Verruca vulgaris is usually benign and most often occurs in areas that endure frequent mild trauma (e.g. fingers, fingernails, hands, knees and face). Hands are most commonly affected due to the increased probability of direct contact with HPV contaminated fomites. Autoinoculation is mainly observed in young children due to their inherent tendency to touch and scrape the surfaces of the already present warts leading to the spread of viral particles to unaffected skin. The clinical manifestation is strongly dependent upon the location of infection. Mild pain is reported in cases where warts are present in weight-bearing regions like the back of the feet. Morphological characteristics of common warts include [9]:

• Segregation - sharply demarcated
• Shape - round or irregular (e.g. the unusual types like pedunculated or cauliflower shaped warts most commonly appear in the scalp and neck area with a size ranging from as small as 1 mm to as large as 1 cm)
• Color - yellow, brown, light gray or gray-black 
• Size - 2 to 10 mm in diameter
• Texture - rough and firm
• Frequent locations - fingers, hands, knees, face, neck and elbows

• Fever

  More Info: Herpes zoster Measles Measles, aka rubeola, is a contagious childhood viral infection characterized by fever, coryza (acute rhinitis), cough, conjunctivitis, and cutaneous and mucosal lesions. [utmb.edu]

  'Erythema Multiforme' 27 February, 2015 This pediatric patient presented with symptoms of a fever, upper respiratory tract infection and new erythematous targetoid lesions on the abdomen and all four limbs. [nursingtimes.net]

  After treatment, fever develops. Warts don't disappear completely after treatment. Other warts appear after treatment. Last updated 6 April 2018 [nmihi.com]

  Case 2 A 77-year-old man with a 37-year history of pustular psoriasis being treated with brodalumab, a human monoclonal antibody that binds to interleukin (IL) 17 receptor A (IL17R) with high affinity, was hospitalized for erythroderma and high fever. [hindawi.com]

  A is incorrect because CMV infection presents with fever, pneumonitis, hepatitis, encephalitis, chorioretinitis, gastroenteritis and a wide variety of skin manifestations, including morbilliform eruption, blueberry muffin rash in babies and ulcers. [pathologyoutlines.com]

• Fatigue

  Such movement is governed by the rotator muscles of the hip, which can tighten under the extra load, becoming fatigued and painful. [telegraph.co.uk]

• Blister

  A blister may form and may contain blood. If the blister is bothersome, you may take the following steps: clean the blister with alcohol and nick the blister top with a clean needle. Gently press out the fluid and/or blood with a clean tissue. [childrens.com]

  On the other hand, highest side effect for Group D is irritation 29(96.7%), then burning 22(73.3%), pain 11(36.7%), pruritus 06(20%), blister formation 04(13%) and erythema 01(3.3%). [ncbi.nlm.nih.gov]

  The resultant blister or almost-blistered skin sloughs over days to weeks and lifts the wart infected skin off Surgery with a curette or scalpel can be used to physically remove Common Warts. [dovemed.com]

• Hyperkeratosis

  Microscopic Features: [1] Hyperkeratosis (more keratin - thick stratum corneum) - in "columns"; keratin in separate towers - not a flat thick sheet. Hypergranulosis (thicker stratum granulosum). [librepathology.org]

  Differential diagnosis Verruca vulgaris: Seborrheic keratosis: Variable combinations of hyperkeratosis, papillomatosis, acanthosis Horn pseudocysts No hypergranulosis, koilocytes or tiers of parakeratosis Epidermal nevus: Hyperkeratosis, papillomatosis [pathologyoutlines.com]

  (Med J Indones 2008; 18: 135-8) Key words: papilloma viruses, hyperkeratosis, orthokeratosis Copyright (c) 2009 Mona S. Haroen, Herliyani M. Purba, Eddy Kartadjukardi, Sri A. [mji.ui.ac.id]

  parakeratosis, hypergranulosis, koilocytosis, and papillomatosis. verruca vulgaris verruca vulgaris Wart Dermatology A benign skin tumor induced by HPV and histologically characterized by hyperkeratosis, parakeratosis, acanthosis. [medical-dictionary.thefreedictionary.com]

