CXCR4 WHIM syndrome is a cancer predisposition condition for virus-induced malignancies

Warts, hypogammaglobulinaemia, infections and myelokathexis syndrome (WHIMS) is a rare combined primary immunodeficiency caused by the gain of function of the CXCR4 chemokine receptor. We present the prevalence of cancer in WHIMS patients based on data from the French Severe Chronic Neutropenia Registry and an exhaustive literature review. The median follow-up of the 14 WHIMS 'patients was 28.5 years. A central review and viral evaluation of pathological samples were organized, and we conducted a thorough literature review to identify all reports of WHIMS cases. Six French patients were diagnosed with cancer at a median age of 37.6 years. The 40-year risk of malignancy was 39% (95% confidence interval [CI]: 6%-74%). We observed two human papillomavirus (HPV)-induced vulvar carcinomas, three lymphomas (two Epstein-Barr virus [EBV]-related) and one basal cell carcinoma. Among the 155 WHIMS cases from the literature, 22 cancers were reported in 16 patients, with an overall cancer 40-year risk of 23% (95% CI: 13%-39%). Malignancies included EBV-associated lymphoproliferative disorders and HPV-positive genital and anal cancers as in the French cohort. Worldwide, nine cases of malignancy were associated with HPV and four with EBV. Immunocompromised WHIMS patients appear to be particularly susceptible to developing early malignancy, mainly HPV-induced carcinomas, followed by EBV-related lymphomas.

Does HPV biotype influence the characteristics and evolution of plantar warts?

BACKGROUND

Few studies have addressed the relationship of human papillomavirus (HPV) biotypes to patient characteristics and the clinical signs, course, and response to the treatment of plantar warts.

OBJECTIVE

Analyze the HPV types associated with plantar warts and their relationship with warts characteristics, patient characteristics and response to treatment.

METHODS

A total of 372 patients sampled for hyperkeratosis of a plantar wart were included. Multiplex polymerase chain reaction (PCR) was performed to detect the HPV biotype.

RESULTS

The prevalence of HPV was 81.2%, and HPV1 was the most prevalent biotype (36.1%). HPV1 was the most prevalent biotype in patients < 70 years old (90.9% in < 10 years), and biotypes 2, 19 and 27 were the most prevalent in patients > 70 years old (p = 0.012). HPV1 was the most frequent in patients with one (39,9%) or two (47.1%) warts and HPV5 (33.3%) in patients with three warts (p < 0.001). Cure, spontaneous resolution, and recurrence were higher in HPV1 (p < 0.001). HPV14 warts healed the fastest (2 months quartile 1-3 (2.0-2.0)), and HPV5 (10.977 (6.0-20.0)) and HPV27 (7.5 (3.0-10.0)) warts (p = 0.033) took the longest to heal.

CONCLUSIONS

HPV biotype is associated with age and the number of warts and appears to influence the natural history of warts and their response to treatment.

Flat Warts (Verrucae Planae) Confined to the Pigment of a Tattoo: A Rare Tattoo-associated Complication

