Dermatology Online Journal

Verruca vulgaris in a plaque of acanthosis nigricans
Atif Ahmed MD¹, Mark Matthews MD², John C Browning MD³
Dermatology Online Journal 17 (6): 9

1. San Antonio Uniformed Services Health Education Consortium, Wilford Hall Medical Center and San Antonio Military Medical Center, San Antonio, Texas
2. Pathology Reference Laboratory, San Antonio, Texas
3. Division of Dermatology and Cutaneous Surgery and Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, Texas. Browningj3@uthsca.edu

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Abstract

Warts are common cutaneous tumors, induced by different strains of the human papilloma virus. Many people develop one or more warts in their lifetime, most of which resolve spontaneously. We present a case of multiple warts within a plaque of acanthosis nigricans probably related to autoinoculation.

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Figure 1	Figure 2
Figure 1. Numerous, grouped skin-colored papules within a velvety hyperpigmented plaque around the neck. Figure 2. Verrucous papules along the proximal and lateral nail folds.

Case report

A 13-year-old obese male with a 2-year history of common warts on the fingers presented to the pediatric dermatology clinic with a 2-month history of bumps on his neck. Physical exam revealed numerous, grouped skin-colored papules within a velvety hyperpigmented plaque around the neck (Figure 1). Exam also demonstrated verrucous papules on the mid lower mucosal lip. Upon further questioning, the patient admitted to biting his fingernails and finger tips consistent with the exam which demonstrated involvement of the proximal and lateral nail folds (Figure 2). He also admitted to frequently rubbing his neck as a nervous habit. He did not have any genital warts or warts located on other parts of his body.

Figure 3	Figure 4
Figure 3. Scanning magnification shows a small punctate lesion with verrucoid epidermal hyperplasia and overlying hyperkeratosis. Figure 4. High magnification further demonstrates the superficial keratinocytic nuclear enlargement, prominence of cytoplasmic keratohyaline granules, and overlying hyperkeratosis characteristic of verruca.

Shave biopsy of one of the neck papules revealed epidermal papillomatosis and superficial keratinocytic nuclear enlargement, prominence of cytoplasmic keratohyaline granules, and overlying hyperkeratosis characteristic of verruca (Figures 3 and 4). We elected not to send the specimen for HPV typing because it would not change management. Koebnerization of dermatologic conditions like psoriasis, lichen planus, lichen nitidus, and warts is well known but we wanted to bring the likely seeding of a plaque of acanthosis nigricans to the attention of the readers. We suspect that the patient irritated one of his warts and then proceeded to scratch his neck. Dozens of new warts appeared on his neck within a couple of months. After failing topical imiquimod, the neck warts, along with the other warts, were removed by curettage and electrodesiccation followed by laser treatment of the base. The child has not had recurrence of any warts.

The natural history of common warts is of spontaneous resolution but treatment is often warranted because of social stigma, pain, bleeding, and in cases of periungual involvement, to prevent nail dystrophy. In this case, the child was being teased because of the warts on his neck. Treatment options range from destructive modalities like cryotherapy, curettage, cautery, and laser to immunomodulators such as candida antigen injection or topical imiquimod [1, 2, 3]. Nothing works with 100 percent efficacy and treatment must be tailored to the individual.

Childhood obesity continues to be a problem in the United States and the rest of the developed world. Acanthosis nigricans is often seen in obese individuals and is thought to be a cutaneous sign of insulin resistance [4]. Skin tags can also be seen in obese patients but the eruptive nature of our patient’s papules as well as the histologic findings confirmed the diagnosis of warts. Warts have also been reported within the pannus of obese patients [5] and we present this case in order to make clinicians aware of another potential dermatologic manifestation that can be seen in these patients.

References

1. Clifton MM, Johnson SM, Roberson PK, et al. Immunotherapy for recalcitrant warts in children using intralesional mumps or Candida antigens. Pediatr Dermatol 2003; 20:268. [PubMed]

2. Grussendorf-Conen EI, Jacobs S. Efficacy of imiquimod 5% cream in the treatment of recalcitrant warts in children. Pediatr Dermatol 2002; 19:263. [PubMed]

3. Ross BS, Levine VJ, Nehal K, et al. Pulsed dye laser treatment of warts: an update. Dermatol Surg 1999; 25:377. [PubMed]

4. Higgins SP, Freemark M, Prose NS. Acanthosis nigricans: a practical approach to evaluation and management. Dermatol Online J. 2008 Sep 15;14(9):2. [PubMed]

5. Staples CG, Henderson D, Tsongalis GJ, Fernandez M, Krejci-Manwaring J. Condylomata of the pannus in 3 obese patients: a new location for a common disease. Arch Dermatol. 2010 May;146(5):572-4. [PubMed]

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