• Keratosis

  Senile keratosis, Bowen's disease and seborrhoeic keratosis showed the predominance of the CEA-related antigens over CEA weakly expressed. Strong expression of both CEA and NCA-50/90 was seen only in SCC. [ncbi.nlm.nih.gov]

  Hypertrophic actinic keratosis - often accompanied by solar elastosis. Actinic keratosis with superimposed lichen simplex chronicus. [3] Seborrheic keratosis - may have focal clear cell changes. Condyloma acuminatum - genital region. [librepathology.org]

  Some pathologists use the term “verrucal keratosis” or similar in cases where a clear distinction cannot be made. [dermnetnz.org]

• Dermatitis

  acute + Dyshidrotic dermatitis + Eczema atopicum (dermatitis atopica) + Subacute and chronic (eczem) dermatitis + Microbial eczema + Granuloma gluteale infantum + Toxic contact (irritative) dermatitis, acute + Toxic contact (irritative) dermatitis, [atlases.muni.cz]

  Dermat., 15, 433 (1950). Article CAS Google Scholar Bunting, H., Proc. Soc. Exp. Biol. and Med., 84, 327 (1953). Article CAS Google Scholar Siegel, B. V., J. Invest. Dermat., 35, 91 (1960). Article CAS Google Scholar Brenner, S., and Horne, R. [nature.com]

  These include successful results in controlled trials on verruca vulgaris, psoriasis, and atopic dermatitis. On a further inspection, a giant verruca is found on another sofa. Jack then remembered the verruca and the puzzle piece. [dictionary.cambridge.org]

  Predisposing factors are hyperhidrosis, immunosuppression or atopic diathesis (children with atopic dermatitis seem to be more susceptible to viral inoculation). Autoinoculation is a typical phenomenon in children. [altmeyers.org]

  Warts are particularly common in: School-aged children, however they may occur at any age Dermatitis, due to a defective skin barrier People with drug-induced immunosuppression such as with long-term azathioprine or ciclosporin use, or have human immunodeficiency [dermnetnz.org]

• Eruptions

  (June 16, 2022) Verruca Vulgaris Eruption Arising in the Setting of a Tyrosine Kinase Inhibitor. [cureus.com]

  A purpuric hand and foot eruption may occur. More Info: Erythema infectiosum [utmb.edu]

  Pagina 165 - Brown, JA The effects of early corticosteroid therapy on the skin eruption and pain of herpes zoster. JAMA. ‎ [books.google.it]

  A is incorrect because CMV infection presents with fever, pneumonitis, hepatitis, encephalitis, chorioretinitis, gastroenteritis and a wide variety of skin manifestations, including morbilliform eruption, blueberry muffin rash in babies and ulcers. [pathologyoutlines.com]

  Phototoxic and photoallergic reactions + Berloque dermatitis + Syndrome Favre-Racouchot + Actinic damage of the skin + Metabolic and nutrition problems + Pellagra + Rachitis, avitaminosis D + Scorbut, avitaminosis C + Drug reactions + Lichenoid drug eruptions [atlases.muni.cz]

• Fear

  Having lost part of the finger on the right hand, the patient had crippling anxiety and fear that the remaining warts would claim his other fingers and his livelihood. Cyclosporine was replaced with everolimus. [indianjnephrol.org]

  They can affect the patient’s quality of life causing discomfort, embarrassment and fear of negative appraisal in the society. [bjbms.org]

  However, there may be associated difficulties in treatment that are accentuated in the pediatric population, such as pain or fear of needles upon injection of lidocaine to locally anesthetize the area. [clinmedjournals.org]