Tattoos are a form of decorative body art in which pigment dyes of different colors are inoculated into the skin. It is estimated that 15-25% of general population has one or more tattoos (1), and the reasons for the popularity of this procedure may include greater social acceptance, aesthetic appeal, or perhaps the option of using laser removal techniques to eliminate unwanted tattoos. Even though modern professional tattoos are usually performed in sterile conditions, complications still occur, and with increasing numbers of people getting tattoos, the incidence of tattoo-associated side-effects presenting to dermatologists, which may be as high as 2%, is likely to increase (2). Herein we present a case of a 43-year-old male patient with multiple HPV-associated flat warts (verrucae planae) confined to the black pigment of a tattoo done 15 years ago. A 43-year-old patient presented to our clinic due to eczema on the trunk. However, during skin examination, we observed asymptomatic verrucous papules confined to the black ink of a tattoo done 15 years ago on the lateral side of his right lower leg (Figure 1a). Clinical examination showed multiple, discrete, skin-colored, verrucous papules disseminated exclusively within the lines of the black-colored tattoo. Full skin examination did not reveal any similar lesions anywhere else on the body. Dermoscopically, papules showed a discretely papillomatous surface and sharp borders (Figure 1b). The patient had another black tattoo on his trunk, in which no similar lesions were found. All his tattoos had been done more than 15 years ago in a professional tattoo salon and with no previous history of cutaneous lesions within tattoos. The patient had no other medical conditions and was not taking any medications. Additionally, no history of warts or other HPV-related lesions of the skin or mucosal membranes could be established. A biopsy of an individual papule was taken and sent for a histopathological analysis, which subsequently showed hyperkeratotic, orthokeratotic, and parakeratotic acanthotic epidermis with hypergranulosis and rare cells with perinuclear halo indicative of koilocytes (Figure 3b). Immunohistochemical analysis showed negative reaction for p16 and p53, while Ki67 was positive only in rare basal and suprabasal cells. These findings were indicative of low-risk HPV, and the diagnosis of HPV-induced verruca plana was ultimately established. The patient was then successfully treated with cautious curettage of the lesions, leaving no scars. Due to the growing popularity of tattoos, especially among younger populations, it is necessary to emphasize the possibility of various tattoo-related side-effects that can still occur due to improper preparation of the tattoo location, contamination of ink products, improperly sterilized instruments, or due to insufficient personal hygiene following tattooing (3). In the past, tattoo-associated infections were significantly more frequent, with the highest prevalence of Staphylococcus and Streptococcus infections causing impetigo, folliculitis, cellulitis, erysipelas, or sepsis (2), but recent improvement and efforts in using sterile techniques in tattooing has led to a significant drop in the number of tattoo-related infections. In this short report, we present a case of a different and a relatively rare type of tattoo-associated infection - flat warts i.e., verrucae planae. Flat warts are usually caused by HPV-3, -6B, -10, -28, and -49. Typical predilection sites are the face, dorsal sides of the hands or feet, arms, and legs, and they usually appear as skin-colored, pink, or brown, flat-topped discrete papules. It is believed that HPV can be inoculated through contaminated ink, instruments, the artist's saliva, or that it may be a pre-existing unnoticed wart in the tattooed area (4-6). The latency period between tattooing and HPV infection can range from several months to 10 years, with a mean period of 5 years (3). This may suggest that the immune system can control the infection for some time, and that some form of immune suppression may result in the development of a clinical disease. In our case, the latency period could not be established due to the patient's unawareness of the lesions, and no potential trigger could be identified. The occurrence of lesions on only one of the patient's tattoos as well as their confinement to the black pigmented ink may indicate a correlation to this specific pigment. Ramey et al. (6) conducted a study in which they assessed the localization of warts in differently colored tattoos. The results showed that black ink tattoos had a seven times higher risk of developing warts when compared with colored ink. At first it was thought that this was due to HPV inoculation via contaminated instruments, ink, or autoinoculation of the patient's own warts, but some evidence indicates that it is unlikely for HPV to survive in ink and that if the warts were inoculated they would occur equally in all ink colors. A different theory by Ruocco et al. (7) explains this phenomenon through an "immunocompromised district" mechanism, in which polycyclic aromatic hydrocarbons found in black ink produce reactive oxygen species (ROS) that can damage cellular structures and consequently increase the risk of a variety of infections, including HPV. Moreover, black ink contains almost pure nanoparticles, which are associated with greater ROS production than the larger particles found in colored ink (7,8). There are several treatment options for verrucae planae, such as liquid nitrogen cryotherapy, topical 5% fluorouracil, topical 5% imiquimod, 0.025-0.050% tretinoin, 10% salicylic acid, or 10-30% glycolic acid. These treatments have differing success rates. Destructive modalities, such as surgical excision, curetting, or laser ablation may significantly damage the tattoo and cause scarring, and are thus not regularly performed. It's necessary to emphasize that despite today's sterile methods of tattooing, complications may still occur and medical professionals, namely dermatologists, should be aware of them. A person who wishes to get a tattoo should be advised to visit a licensed tattoo artist at a licensed tattoo parlour only. Patients with pre-existing dermatoses characterized by an isomorphic phenomenon, such as psoriasis or lichen planus, are particularly prone to developing a tattoo-associated adverse reaction, and those with severe dermatoses should be advised to avoid tattooing. Additionally, people with a previous history of warts should be aware of the possibility of warts occurrence, even years or decades after tattooing. Even though most of tattoo-related side effects are merely inconveniences, there is a potential for serious complications and patients should be advised as such.

Skin surface material for detecting human papillomavirus infection of skin warts

Warts, caused by human papillomavirus (HPV) infection, have various clinical presentations, making them difficult to differentiate from clavus, callus, and sometimes, squamous cell carcinoma. Although skin biopsies are the gold standard, a less-invasive method of examining these lesions is desired. Ninety patients with warts and related diseases, such as clavus and callus, were recruited to explore new differentiation methods using the surface of the warts. DNA was extracted from three types of specimens in each case: surface swab, shaved hyperkeratotic scale, and post-shaved surface swab. Total DNA was successfully extracted from these three specimens and was sufficient for subsequent HPV DNA detection. We analyzed samples for the HPV type and HPV viral load using polymerase chain reaction (PCR). Fifty-five cases were PCR-positive, and HPV1a, 2a, 4, 27, 57, and 65 were detected. The amount of HPV1a DNA produced was significantly greater than that of other HPV types. Regarding the correlation between the clinical diagnosis and HPV detection, the positive agreement rate was 90.9%, the negative agreement rate was 40.0%, and the overall agreement rate was 71.1%. Ten of the 21 cases clinically diagnosed as plantar warts were PCR-negative, especially in elderly patients. This suggests that it is difficult to distinguish plantar warts from clavus and callus in clinical practice. Although the amount of HPV DNA in the removed keratinization scale was highest for all HPV types, HPV detection by swabbing before and after shaving is also useful for follow-up as well as for differential diagnosis.

