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Nongenital Warts Clinical Presentation

  • Author: Philip D Shenefelt, MD, MS; Chief Editor: William D James, MD  more...
 
Updated: Feb 25, 2016
 

History

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.

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Physical

Common warts

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).

Common wart on the hand. Common wart on the hand.

Filiform warts

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.[4] 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.

Plantar warts. Plantar warts.

Flat warts

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

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.

Mosaic warts

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,[1] 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.

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Causes

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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Contributor Information and Disclosures
Author

Philip D Shenefelt, MD, MS Professor, Department of Dermatology and Cutaneous Surgery, University of South Florida College of Medicine; Past Chief, Section of Dermatology, James A Haley Veteran Affairs Medical Center

Philip D Shenefelt, MD, MS is a member of the following medical societies: American Academy of Dermatology, Florida Medical Association, Noah Worcester Dermatological Society, Society for Clinical and Experimental Hypnosis, American Contact Dermatitis Society, American Association for Physician Leadership, American Medical Association, American Society of Clinical Hypnosis

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Lester F Libow, MD Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Joshua A Zeichner, MD Assistant Professor, Director of Cosmetic and Clinical Research, Mount Sinai School of Medicine; Chief of Dermatology, Institute for Family Health at North General

Joshua A Zeichner, MD is a member of the following medical societies: American Academy of Dermatology, National Psoriasis Foundation

Disclosure: Received consulting fee from Valeant for consulting; Received grant/research funds from Medicis for other; Received consulting fee from Galderma for consulting; Received consulting fee from Promius for consulting; Received consulting fee from Pharmaderm for consulting; Received consulting fee from Onset for consulting.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Margaret H. Rinker, MD, to the development and writing of this article.

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Plantar warts.
Common wart on the hand.
 
 
 
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