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plantar wart

Etiology: 1) all warts are caused by human papilloma virus (HPV) 2) HPV types 1,4 3) immunosuppression increases risk of severe cases [5] Clinical manifestations: 1) occur on the plantar aspect of the foot 2) most frequently occurs at pressure points a) heel b) metatarsal head 3) endophytic papule or verrucous plaques, partially or fully inverted - dry rough surface that interupts the normal skin lines - pinpoint hemorrhagic macules of thrombosed capillaries - 2 cm plantar wart on heel not unusual [6] 4) may be exophytic in non-mobile patients 5) covered by a thick callus 6) skin-colored with black punctae (capillary loops) on close inspection or after removal of callus 7) tender with pressure * image of severe case in immumocompromised woman [5] Differential diagnosis: - plantar corns - Tinea pedis (erythematous, often involves interdigital webspaces with maceration) [6] - erythrasma - macules, generally large & scaling, sharply marginated - pink/red to brownish red in color - intertriginous areas of toes, groin & axillae - skin folds: groin, subpanniculus, intergluteal, inframammary - skin often has thin, wrinkled appearance similar to cigarette paper - Wood's lamp: coral-red fluorescence - pitted keratolysis - manifests as scale & pitting of the skin surface - involved areas are white when stratum corneum is fully hydrated - toe webs, balls or heel of foot in contact with shoe - foot odor (malodorous) - hyperhidrosis - black heel - can mimic the thrombosed capillaries of plantar warts - black heel lesions do not obscure dermatoglyphics & can be removed by scraping - this differentiates them from plantar warts [7] Management: 1) see verruca vulgaris (wart) 2) pharmacologic agents a) podophyllin 25% resin solution applied weekly b) cantharidin, 0.7% colloidin solution 3) cryotherapy every 2 weeks as effective as topical salicylic acid [3] & a visa versa [4] - 6 month cure rate 31-34% [4]

Related

papillomavirus

General

verruca vulgaris (warts)

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 958
  2. Anderson, Advance/Laboratory June 2001, pg 91
  3. Bruggink SC et al. Cryotherapy with liquid nitrogen versus topical salicylic acid application for cutaneous warts in primary care: Randomized controlled trial. CMAJ 2010 Oct 19; 182:1624 PMID: 20837684
  4. Cockayne S et al. Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae): A randomised controlled trial. BMJ 2011 Jun 7; 342:d3271. PMID: 21652750
  5. D'Souza GF, Zins JE. (image) Severe Plantar Warts in an Immunocompromised Patient. N Engl J Med. 2017 Jul 20;377(3):267. PMID: 28723340 Free Article http://www.nejm.org/doi/full/10.1056/NEJMicm1616238
  6. NEJM Knowledge+ Dermatology
  7. Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022