Comparative Study Among CO 2 Laser, Intralesional Vitamin D3, and Combined Intralesional Vitamin D3 and CO 2 Laser in Treatment of Palmoplantar Warts

BACKGROUND

Many therapeutic modalities are used for palmoplantar warts; whether destructive, such as chemical cautery, electrocautery, cryocautery, surgical removal, and laser ablation, or immunotherapeutic, stimulating the immune system against the virus such as intralesional vitamin D3 injection.

OBJECTIVE

To compare the efficacy of intralesional vitamin D injection combined with CO 2 laser to the efficacy of either modality alone.

PATIENT AND METHODS

Eighty age- and sex-matched patients with palmoplantar warts were divided into 4 groups: Group A received intralesional vitamin D3 injections, group B received ablative CO 2 laser, group C received CO 2 laser and intralesional vitamin D3 injection, and group D (control group) were injected intralesionally with normal saline. Assessment was performed clinically, photographically, and dermoscopically before and after treatment to evaluate the response, and then, another assessment was performed after 3 months to detect any recurrence.

RESULTS

Complete clearance was seen in 90% of cases in group C, in 80% in group A, and in 75% in group B with no statistically significant difference.

CONCLUSION

Intralesional vitamin D, CO 2 laser, and the combination show comparable efficacy and recurrence rates. Intralesional vitamin D maybe a better option for people with a relative contraindication to CO 2 laser.

[Early detection of WHIM symdrome. A case report]

BACKGROUND

WHIM syndrome corresponds to an inborn error of innate and intrinsic immunity, characterized by: warts (Warts), Hypogammaglobulinemia, Infections and Myelocathexis, for its acronym in English.

CASE REPORT

4-year-old male, with severe neutropenia and B-cell lymphopenia from birth, without severe infections or warts; the panel genetic sequencing study of primary immunodeficiencies with the CXCR4 c.1000C>T (p.Arg334*) variant, which is associated with WHIM syndrome.

CONCLUSIONS

The diagnosis of severe neutropenia from birth should include the search for inborn errors of immunity, through genetic sequencing studies, especially in asymptomatic or oligosymptomatic patients.

High versus low dose oral isotretinoin in the treatment of cutaneous and genital warts

Although oral isotretinoin has been considered as a potential therapeutic option for the treatment of different types of warts, the optimum dosage regimen is not yet well-established. To evaluate the efficacy and adverse effects of high versus low doses of oral isotretinoin in the treatment of cutaneous and genital warts. The study included 100 patients who were randomly assigned to two groups, 50 patients in each. Group 1 received 0.6 mg/kg/day (high dose isotretinoin) and Group 2 received 0.3 mg/kg/day (low dose isotretinoin). In both groups, therapy was given daily until resolution was achieved or for a maximum of 3 months. Complete clearance of warts was observed in 76% of the high dose isotretinoin group and in 46% of the low dose isotretinoin group. There was a statistically significant difference in the therapeutic response between the two groups. Recurrence was higher in the low dose group (26%) than the high dose group (7.8%). Adverse effects were mild and tolerable. High dose of systemic isotretinoin is more effective than low dose and seems to be a promising well-tolerated and effective therapeutic option for the treatment of cutaneous and genital warts.

Intralesional combined furosemide and digoxin in cutaneous warts treatment: A randomized controlled clinical trial

Although being a benign lesion, Warts can affect the quality of life by causing discomfort, disfigurement, and social embarrassment besides the tendency to spread. Cutaneous wart treatment faces many challenges as the development of an antiviral drug that can eradicate the human papilloma virus (HPV) is difficult. This clinical study aimed to assess the efficacy and safety of intralesional combined furosemide and digoxin in the treatment of multiple cutaneous warts. This double blinded randomized clinical trial included 80 adult patients with multiple cutaneous warts (≥2 warts) who were randomized into two groups, Group I (40 patients) treated with intralesional combined furosemide and digoxin and Group II (40 patients) who were treated with intralesional normal saline solution as a control group, weekly till improvement or for maximum five sessions. Clinical and dermoscopic evaluation at baseline, every session, and monthly for 6 months after the last session to detect any recurrence was performed. Complete wart clearance was observed in 92.5% of patients in the intralesional combined furosemide and digoxin group (Group I) compared with 10.0% in saline group (Group II), with highly statistically significant difference (P-value = 0.000). Pain during injection in 95.0% and 45.0% of patients in Group I and Group II respectively, treatment group was superior compared to control group. Intralesional injection of combined furosemide and digoxin can be a safe and effective treatment option in multiple cutaneous warts with minimal side effects in this study.

