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Medical Student Core Curriculum in Dermatology

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1 Medical Student Core Curriculum in Dermatology
Warts Medical Student Core Curriculum in Dermatology Last updated July 29, 2011

2 Module Instructions The following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology. We encourage the learner to read all the hyperlinked information.

3 Goals and Objectives The purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with warts. By completing this module, the learner will be able to: Identify and describe the morphology of various types of warts Discuss the pathogenesis of warts Develop an initial treatment plan for a patient with warts Describe the technique of cryotherapy List the side effects of cryotherapy

4 Case One Megan Driskell

5 Case One: History HPI: Megan is an 8-year-old girl who presents to her pediatrician’s office with bumps on her fingers and hands. They have been present for 3 months without change and are asymptomatic. PMH: no chronic illnesses or prior hospitalizations Allergies: no known allergies Medications: none Family history: no affected family members Social history: lives at home with parents and attends school ROS: negative

6 Case One: Skin Exam

7 Case One: Question 1 How would you describe these lesions?
Hyperkeratotic and umbilicated papules and nodules Hyperkeratotic, endophytic papules and nodules Hyperkeratotic, exophytic papules and nodules Smooth and umbilicated papules and nodules Smooth, exophytic papules and nodules

8 Case One: Question 1 Answer: c How would you describe these lesions?
Hyperkeratotic and umbilicated papules and nodules (these papules are not umbilicated) Hyperkeratotic, endophytic papules and nodules (these papules are growing outward, not inward) Hyperkeratotic, exophytic papules and nodules Smooth and umbilicated (marked by a depressed spot) papules and nodules (more characteristic of molluscum contagiosum) Smooth, exophytic papules and nodules (these papules are not smooth)

9 Clinical Features of Verruca Vulgaris
Hyperkeratotic, exophytic (growing outward), dome-shaped papules or nodules Most common on fingers, dorsal hands, knees or elbows but may occur anywhere Punctate black dots representing thrombosed capillaries May koebnerize – spread with skin trauma

10 Epidemiology One of the top three skin problems in children
Cutaneous warts occur in 20% of school-aged children; also commonly found in young adults Males and females are equally affected

11 Case One: Question 2 Verruca vulgaris is caused by:
Human immunodeficiency virus Human papillomavirus Pox virus Herpes virus Varicella-zoster virus

12 Case One: Question 2 Answer: b Verruca vulgaris is caused by:
Human immunodeficiency virus Human papillomavirus Pox virus Herpes virus Varicella-zoster virus

13 Human Papillomavirus (HPV): Overview
Warts are caused by HPV HPV infects skin and mucosal epithelia HPV causes a variety of wart morphologies Verruca vulgaris: common warts Verrucae planae: flat warts Palmoplantar warts Condylomata acuminata: external genital warts The type of HPV determines the wart morphology 13

14 Role of HPV in Cutaneous Disease
HPV can be transmitted by skin-to-skin contact or through contaminated surfaces or objects Patients can also spread virus from lesion to unaffected skin HPV infects the basal keratinocytes of cutaneous and mucosal epithelium

15 Clinical Features of Verrucae Planae: Flat Warts
Skin-colored or pink Smooth-surfaced, slightly elevated, flat-topped papules Dorsal hands, arms, face (exposed surfaces)

16 Clinical Features of Palmoplantar Verruca
Thick, endophytic papules Central depression Plantar warts may be painful when walking Mosaic warts: plantar warts coalescing into large plaques

17 General Treatment Principles
Majority of all warts will spontaneously resolve in 1-2 years without scar Therefore important to choose a therapy with low toxicity and low risk of scarring No specific antiviral therapy for cure Most treatments are destructive or aim at stimulating the immune response to HPV Recurrence rates are high

18 Common Wart Treatment Options
Watchful waiting – majority of all warts will spontaneously resolve in 1-2 years without scarring Cryotherapy – liquid nitrogen (see following slide for more information) Salicylic acid – with occlusion and removal of the dead skin (filing, pumice stone) For patients who do not respond to the above therapies, refer to a dermatologist

19 Cryotherapy Click here for an instructional video on cryotherapy
Side effects of cryotherapy include: PIPA (post-inflammatory pigment alteration) In individuals with darker skin types, more likely to cause hypopigmentation (see pre and post-cryo photos below) Scar Pain Blister Nail dystrophy

20 Side Effects of Cryotherapy
Post inflammatory hyperpigmentation Wart ring post cryotherapy

21 Flat Wart Treatment Options
Common 1st line tx: Cryotherapy Salicylic acid (caution using on face) Topical tretinoin

22 Palmoplantar Wart Treatment Options
1st line treatment is the same as common wart therapy (often requires stronger dosing, e.g. 40% salicylic acid vs. 17% salicylic acid) Referral to a dermatologist may be made for chemotherapeutic agents (e.g. topical 5-Fluorouracil)

