Differential diagnoses: Warts

Dr Nigel Stollery compares four types of warts and offers clues for their diagnosis.

Filiform warts

Presentation

  • Long, narrow, protruding warts with finger-like appearance
  • Less common than other forms of viral wart
  • Most commonly found on the head, especially eyelids and lips
  • Caused by HPV types 1, 2, 4, 27 and 29

Management

  • Topical treatment less effective
  • Location often means topical salicylic acid not advisable
  • Small prominent warts can be tied or snipped, but may recur
  • Shave and cautery or cryotherapy are options
  • Given time, lesions often clear without treatment

Seborrhoeic warts

Presentation

  • The most common benign tumour in older patients
  • Incidence increases with age
  • Typical 'stuck on' appearance
  • Variations in colour from white to black
  • No aetiological factors identified, but more common on sun-exposed areas
  • Not contagious
  • Family trait in about half of those affected
  • Occur on any site of the body except palms and soles

Management

  • Treatment not usually required
  • For symptomatic warts, cryotherapy or curettage and cautery are options

Molluscum contagiosum

Presentation

  • Very common in children
  • Often multiple papules with umbilicated centre
  • Contagious and autoinoculation may occur to other areas
  • Worse in children with eczema
  • Caused by the DNA pox virus
  • In adults, may be sexually transmitted

Management

  • Treatment usually ineffective
  • Topical imiquimod may be helpful in severe cases
  • Usually resolves without treatment, but can take months
  • Mean duration of an outbreak is eight to 18 months
  • Treat any eczema with topical steroids to reduce scratching

Common warts

Presentation

  • Affect 7-12% of the population
  • Increased incidence in immunosuppressed individuals
  • Twice as common in white skin, compared to darker skin
  • Occur as nodules with hyperkeratotic surface
  • Most common on the hands
  • Caused by HPV virus

Management

  • Treatment not always required
  • In children, 50% will resolve by six months
  • Overall, 65% will disappear without treatment in two years
  • Options include keratolytics, electrocautery and cryotherapy
  • In severe, persistent cases, bleomycin injections may help

Dr Stollery is a GP in Kibworth, Leicestershire, and clinical assistant in dermatology at Leicester Royal Infirmary

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