Disease Progression of WHIM Syndrome in an International Cohort of 66 Pediatric and Adult Patients

Warts, hypogammaglobulinemia, infections, and myelokathexis (WHIM) syndrome (WS) is a combined immunodeficiency caused by gain-of-function mutations in the C-X-C chemokine receptor type 4 (CXCR4) gene. We characterize a unique international cohort of 66 patients, including 57 (86%) cases previously unreported, with variable clinical phenotypes. Of 17 distinct CXCR4 genetic variants within our cohort, 11 were novel pathogenic variants affecting 15 individuals (23%). All variants affect the same CXCR4 region and impair CXCR4 internalization resulting in hyperactive signaling. The median age of diagnosis in our cohort (5.5 years) indicates WHIM syndrome can commonly present in childhood, although some patients are not diagnosed until adulthood. The prevalence and mean age of recognition and/or onset of clinical manifestations within our cohort were infections 88%/1.6 years, neutropenia 98%/3.8 years, lymphopenia 88%/5.0 years, and warts 40%/12.1 years. However, we report greater prevalence and variety of autoimmune complications of WHIM syndrome (21.2%) than reported previously. Patients with versus without family history of WHIM syndrome were diagnosed earlier (22%, average age 1.3 years versus 78%, average age 5 years, respectively). Patients with a family history of WHIM syndrome also received earlier treatment, experienced less hospitalization, and had less end-organ damage. This observation reinforces previous reports that early treatment for WHIM syndrome improves outcomes. Only one patient died; death was attributed to complications of hematopoietic stem cell transplantation. The variable expressivity of WHIM syndrome in pediatric patients delays their diagnosis and therapy. Early-onset bacterial infections with severe neutropenia and/or lymphopenia should prompt genetic testing for WHIM syndrome, even in the absence of warts.

Clinical guideline for the diagnosis and treatment of cutaneous warts (2022)

AIM

Cutaneous warts caused by human papillomavirus are benign proliferative lesions that occur at any ages in human lives. Updated, comprehensive and systematic evidence-based guidelines to guide clinical practice are urgently needed.

METHODS

We collaborated with multidisciplinary experts to formulate this guideline based on evidences of already published literature, focusing on 13 clinical questions elected by a panel of experts. We adopted Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to form classification of recommendations as well as the improved Delphi method to retain respective recommendations with a consensus degree of over 80%.

RESULTS

Our guideline covered aspects of the diagnosis and treatment of cutaneous warts such as diagnostic gold standard, transmission routes, laboratory tests, treatment principle, clinical cure criterion, definitions, and treatments of common warts, flat warts, plantar warts, condyloma acuminatum, and epidermodysplasia verruciformis. Recommendations about special population such as children and pregnant women are also listed. In total, 49 recommendations have been obtained.

CONCLUSIONS

It is a comprehensive and systematic evidence-based guideline and we hope this guideline could systematically and effectively guide the clinical practice of cutaneous warts and improve the overall levels of medical services.

Palmar and Plantar Pits, More than Just Viral Warts

A 40-year-old woman with a family history of gastric, pulmonary, and endometrial cancers (parents and grandparents) was referred to our institution with a 3-year history of progressive pruritus with palmar and plantar papules. On physical examination, there were keratotic yellowish pinpoint papules on the hands (Figure 1) and yellowish keratotic plaques and papules on the plantar pressure points (Figure 2). The diagnosis of punctate palmoplantar keratoderma was confirmed histopathologically (Figure 3), and treatment was initiated with 30% urea cream, which proved helpful. Molecular studies were requested, which documented a variant in the AAGAB gene. After treatment, the patient slightly improved and clinical symptoms were better tolerated.

Risk of Anogenital Warts in Renal Transplant Recipients Compared with Immunocompetent Controls: A Cross-sectional Clinical Study

Renal transplant recipients have increased risk of human papilloma virus-related anogenital (pre)cancers. Less is known about their risk of anogenital warts. The aim of this study was to estimate the prevalence and odds of anogenital warts in renal transplant recipients compared with immunocompetent controls, and to assess risk factors for intra- and perianal warts in renal transplant recipients. The study examined 248 renal transplant recipients and 250 controls for cutaneous and mucosal anogenital warts. Participants completed a questionnaire on lifestyle and sexual habits. For external anogenital warts (including penile, vulvar and perianal warts), renal transplant recipients had higher prevalence and odds than controls, both in men (8.1% vs 1.6%, adjusted odds ratio (OR_adjusted)=5.09, 95% confidence interval (95% CI), 1.03–25.04) and women (11.3% vs 1.6%, OR_adjusted=8.09, 95% CI 1.69–38.82). For intra-anal warts, there was no clear pattern of higher odds in renal transplant recipients than controls. Current smoking and having had receptive anal sex increased the risk of intra-/perianal warts in renal transplant recipients. In conclusion, renal transplant recipients in this study had higher odds of external anogenital warts than controls.

