Dermatology Case 2

Abigail Ramirez Eileen Jill Ramos Joanna Marie Rayos del Sol

RAMIREZ, Abigail P.

Chief Complaint and History

A 54 year old Japanese sushi cook Chief Complaint: Multiple keratotic papules over his 3rd, 4th, and 5th finger of his right hand. HPI: 6 months prior to consult, patient noted 2 to 3 skin colored hard intraepidermal papule which slowly enlarged in time

RAMIREZ, Abigail P.

Physical Examination
There are several 1x1 to 1.5x1.5 cm grey colored rough surfaced papules with hemorrhagic dots found over the sides of the 3rd, 4th, and 5th finger of the right hand. He also has a few flat topped slightly pink nonscaly papule over the right hand, some forming a linear line over the right forearm.

RAMIREZ, Abigail P.

Salient Features
Pertinent Positives
Japanese Sushi Cook Chief complaint of multiple keratotic papules over the 3rd, 4th, and 5th finger of his right hand.
6 months PTA: Skin colored hard intraepidermal papule which slowly enlarged in time PE : several 1x1 to 1.5x1.5 cm grey colored rough surfaced papules with hemorrhagic dots PE: few flat topped slightly pink non-scaly papule over the right hand, some forming a linear line over the right forearm

Pertinent Negatives

RAMIREZ, Abigail P.

Clinical Impression
VerrucaVulgaris (common wart) Verruca Plana (flat wart)

RAMIREZ, Abigail P.

Differential Diagnosis
VerrucaVulgaris Verruca Plana Forehead, cheeks, nose, around the mouth, backs of the hands. MolluscumCont agiosum In adults, lower abdomen, upper thighs, penile shaft in men

Patient Manifestations Sites

Sides of the 3rd, Hands favors 4th, 5th fingers of the fingers and palms the right hand

Lesion

1x1 to 1.5x1.5 cm grey colored rough surfaced papules with hemorrhagic dots

Pinpoint to >1cm, average about 5mm. Presents as elevated, rounded papules with a rough grayish surface Black dotsmay be visible at the surface of wart

2-4mm flat topped papules that are slightlyerythematous or brown on pale skin and hyperpigmented on dark skin

SmoothSurfaced , dome-shaped, pearly papules; average of 35mm in diameter

Useful Finding

Papules with hemorrhagic dots

Tendency of warts to Koebnerize, forming linear, slightly raised, papular lesions

Centralumbilicat ion

RAMIREZ, Abigail P.

Differential Diagnosis
VerrucaVulgaris Hands favors the fingers and palms Verruca Plana Forehead, cheeks, nose, around the mouth, backs of the hands. MolluscumCont agiosum In adults, lower abdomen, upper thighs, penile shaft in men

Patient Manifestations Sites Right hand and right forearm

Lesion

flat topped slightly pink non-scaly papule

Pinpoint to >1cm,averagea about 5mm. Presents as elevated, rounded papules with a rough grayish surface Black dots may be visible at the surface of wart

2-4mm flat topped papules that are slightlyerythematousor brown on pale skin and hyperpigmented on dark skin

SmoothSurfaced , dome-shaped, pearly papules; average of 35mm in diameter Centralumbilicat ion

Useful Finding

Some forming a linear line over the right forearm

Tendency of warts to Koebnerize, forming linear, slightly raised, papular lesions

RAMIREZ, Abigail P.

Diagnosis
VerrucaVulgaris (common wart) Verruca Plana (flat wart)

RAMOS, Eileen Jill

Verruca Vulgaris (Common warts)

Age
of
Area
of
Hallmark
Etiology
Predisposing
Additional
Info
Predilection
Predilection
Factors
y Ranges:
pinpoint
y 5-20
y/o
y Fingers
&
y Verrucous
y HPV
y Frequent
y Spontaneously
to
1cm
Palms
of
1,2,4, immersion
of
resolve

y Presents
hands
27
hands
in
y No
y Periungal
water

elevated,
dermatoglyphies
y Meat
handlers
(fingerprint
rounded
papules
(nail
with
rough
folds)

biters)
(butcher)

grayish
surface
by
y Fish
handlers
y Spread
y
Mother
wart
auntoinoculation

grows
slowly
suddenly
many
warts
erupt
will
y On
surface
of
wart,
black
tiny
dot
to
due
thrombosed,
dilated
capillaries
(aid
diagnosis)


Lesion

Andrews Diseases of the Skin: Clinical Dermatology 10th edition.

RAMOS, Eileen Jill

Andrews Diseases of the Skin: Clinical Dermatology 10th edition.

RAMOS, Eileen Jill

Verruca Plana (Flat Warts)

Age
of
Area
of
Hallmark
Etiology
Additional
Info
Predilection
Predilection
y 2-4mm
flat
y Children
y Forehead
y Tendency
y HP
y Autoinoculation
topped
papule
and
y Cheeks
of
warts
to
3,10,28, y Highest
of
risk
y Slightly
young
Koebnerize,
41
y Nose
spontaneous
forming
erythematous
or
adults
y Areas
of
remission
linear,
brown
pale
on
mouth
slightly
skin
y Back
of
raised,
y Hyperpigmented
hands
papular
on
dark
skin
lesions

Lesion

Andrews Diseases of the Skin: Clinical Dermatology 10th edition.