• Confusion

  Molluscum contagiosum – The large viral inclusions of molluscum should not be confused with the very large basophilic inclusions which may be seen in some verrucae (figure 2). [dermnetnz.org]

• Neuralgia

  Cervix | Bowenoid Papulosis | Epidermodysplasia Verruciformis #3 Stephen K Tyring Department of Dermatology, The University of Texas McGovern star star star star star_half Known for Human Papillomavirus | Epidermodysplasia Verruciformis | Postherpetic Neuralgia [keyopinionleaders.com]

  The major morbidity with herpes zoster is postherpetic neuralgia, which is quite painful. [utmb.edu]

• Seizure

  Roseola is believed to be one of the major causes of febrile seizures. Toddlers are most often affected. [utmb.edu]

The clinical presentation often helps in accurate diagnosis of warts. Skin biopsy of warts is generally not performed. The most important feature to look out for include:

• Absence of skin lines across the surface
• Occurrence of thrombosed capillaries (pinpoint black dots) 
• Bleeding from warts when shaved

Histological tests to detect and identify the structural proteins are mainly conducted when the warts are treatment resistant or when presented in immunocompromised patients. Low sensitivity is the major disadvantage of this test. Molecular analytical techniques like southern blot hybridization is more sensitive and specific for detecting and identifying the HPV type. Polymerase chain reaction (PCR) can be used to detect the presence of specific viral DNA. However, it should be noted that HPV can only be detected in relatively younger lesions.

HPV infection does not have a cure in modern medicine and therapies are mainly available for removal of warts. Patients respond differently towards different treatment and none is found to be 100% effective [6] [10]. The course of treatment mainly depends upon the site of infection and sometimes more than one treatment method is required for effective management [1]. Medical intervention is often necessary for individuals with spreading, extensive and painful warts or persistent warts aged over 2 years. The least invasive, time consuming and pricey methods are to be tried first before going in for costly and invasive procedures.

Usage of topical agents, intralesional injections and systemic agents are some of the noninvasive procedures that are available. Many topical agents are available for treating common warts. Application of topical agents is generally done by a trained personnel under medical supervision. Salicylic acid (SCA) is one of the important topical agents used for treating warts [11]. SCA can be applied in many forms, liquid, or as a plaster or as SCA impregnated tape. Another topical agent in common use is cantharidin. It is a blistering agent extracted from the blister beetle. Contact with cantharidin results in epidermal necrosis and blistering which in turn help in the destruction of warts. It is used as a mono therapy agent or as an add-on therapy agent (1%) in combination with Podophyllum (5%) and SCA (30%) in collodion base. Formerly vitamin A was also used as a topical agent for treating common warts [1]. Dibutyl squaric acid commonly termed as squaric acid dibutyl ester (SADBE) and diphencyclopropenone (DCP) are the other two contact immunotherapueatic agents used to treat warts. Trichloroacetic acid is used as a tissue necrotic agent to remove isolated warts by tissue destruction.

Treatment of isolated lesions is carried out using laser surgery and electrodesiccation with curettage or both. The major disadvantage of these procedures are that at times it may cause permanent scarring. Electrocautery and cryosurgery with liquid nitrogen (-196ºC) are the other two extremely effective but painful treatment options. The procedure involves the careful application of liquid nitrogen using cryospray or cotton bud applicator to the affected area covering 1-2 mm of surrounding normal skin. The procedure has to be repeated every 1-4 weeks depending on the size and severity of the infection for at least 3 months for complete removal of warts.

Carbon dioxide laser has been yet another high-precision technique used to remove warts via incision and excision of tissues with subsequent sealing of minute blood vessels. Better prognosis with a less chance of postoperative morbidity and related complications are the major plus points of carbon dioxide laser treatment. Another major advantage of CO2 laser therapy is its excellent long term results. This method is mainly used to manage intraepithelial neoplastic lesions. The excision can be performed following two different methods:

• Vaporization of the lesion until healthy tissue is seen underneath.
• Usage of beam as a blade to remove lesions covering appropriate margins of healthy skin in order to prevent any future autoinoculation. This method is more effective when compared to the vaporization technique.