[A woman with papules in a tattoo]

A healthy 21-year-old woman presented with multiple, 1-4 mm, skin-coloured papules following the ink pattern of a feather-shaped tattoo; this was diagnosed as a human-papilloma-virus induced cutaneous verrucae plana (flat wart). Minor trauma can result in auto-inoculation or pseudo-koebnerization; it is, therefore, important to not to tattoo through a wart to avoid spreading the disease.

A deep learning system for differential diagnosis of skin diseases

Skin conditions affect 1.9 billion people. Because of a shortage of dermatologists, most cases are seen instead by general practitioners with lower diagnostic accuracy. We present a deep learning system (DLS) to provide a differential diagnosis of skin conditions using 16,114 de-identified cases (photographs and clinical data) from a teledermatology practice serving 17 sites. The DLS distinguishes between 26 common skin conditions, representing 80% of cases seen in primary care, while also providing a secondary prediction covering 419 skin conditions. On 963 validation cases, where a rotating panel of three board-certified dermatologists defined the reference standard, the DLS was non-inferior to six other dermatologists and superior to six primary care physicians (PCPs) and six nurse practitioners (NPs) (top-1 accuracy: 0.66 DLS, 0.63 dermatologists, 0.44 PCPs and 0.40 NPs). These results highlight the potential of the DLS to assist general practitioners in diagnosing skin conditions.

Intralesional versus intramuscular bivalent human papillomavirus vaccine in the treatment of recalcitrant common warts

BACKGROUND

Despite the availability of different therapeutic modalities, treatment of recalcitrant common warts is still challenging. Cervarix (GlaxoSmithKline, Brentford, UK), a recombinant bivalent human papillomavirus (HPV) vaccine, has shown promising efficacy in the treatment of warts.

OBJECTIVES

To evaluate the beneficial effects and tolerability of intramuscular versus intralesional bivalent HPV vaccine in the treatment of recalcitrant common warts.

METHODS

The study included 44 adult patients with multiple recalcitrant common warts; 22 patients received intramuscular injection of bivalent HPV vaccine at 0, 1, and 6 months or until complete clearance of warts, and the other 22 patients received intralesional injection of 0.1 to 0.3 mL of bivalent HPV vaccine into the largest wart at 2-week intervals until complete clearance or for a maximum of 6 sessions.

RESULTS

Complete clearance of warts was observed in 18 patients (81.8%) of the intralesional group and 14 patients (63.3%) of the intramuscular group; however, the difference was not statistically significant. Adverse effects were transient and insignificant, and no recurrence was reported in either group.

LIMITATIONS

Small study sample and different dosing schedules.

CONCLUSIONS

Bivalent HPV vaccine, particularly by intralesional injection, seems to be a potential therapeutic option for the treatment of multiple recalcitrant common warts.

Viruses in Skin Cancer (VIRUSCAN): Study Design and Baseline Characteristics of a Prospective Clinic-Based Cohort Study

BACKGROUND

Accumulating evidence suggests that cutaneous viral infections are risk factors for the development of keratinocyte carcinomas. The Viruses in Skin Cancer (VIRUSCAN) Study, a prospective cohort study, was established in 2014 to investigate the risk of keratinocyte carcinoma associated with cutaneous human papillomavirus and polyomavirus infection and the possible interaction with ultraviolet radiation exposure (UVR).

METHODS/RESULTS

VIRUSCAN incorporates repeated measures of viral infection using multiple markers of infection and quantitative measures of UVR using a spectrophotometer. Participants were recruited between July 14, 2014 and August 31, 2017 at the University of South Florida Dermatology Clinic in Tampa, FL. After excluding 124 individuals with prevalent keratinocyte carcinomas at baseline, 1,179 participants (53.2% women, 46.8% men, all ages 60 years and older) were followed for up to 4 years with routine skin exams occurring every 6 to 12 months. Here, we present the VIRUSCAN Study design, methods, and baseline characteristics, including demographics, sun exposure behavior, quantitative UVR exposure measurements, and cutaneous viral prevalence, for the full study cohort.

CONCLUSIONS

The VIRUSCAN Study will provide critical temporal evidence needed to assess the causality of the role cutaneous viral infections play in the development of keratinocyte carcinomas, as well as the potential interaction between cutaneous viral infections and UVR exposure.

IMPACT

Study findings will be valuable in future development of novel keratinocyte carcinoma prevention strategies.

A Giant Cutaneous Horn: One of the Largest Recorded

We present a case of one of the largest cutaneous horns recorded in the known literature as an opportunity to explore diagnostic considerations and treatment options. Cutaneous horns are common exophytic neoplasms composed of dense keratin that are always secondary to primary lesions, which can be benign or malignant. Due to the variance of the primary lesion, diagnostic biopsies are necessary to rule out a malignant origin. Several case reports of giant cutaneous horns may suggest that a larger size indicates a verrucous origin, although a biopsy is necessary as this association has only been noted in very few cases. If the primary lesion is found to be malignant and extending to the biopsy margins, further treatment is required, whereas a benign origin usually requires no further treatment. J Drugs Dermatol. 2019;18(7):697-698.

