimeters. The surface
of the lesion commonly takes on a rough nely papillomatous (verruciform) surface with many characteristic