Nongenital Warts Clinical Presentation
- Author: Philip D Shenefelt, MD, MS; Chief Editor: William D James, MD more...
HPV is spread by direct or indirect contact. It can resist desiccation, freezing, and prolonged storage outside of host cells. Autoinoculation also may occur, causing local spread of lesions. The incubation period for HPV ranges from 1-6 months; however, latency periods of up to 3 years or more are suspected.
Common warts also are termed verruca vulgaris. They appear as hyperkeratotic papules with a rough, irregular surface. They range from smaller than 1 mm to larger than 1 cm. They can occur on any part of the body but are seen most commonly on the hands and knees (see image below).
Filiform warts are long slender growths, usually seen on the face around the lips, eyelids, or nares.
Deep palmoplantar warts (myrmecia)
Deep palmoplantar warts also are termed myrmecia. They begin as small shiny papules and progress to deep endophytic, sharply defined, round lesions with a rough keratotic surface, surrounded by a smooth collar of calloused skin (see the image below). Because they grow deep, they tend to be more painful than common warts. Myrmecia warts that occur on the plantar surface usually are found on weight-bearing areas, such as the metatarsal head and heel. When they occur on the hand, they tend to be subungual or periungual.
Flat warts also are termed plane warts or verruca plana. They are characterized as flat or slightly elevated flesh-colored papules that may be smooth or slightly hyperkeratotic. They range from 1-5 mm or more, and numbers range from a few to hundreds of lesions that may become grouped or confluent. These warts may occur anywhere; however, the face, hands, and shins tend to be the most common areas. They may appear in a linear distribution as a result of scratching or trauma (Koebner phenomenon). Regression of these lesions may occur, which usually is heralded by inflammation.
Butcher's warts are seen in people who frequently handle raw meat. Their morphology is similar to common warts, with a higher prevalence of hyperproliferative cauliflowerlike lesions. They are seen most commonly on the hands.
A mosaic wart is a plaque of closely grouped warts. When the surface is pared, the angular outlines of tightly compressed individual warts can be seen. These usually are seen on the palms and soles.
Focal epithelial hyperplasia (Heck disease)
Focal epithelial hyperplasia, also termed Heck disease, is an HPV infection occurring in the oral cavity, usually on the lower labial mucosa. It also can be seen on the buccal or gingival mucosa and rarely, on the tongue. The lesions appear as multiple flat-topped or dome-shaped pink-white papules. They usually are 1-5 mm, with some lesions coalescing into plaques. They are seen most frequently in children of American Indian or Inuit descent.
Cystic warts (plantar epidermoid cysts)
A cystic wart appears as a nodule on the weight-bearing surface of the sole. The nodule usually is smooth with visible rete ridges but may become hyperkeratotic. If the lesion is incised, cheesy material may be expressed. The etiology of these lesions is uncertain. One theory is that a cyst forms, originating from the eccrine duct, and secondary HPV infection occurs. Another theory is that the epidermis infected with HPV becomes implanted into the dermis, forming an epidermal inclusion cyst.
Warts are caused by HPV, which is a double-stranded, circular, supercoiled DNA virus enclosed in an icosahedral capsid and comprising 72 capsomers. More than 100 types of HPV have been identified. Note the following wart types and HPV types:
Common warts - HPV types 2 and 4 (most common), followed by types 1, 3, 27, 29, and 57
Deep palmoplantar warts (myrmecia) - HPV type 1 (most common), followed by types 2, 3, 4, 27, 29, and 57
Flat warts - HPV types 3, 10, and 28
Butcher's warts - HPV type 7 (although some data suggest the association may be weak)
Focal epithelial hyperplasia (Heck disease) - HPV types 13 and 32
Cystic warts - HPV type 60
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