Plantar Warts: Epidemiology, Pathophysiology, and Clinical Management

Verrucae plantaris (plantar warts) are common cutaneous lesions of the plantar aspect of the foot that are caused by the human papillomavirus (HPV). Ubiquitous in our environment, asymptomatic infection with HPV occurs frequently, with most infections controlled or cleared by cellular and humoral immune responses. However, certain populations have been observed to manifest plantar warts at higher rates compared with the general population, placing them at increased risk for wart-induced pain and complications. Plantar warts shed HPV, which can then infect other sites in the plantar region or spread to other people. Although controlling risk factors is useful in preventing infection, the pervasive nature of HPV makes these preventive measures frequently impractical. This literature review outlines the current knowledge regarding the relationship between plantar wart pathophysiology, HPV transmission, and epidemiologic characteristics. Given the high propensity for treatment resistance of plantar warts and no established, practical, and reliable method of prevention, HPV prophylaxis for populations that demonstrate high rates of plantar warts may be of benefit in controlling the spread of lesions.

Eccrine porocarcinoma presenting as a recurrent wart

Eccrine porocarcinoma (EPC) is an exceedingly rare sweat gland tumor most commonly seen in older patients. Diagnosis of EPC is rare, representing a small percentage of cutaneous malignancies. In the absence of established guidelines, wide local excision (WLE) has traditionally been considered the standard treatment. However, there is growing evidence of increased local recurrence and nodal metastasis associated with WLE. More recently, Mohs micrographic surgery (MMS) is emerging as an effective treatment method with higher cure rates. We report a case of EPC presenting as a recurrent wart in a 36-year-old man that was successfully treated with MMS.

Amelanotic acral melanoma misdiagnosed as verruca plantaris

We report a case of amelanotic acral melanoma in a 42-year-old Chinese woman. Ten months previously the patient found a 2-cm asymmetric erythematous macular plaque on her left sole. The lesion was diagnosed as verruca plantaris by every physician the patient consulted. One month ago, an enlarged lymph node was detected in the left groin, which biopsy reported as metastatic melanoma. Dermoscopy suggested verruca plantaris, and positron emission tomography (PET) revealed increased glucose metabolism in the macular plaque. Finally, biopsy of the plaque revealed amelanotic melanoma. Misdiagnosis and diagnostic delay are usually associated with poorer patient outcomes. Awareness of atypical presentations of acral melanoma is thus important for decreasing misdiagnosis rates and improving patient outcomes.

[A woman with a growing mass close to the fingernail]

A 23-year-old woman had a painful, growing mass close to the nail of her left index finger. The differential diagnosis consisted of acquired digital fibrokeratoma, digital fibromyxoma, periungual fibroma or verruca vulgaris. Surgical excision of the mass was performed, and histopathological analysis revealed a subungual exostosis.

Common Foot Problems: Over-the-Counter Treatments and Home Care

Most foot disorders do not require podiatry referral or complex interventions. After the clinical diagnosis is made, these conditions can typically be managed with over-the-counter (OTC) and home remedies, with guidance from the primary care physician. Stretching and strengthening exercises, along with the use of heel cups, resolve most plantar fasciitis cases and are at least as effective as nonsteroidal anti-inflammatory drugs or steroid injections. Hallux rigidus is best managed with a hard-soled shoe or rigid insert that relieves pain by restricting motion across the metatarsophalangeal joint. Hallux valgus responds to use of wide toe box shoes, and surgery is not clearly beneficial beyond one year. Plantar warts can be treated effectively at home with OTC salicylic acid and cryotherapy topical agents, which have equal effectiveness to liquid nitrogen. In patients with corns and calluses, OTC topical salicylic acid has short-term benefits, and pads and inserts that more evenly redistribute contact forces have long-term benefits. Inserts are commonly recommended to redistribute forefoot pressure and relieve pain. Several OTC preparations are available for the treatment of tinea pedis, with topical allylamines being the most effective. Although OTC topical treatments have been widely used for onychomycosis, they have poor long-term cure rates compared with prescription oral medications.

Prevalence, incidence and correlates of low risk HPV infection and anogenital warts in a cohort of women living with HIV in Burkina Faso and South Africa

OBJECTIVE

To report the prevalence and incidence of low-risk human papillomavirus infection (LR-HPV) and anogenital warts (AGW) among women living with HIV (WLHIV) in Burkina Faso (BF) and South Africa (SA), and to explore HIV-related factors associated with these outcomes.

METHODS

We enrolled 1238 WLHIV (BF = 615; SA = 623) aged 25-50 years and followed them at three time points (6, 12 and 16 months) after enrolment. Presence of AGW was assessed during gynaecological examination. Cervico-vaginal swabs for enrolment and month 16 follow-up visits were tested for HPV infection by Inno-LiPA® genotyping. Logistic regression was used to assess risk factors for prevalent infection or AGW. Cox regression was used to assess risk factors for incident AGW.