Warts are most common among children and in teenagers between ages 18 and 20. The prognosis is relatively fair and recurrence is mainly reported in immunocompromised patients. Resistance towards treatment and recurrence of infection is frequently encountered while managing HPV infections in immunocompromised patients. External factors like persistent localized trauma (e.g. in patients who are athletes, mechanics, butchers) are considered as risk factors for contracting the infection and for the recurrence of HPV infection. New HPV warts reappear in about 35% of cases within 1 year of primary infection. Spontaneous disappearance of warts without scarring occurs in one half and two-third of cases within the first and second year of infection respectively [8]. The disappearance of wart without scarring is termed as spontaneous regression or involution. Scarring is the common side effect of removal of warts by medical intervention and such practices should avoid to prevent the formation of multiple scars in case of recurrence. Common warts beneath the fingernails (subungual warts) are difficult to treat as most of treatment options available are ineffective and may also lead to nail damage.

HPV is a double-stranded DNA virus with a circular genome enclosed in an icosahedral protein cover. Warts are generally seen on the back of phalanges or on the knees. The major HPV types reported are HPV-2 and HPV-4. The other types of HPV causing warts are HPV-1, HPV-3, HPV-27 and HPV-57. The identification of the type of HPV does not help in the treatment of warts [1]. Major sites of infection include regions enduring frequent mechanical stress and strain resulting in minor epithelial damage such that the virus can gain access to the otherwise impenetrable barrier. Transmission occurs mainly through direct contact or indirectly via fomites. Using common swimming pools and bathrooms may lead to the spread of infection, where the virus gain entry through the damaged skin [1]. Patients already infected with HPV may get re-infected (autoinoculation) via scraping, shaving or by minor skin aberrations [2] [3].

Verruca vulgaris is universal in occurrence, concerning around 7 to 12% of the total population. HPV is capable of infecting individuals of all ages, but is most frequently seen in children with peak incidence during teenage years, after which there is a sharp decline [4]. The prevalence of common warts varies dramatically in different age groups, with different geographic location and time. Verruca vulgaris accounts for about 70% of all the warts that are presented clinically [5]. The prevalence of warts was estimated to be approximately 0.84% and 12.9% in the United States and Russia, respectively, based on the observations of two separate populations based studies in the respective countries.

Warts can affect the epithelial membranes anywhere in the body. They gain access via minute skin aberrations. The exact mechanism by which they reach the basal or proliferating squamous epithelium is not fully understood [6] [7]. The presentation of warts occurs after a specific incubation period of the virus inside the host. The HPV, once inside the host injects its genome into the host cell leading to uncontrolled cell replication and increased blood supply to the site which in turn help them to multiply rapidly [7]. The site of replication of HPV is restricted to differentiated epithelial cells of the upper region of the epidermis. HPV is incapable of penetrating beyond this level to have a systemic dissemination and infection. Viral particles can be observed in the basal layer also. Histopathologic studies of site of infection reveal the presence of pronounced papillomatous epidermis and overlying tiers of parakeratosis along with hypergranulomatosis. Other pronounced observations include presence of large pink inclusions in the upper epidermis, especially in the incidence of acral skin. Presence of vacuolated keratinocytes (also known as koilocytes) with a small shrunken nucleus encircled by a perinuclear clearing area are also observed. Smaller basophilic granules are also found in some lesions.

Most of the cases are benign with no manifestations, especially in immunocompetent individuals. In such individual antibody mediated immunity provides protection and cell mediated immunity helps in regression of already present infection. Immunocompromised patients with HIV infection or those who have undergone kidney transplant or other organ transplantation have a higher risk of contracting infection with lesions that are resistant to treatment. Recommendations for preventing infections in such patients include

• Avoid physical contact with warts on other individual’s body.
• Avoid autoinoculation by touching the warts present in one's own body.
• While in public utility spaces, wear protective shoes or gloves to prevent direct skin contact with an inanimate surface that may be contaminated with HPV particles.