RAMOS, Eileen Jill

Andrews Diseases of the Skin: Clinical Dermatology 10th edition.

RAYOS DEL SOL, Joanna Marie

Management
Many warts give no trouble, need no treatment and go away by themselves.
Up to 30% of common warts tend to spontaneously regress and disappear within 6 months Up to 75% will disappear in three years

They rarely recur but can be re-infected. To prevent re-infection, the source of infection should also be treated.
Two approaches: 1. Based on destruction of the wart: slowly or quickly 2. Based on induction of local immune reactions (immunotherapy)

RAYOS DEL SOL, Joanna Marie

Management:
Home Application First Line: Salicylic Acid
Salicylic Acid 17% (OTC)
Apply daily to wart As effective as Cryotherapy

Occlusal (17% salicylic acid)

Second line KeratolyticAgents

Cantharidin RetinA (Tretinoin) 0.05% cream applied qhs to warts

RAYOS DEL SOL, Joanna Marie

Management:
Clinic Procedures First line therapy
Cryotherapy (50% efficacy)

Second line therapy

Wart Immune Therapy
Imiquimod Cream 5% Intralesional Candida Injection Cimetidine Wart Therapy (No more effective than Placebo)

Other measures that have been used

Curattages electrodessication Topical 5-FU

RAYOS DEL SOL, Joanna Marie

Management:
Advanced Dermatologic Procedures Pulse dye laser CO2 Laser IntralesionalBleomycin

RAYOS DEL SOL, Joanna Marie

Treatment
Cryotherapy
freezing with liquid nitrogen or CO2 spray
Complications: Hypopigmentation (Melanocytes are very cold sensitive) Hyperpigmentation (in darker skinned individuals) Atrophy in skin areas directly over bone Neuropathy where nerves are superficial

N.B. Patients with cryoglobulinemia, poor peripheral circulation, and Reynauds may develop blisters.

10-20% salycylics lactic acid

The normal moisture of the body draws the active chemical into the wart, the acid dissolves the bonds between the skin cells, and the wart tissue crumbles apart as a result.

Keratolytics: Retinoids
ability to alter keratinization and accelerate the clearing of warts by inducing an irritant dermatitis disrupt intercellular adhesion structures May produce doughnut wart

RAYOS DEL SOL, Joanna Marie

Treatment Cimetidine Wart Therapy

H2 receptor antagonist that employs the ability of the immune system to recognize certain viral and fungal antigens. enhances delayed-type hypersensitivity reaction that block H2 receptor stimulation of T-cells.

Candida injection (Intralesional Wart Therapy)

believed that the delayed-type hypersensitivity reaction induced by these antigens increases the ability of the immune system to recognize and clear HPV most common side effect was itching at the injection site. Other side effects: influenza-like illness that lasted less than 24 hours and improved with nonsteroidal anti-inflammatory drugs. Intralesionalimmunotherapy is a promising treatment that warrants more clinical trials to further evaluate its effectiveness

RAYOS DEL SOL, Joanna Marie

Treatment
Imiquimod Cream 5%
imidazoquinolin heterocyclic, an immune response modifier that increases local cytokine production, with a subsequent activation of both the innate (rapid, nonspecific) and adaptive (specific, cellular, and humoral) immune systems induces peripheral monocytes and macrophages to release interferon and interleukin (IL)-12. Both cytokines promote a cell-mediated immune response led by CD8+ cytotoxic T cells and natural killer cells.

Bleomycin

a chemotherapeutic agent, inhibits DNA synthesis in cells and viruses. Disadvantages: Severe pain Hemorrhagic eschar digital necrosis nail dystrophy Risk of scarring High cost

RAYOS DEL SOL, Joanna Marie

Surgical ablation:
Curattages electrodessication Risk for painful scars Lesions larger than 1 cm should be excised instead CO2 Laser destruction Slow healing Risk of painful scars Special equipment and Training Very Expensive

Pulsed dye laser therapy - selectively target hemoglobin contained in blood vessels within the wart. As the hemoglobin heats up, thermal energy is dissipated to surrounding tissues, leading to cauterization of blood vessels. The result is a necrotic wart that eventually sloughs off.

RAYOS DEL SOL, Joanna Marie

Treatment Considerations for Nongenital Cutaneous Warts

HPV infection First-line therapy Common Salicylic acid, warts(Verruca vulgaris) cryotherapy Second-line therapy Cantharidin* Third-line therapy Bleomycin, intralesional immunotherapy, pulsed dye laser therapy

Flat warts(Verruca plana)

Salicylic acid, imiquimodcream

Cryotherapy, retinoids

Intralesional immunotherapy, pulsed dye laser therapy

Plantar warts(Verruca plantaris)

Salicylic acid

Cryotherapy, Bleomycin, surgical intralesional excision immunotherapy, pulsed dye laser therapy

THANK YOU!