RESULTS

Women in SA were more likely than those in BF to have prevalent LR-HPV infection (BF: 27.1% vs. SA: 40.9%; p<0.001) and incident LR-HPV infection (BF: 25.8% vs. SA: 31.6%, p = 0.05). Prevalence of persistent LR-HPV was similar in the two countries (BF: 33.3% vs. SA: 30.4%; p = 0.54), as were prevalence and incidence of AGW (Prevalence: BF: 7.5% vs. SA: 5.7%; p = 0.21; Incidence: BF: 2.47 vs. SA: 2.33 per 100 person-years; p = 0.41). HPV6 was associated with incident AGW (BF: adjusted Hazard Ratio (aHR) = 4.88; 95%CI: 1.36-17.45; SA: aHR = 5.02; 95%CI: 1.40-17.99). Prevalent LR-HPV (BF: adjusted Odds Ratio [aOR = 1.86]; 95%CI: 1.01-3.41; SA: aOR = 1.75; 95%CI: 0.88-3.48); persistent LR-HPV (BF: aOR = 1.92; 95%CI: 0.44-8.44; SA: aOR = 2.81; 95%CI: 1.07-7.41) and prevalent AGW (BF: aOR = 1.53; 95%CI: 0.61-3.87; SA: aOR = 4.11; 95%CI: 1.20-14.10) were each associated with low CD4+ counts (i.e. <200 vs. >500 cells/μL). Duration of ART and HIV plasma viral load were not associated with any LR-HPV infection or AGW outcomes.

CONCLUSION

LR-HPV infection and AGW are common in WLHIV in sub-Saharan Africa. Type-specific HPV vaccines and effective ART with immunological reconstitution could reduce the burden of AGW in this population.

[Late diagnosis of WHIM sydrome]

WHIM syndrome is a primary autosomal dominant immuno deficiency due to CXCR4 mutations characterized by mucocutaneous warts, hypogammaglobulinemia, recurrent bacterial infections and myelokathesis. Treatment consists in prophylactic antibiotics, immunoglobulin replacement and granulocyte or granulocyte/monocyte colony stimulating factors. We present the case of a 21 year old woman who showed leukopenia at 10 months of age and one year later multiple infections with hypogammaglobulinemia requiring intravenous immunoglobulin. During follow up she developed chronic neutropenia. A bone marrow aspiration showed increased myeloid series with predominance of immature elements. On the basis of infections, low levels of IgG, IgA, IgM and lymphopenia with absent memory B cells, a diagnosis of common variable immunodeficiency was made. She started intravenous immunoglobulin replacement and prophylactic antibiotics. At age 20, small warts in hands that progressed to forearms, knees, abdomen and face were recorded. CXCR4 gene sequencing was done detecting a heterozygous p.Arg334STOP mutation, confirming WHIM syndrome. This disease is infrequent and difficult to diagnose.

A case series of verrucae vulgares mimicking hyperkeratosis in individuals with diabetic foot ulcers

BACKGROUND

Diabetic foot ulcers are a common complication in the advanced stages of diabetes mellitus. Certain lesions may be refractory to usual treatments with prolonged healing. In these cases, differential diagnoses to classical ulcers should be considered. Although plantar warts are a common and easy-to-diagnose finding in the general population, diagnosis can be challenging in people with diabetic foot ulcers, as they mimic hyperkeratosis in these people.

CASE REPORT

We report seven cases of people with diabetic foot ulcers and verrucae vulgares mimicking treatment-refractory hyperkeratosis, presenting to our centre between 2014 and 2016. Diagnosis was aided by the clinical presentation, followed by dermoscopy and punch biopsy. Treatment included topical application of 5-fluoruracil and salicylic acid (four people), cryotherapy (three people) and surgical excision (three people), all in combination with local pressure offloading. In five people, the verrucae were completely removed after a mean treatment period of 9.4 months; two individuals were lost to follow-up.

CONCLUSION

Verrucae may be more common in people with diabetic foot lesions and polyneuropathy than generally assumed. Typical findings include small, pinhead-sized bleedings within and surrounding hyperkeratous lesions. These findings should alert the clinician for the potential presence of a verruca. In such cases, biopsy should be performed to enable specific diagnosis and treatment.

Recalcitrant Verrucae in Patients With DOCK8 Deficiency

An 18-year-old Caucasian man presented with extensive recalcitrant verrucae on his trunk and extremities that were unresponsive to cryotherapy, salicylic acid, topical imiquimod, CO₂ laser, candida antigen, and intralesional bleomycin. He had a diagnosis of hyperimmunoglobulin E syndrome until 2011, when he was determined to have DOCK8 immunodeficiency after genetic testing at the National Institutes of Health. In addition to verrucae, he had a personal history of eczematous dermatitis, osteomyelitis, molluscum infections, cutaneous abscesses, recurrent pneumonia, and severe food allergy.