Verruca vulgaris (common wart) is a common, epidermal lesion caused by infection with human papillomavirus (HPV) of skin areas that frequently endure minor trauma. They are often seen in areas beneath the nail and cuticle. Over 100 types of HPV are known to cause the infection. Warts are mainly transmitted by direct contact or by autoinoculation. Presently there is no treatment available to cure the infection. Removal of warts using topical agents, systemic agents, surgical methods, intralesional injections, laser treatment, cryotherapy and electrodessication are prescribed in cases of substantial spreading of warts or when they persist over 2 years. Major risk factors for contracting infection include usage of common showers, occupational meat handling and immune suppression.

Verruca vulgaris (common wart) is a non-cancerous skin growth that appears on the top layer of skin as a result of localized human papilloma viral (HPV) infection. HPVs are small DNA viruses that infect the skin and mucous membranes. Warts are mainly seen in children and young adults. Most of the warts have a rough texture with light or dark nodulated surface. The spread of infection mainly occurs through direct contact with warts of other individuals or through fomites contaminated with viral particles. Autoinoculation occurs when the infection spread to other part of the body in an already infected person by touching or scratching of warts. The main sites of infection include hands, fingers/toe beds and knees.

Common warts are generally harmless and spontaneously disappear and therefore treatment is not required in most of the cases. Approximately 65% of warts goes away within 2 years of infection without any medical intervention. However, it should be noted that there is always a risk of enlargement and spreading of infection to other areas via autoinoculation (self-inoculation).

Medical attention is required in the presence of widespread/symptomatic /persistent or spreading warts over 2 years. Spontaneous resolution is difficult and resistance to treatment occurs in adults, immunocompromised patients (e.g. HIV infection and organ transplant patients) and those with persistent warts [1].

Treatment options available include usage of topical agents, systemic agents, intra lesional injections, cryotherapy, laser therapy, electro dessication and surgical excision. Warts in nail and toe bed areas are usually resistant to treatment. Liquid nitrogen can be used in such areas (cryotherapy).

1. Sterling JC, Handfield-Jones S, et al. British Association of Dermatologists. Guidelines for the management of cutaneous warts. Br J Dermatol. 2001;144(1):4–11.
2. Stulberg DL, Hutchinson AG. Molluscum contagiosum and warts. Am Fam Physician. 2003;67(6):1233-1240.
3. Chow KM. Physicians need more evidence on treatments of warts. Am Fam Physician. 2003;68(9):1714-1716.
4. Gibbs S, Harvey I. Topical treatments for cutaneous warts. Cochrane Database Syst Rev. 2006; 3: CD001781.
5. Rivera A, Tyring SK. Therapy of cutaneous human Papillomavirus infections. Dermatol Ther. 2004;17:441-448.
6. Bellew SG, Quartarolo N, Janniger CK. Childhood warts: an update. Cutis. 2004;73:379-384.
7. Silverberg NB. Human papillomavirus infections in children. Curr Opin Pediatr. 2004;16:402-409.
8. Massing AM, Epstein WL. Natural history of warts. A two-year study. Arch Dermatol. 1963;87:306–310.
9. Kirnbauer R, Lenz P, Okun MM. Human Papillomavirus. In: Bolognia J, Jorizzo J, Rapini R, eds. Dermatology. 1st ed. London: Mosby; 2003; 1217–1233.
10. Goldfarb MT, Gupta AK, Gupta MA, Sawchuk WS. Office therapy for human papillomavirus infection in nongenital sites. Dermatol Clin. 1991; 9(2):287-96.
11. Kwok CS, Gibbs S, Bennett C, Holland R, Abbott R. Topical treatments for cutaneous warts. Cochrane Database Syst Rev. 2012; 9:CD001781.