23 Case Two Jonathan Cohen

24 Case Two: History HPI: Mr. Cohen is a 21-year-old man who comes into the STD clinic because of an increasing number of bumps on his penis over the last year. PMH: no chronic illnesses or prior hospitalizations Allergies: no known allergies Medications: none Family history: noncontributory Social history: studying economics at a nearby university ROS: negative

25 Case Two: Skin Exam

26 Case Two: Question 1 How would you describe these lesions?
Pearly, vesicular papules Smooth, indurated plaques Verrucous exophytic papules Waxy, stuck-on plaques

27 Case Two: Question 1 Answer: c How would you describe these lesions?
Pearly, vesicular papules Smooth, indurated plaques Verrucous exophytic papules Waxy, stuck-on plaques

28 Clinical Features of external genital warts
Sessile, exophytic papules May be broad-based papules or large confluent plaques External genitalia, perineum, perianal, inguinal fold, mons pubis

29 Comparison of molluscum and genital warts
Molluscum Contagiosum (smooth, dome-shaped papules with central umbilication) External Genital Warts (hyperkeratotic, exophytic papules and plaques)

30 Case Two: Question 2 What further elements in the patient’s history would you need to complete your evaluation? Medications Sexual history Surgical history Allergies

31 Case Two: Question 2 Answer: b
What further elements in the patient’s history would you need to complete your evaluation? Medications Sexual history Surgical history Allergies 31

32 Clinical Presentation Frequently Associated HPV Type
HPV Infection Clinical Presentation Frequently Associated HPV Type External genital warts High grade intraepithelial neoplasia 6, 11 16, 18,31, 33-35, 40, 45 Genital infection with HPV is transmitted by sexual contact from partners with clinical or subclinical infection

33 External Genital Warts (EGW)
HPV infection is one of the most common STIs Risk factors: sexual intercourse at an early age, numerous partners, unprotected exposure Patients should receive counseling about condom usage, STI prevention, and potential STI testing for sexual partners Effective prophylactic HPV vaccine is available for prevention of genital warts Immunosuppression from HIV infection, organ transplant, etc. can lead to: Increased frequency of HPV infection Persistent infection More difficulties in treatment

34 Back to Case Two

35 Case Two: Question 3 What is the most likely HPV type leading to this patient’s disease? 2 6 16 31 34

36 Case Two: Question 3 Answer: b
What is the most likely HPV type leading to this patient’s disease? 2 6 16 31 34

37 Case Two: Question 4 Which of the following treatments could you use for external genital warts? Cryotherapy Imiquimod Salicylic acid All of the above

38 Case Two: Question 4 Answer: d
Which of the following treatments could you use for external genital warts? Cryotherapy (liquid nitrogen is used to freeze the tissue at the cellular level) Imiquimod (a cream of this interferon inducer can be applied 3x per week, response takes up to 12 weeks) Salicylic acid (this beta hydroxy acid is applied, occluded for 5-6 days, the wart is pared down, and then the cycle is repeated) All of the above

39 Treatment (cont.) Other destructive methods can be used as well to treat EGW Laser Electrocautery and curettage Surgical debulking Always use protective mask

40 Imiquimod: True or False
Imiquimod therapy is an off label use for treatment of external genital warts. True False

41 Imiquimod: True or False
Imiquimod is FDA approved for treatment of EGW Interacts with Toll-like receptors 7 and 8 to increase cytokines from macrophages Clearance of 50% EGW compared to placebo of 11% A disadvantage to this treatment is cost

42 Prevention Reminder: HPV Vaccine
Two HPV vaccines are licensed by the FDA and recommended by the CDC Gardasil™ and Cervarix™ Both vaccines are effective against HPV types 16 and 18, which cause most cervical cancers Gardasil is also effective against HPV types 6 and 11, which cause most genital warts in females and males 100% protection in prevention of genital warts during 5-year follow up period studied

43 Take Home Points Warts are caused by human papilloma viruses
Numerous morphologies exist: common, flat, palmoplantar, external genital Treatment is difficult and there are many options available A vaccine of certain HPV types has proven effective in reducing external genital warts

44 Acknowledgements This module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup from Primary authors: Kari L. Martin, MD; Susan K. Ailor, MD, FAAD. Peer reviewers: Renee M. Howard, MD, FAAD; Erin F. D. Mathes, MD, FAAD, FAAP, Timothy G. Berger, MD, FAAD. Revisions and editing: Sarah D. Cipriano, MD, MPH; Meghan Mullen Dickman. Last revised July 2011.

45 References Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web- Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; Available from: Gibbs S, Harvey I. “Topical treatments for cutaneous warts.” Cochrane Rev. Vol Online at eMedicine:http://emedicine.medscape.com/article/ overview. Updated 12/2009. Kirnbauer R, Lenz P, Okun MM. “Chapter 78. Human Papillomavirus” (chapter). Bolognia JL, Jorizzo JL, Rapini R: Dermatology. 2nd ed. Mosby Elsevier; Silverberg NB. “Human papillomavirus infections in children.” Current Opinion in Pediatrics. 16:


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