An unusual differential diagnosis of penile warts: metastases from rectal carcinoma

Patients with penile lesions, such as virally induced papillomata, frequently present to genitourinary medicine clinics and general practitioners. Their diagnosis is usually based on clinical observation and biopsy is not generally undertaken. Penile lesions may rarely have a more sinister aetiology and represent metastatic spread from solid tumours arising at distant sites. Penile metastases arise most frequently from genitourinary cancers (prostate, bladder and kidney), but may also arise from tumours of the large bowel; other primary sites are extremely uncommon. We report the case of a patient presenting with penile metastases from rectal carcinoma arising during third-line chemotherapy for metastatic disease.

Clinical pearl: the squeeze maneuver

Plantar warts can be distinguished from calluses using the squeeze maneuver, a quick and easy method to diagnose plantar warts. This technique negates the need for an expensive diagnostic tool.

Oral Acyclovir in the Treatment of Verruca

OBJECTIVE

To describe a case in which persistent plantar warts resolved after a ten-day treatment course of oral acyclovir prescribed for herpes zoster.

CASE SUMMARY

A 49 year-old Caucasian female with non-significant past medical history presented to the podiatry clinic for treatment of verrucae. Debridement was performed and monochloroacetic acid was applied to affected areas seven times over seven months. The patient was diagnosed and treated for herpes zoster with acyclovir for ten days. Following acyclovir completion, only one verruca remained with complete resolution at the next follow-up podiatry visit.

DISCUSSION AND CONCLUSION

Few previous trials have supported the use of acyclovir cream in treatment-resistant plantar warts. However, no case reports to date describe the efficacy of oral acyclovir in the treatment of verruca. While a causal relationship has not been solidified between verrucous lesion resolution and treatment with acyclovir, it can be inferred and warrants additional attention.

Dermatoscopy of Verrucous Pigmented Lesions is Essential for Choosing the Appropriate Treatment

Dermatoscopy, as a noninvasive rapid method, which allows the viewing of melanin in the epidermis and papillary dermis, has an important role in diagnosis of the pigmented lesions localized on skin, mucous membrane, scalp and nails. The term of verrucous pigmented lesions includes a series of non-melanocytic and melanocytic, benign and malignant lesions. Among these, the most frequent is the seborrheic keratosis , a common epidermal tumor, affecting the sun exposed areas of adult. At the other end of the spectrum regarding the frequency is the seborrheic keratosis-like melanoma, whose underdiagnosis has a serious impact on the patient's life. In this work we present the clinical and dermoscopical aspects of three cases of verrucous pigmented lesions (two seborrheic keratoses and one seborrheic keratosis-like melanoma) that determined the diagnostic algorithm as well as the therapeutic approach. The above-presented cases underline the importance of dermatoscopy to determine the malignant potential of the pigmented lesions, the final appropriate treatment being possible after the histopathologic confirmation.

Primary intestinal lymphangiectasia with generalized warts

Primary intestinal lymphangiectasia (PIL) is a rare protein-losing enteropathy with lymphatic leakage into the small intestine. Dilated lymphatics in the small intestinal wall and mesentery are observed in this disease. Laboratory tests of PIL patients revealed hypoalbuminemia, lymphocytopenia, hypogammaglobulinemia and increased stool α-1 antitrypsin clearance. Cell-mediated immunodeficiency is also present in PIL patients because of loss of lymphocytes. As a result, the patients are vulnerable to chronic viral infection and lymphoma. However, cases of PIL with chronic viral infection, such as human papilloma virus-induced warts, are rarely reported. We report a rare case of PIL with generalized warts in a 36-year-old male patient. PIL was diagnosed by capsule endoscopy and colonoscopic biopsy with histological tissue confirmation. Generalized warts were observed on the head, chest, abdomen, back, anus, and upper and lower extremities, including the hands and feet of the patient.

Resolution of novel human papillomavirus-induced warts after HPV vaccination

Human papillomavirus (HPV) XS2 was isolated from warts on an immunosuppressed patient. After HPV vaccination, the warts resolved. HPVXS2 was also found in warts and normal skin of HIV-positive patients and rarely in HIV-negative controls. Further studies should elucidate the mechanisms that lead to wart clearance.

Lipoid Proteinosis: An Unusual Presentation with Verruca Vulgaris

Lipoid proteinosis (LP) is a very rare, autosomally recessive, inherited disease. It is also known as Urbach Wiethe disease or Hyalinosis cutis et mucosa. LP usually runs a benign, stable, and slowly progressing course. We present one LP case with additional unusual dermatologic involvement; verruca vulgaris was superimposed on papular lesions of LP. To our knowledge, this case is the first and only one described in the literature. In this presentation, we discuss the possibility of predisposition to Human Papilloma Virus (HPV) infections in LP.