funDERMentals
DISCUSSION
The HPV family has more than 100 distinct DNA types, several of which have particular morphologic characteristics and favored locations. Depending on the affected site, warts can assume many appearances, including planar (flat-topped) papules that generally favor the legs and face of a child or adolescent. Chemotherapy made this patient susceptible, and the lack of a diagnosis in the intervening years compounded the problem.
The perioral hyperpigmentation is, of course, secondary to her lip licking, which dries and irritates the thin facial skin. On a blond or red-haired, fair-skinned patient, it would appear pink or red. But with our patient’s type IV skin, inflammation begets darkening. The two problems are probably unrelated.
Treatment of flat warts on the face of a young woman is problematic, especially when dark skin is a factor. Treatments such as liquid nitrogen would not only be painful if applied to the face but could also cause permanent pigment changes. Irritants and acids (eg, cantharidin or salicylic acid) would have that same potential, so we tend to treat this area with the least invasive, least irritating modalities, knowing that the perfect treatment has yet to be invented.
A sinecatechins ointment —a botanical product made from the extract of green tea leaves—was prescribed. The patient was instructed to apply it three times per day for a month, then return to the clinic for re-evaluation. Treatment alternatives at that point will include imiquimod, which stimulates the skin to produce interferon (known to discourage viral growth) and 5-fluorouracil (5FU) cream, which has also been used with some success for warts. (For the record, I have no financial interest in any of these products.)
Chances are good that with time and treatment, the patient’s warts will disappear. It should be noted that the differential included acne, molluscum contagiosum, and perioral dermatitis. A simple shallow shave biopsy could have been performed to confirm the diagnosis, if necessary.
TAKE-HOME LEARNING POINTS
• The HPV family of warts contains more than 100 distinct genomic types, which can present in a wide variety of morphologies.
• Flat warts (verucca planae) are commonly seen on faces and legs but can appear in other locations. Shaving spreads them.
• No perfect treatment for warts exists. All have drawbacks, including potential for irritation, pain, and dyschromia—the latter a particular problem for patients with darker skin.
• For these patients, sinecatechins ointment, imiquimod, and 5-fluorouracil cream are decent choices.
