Warts Diagnosis and Treatment

Warts Diagnosis and Treatment
By:Rick Lin, DO MPH
Texas Division of KCOM Dermatology Residency Program

Background Information
* Warts are small harmless lesions of the skin
* caused by a virus: the human papilloma virus.
* The appearance of warts can differ based on the type of wart and where it is located on the body.
* Warts are common in children. Most cases occur between ages 12-16 years.
* Up to 30% of warts disappear by themselves within 6 months. Most will disappear without any treatment within 3 years.
* Warts are caused by the DNA-containing human papillomavirus (HPV). There are at least 63 genetically different types of HPVs.
* The virus enters the skin after direct contact with recently shed viruses kept alive in warm, moist environments such as a locker room, or by direct contact with an infected person.
* The entry site is often an area of recent injury. The incubation time—from when the virus is contracted until a wart appears—can be 1-8 months.
* Contrary to popular mythology, touching a frog will not give you warts.

Types of warts
* Common warts (verrucae vulgaris): These common warts typically develop on the hand, especially around the nail. They are gray to flesh colored, raised from the skin surface, and covered with rough, hornlike projections.
* Plantar warts (verrucae plantaris): Plantar warts, by definition, occur on the plantar surface, or bottom, of the foot.
* They usually occur in high pressure areas such as the heel and the metatarsal heads (just behind the toes).
* They usually grow into the skin, not outward like common warts.
* This growing into the skin makes them more difficult to treat.
* Flat warts (verrucae plana): Flat warts are most commonly seen on the face, the back of the hands, and lower legs.
* They usually appear as small individual bumps about 1/4 inch across.
* Flat warts may spread rapidly on the face and lower legs from the activities involved in shaving.

Histopathology
* Verruca vulgaris (common wart) is caused by varous strains of human papilloma virus (HPV 1, 2, 4, 7, 26-29).
* Macroscopically verruca vulgaris may present as hard, rough surfaced papule
2 – 20 mm (solitary or multiple).
* Microscopically, this is an exophytic, symmetric, papillomatous lesion with large keratohyaline granules and characteristic inturning of the rete ridges.

Histopathology
* Parakeratotic columnar tiers of stratum corneum overlie the papillomatous surface.
* Small amounts of hemorrhage may be present within the columns of parakeratosis.
* Other characteristic features include koilocytosis, hypergranulosis and presence of multinucleated cells.

Treatment
* Home care is effective in making the wart or warts go away. No matter what technique you use, warts will disappear 60-70% of the time.
* Techniques may be done with and without medication.
* The ultimate goal of the medical therapies (not the surgical treatments) is to get your body to recognize the wart as something foreign and to destroy it, much like the body destroys a cold virus.

Adhesive tape therapy
* Place several layers of waterproof adhesive tape over the wart region (even duct tape).
* Do not remove the tape for 6-1/2 days. Then take off the tape and open the area to the air for 12 hours.
* Reapply tape for another 6-1/2 days.
* The tape works best in the region around the fingernail.
* Tape works because the air-tight, moist environment under the tape does not allow the virus to grow and reproduce

Salicylic acid therapy
* Salicylic acid is available by many different trade names at the drug store.
o Dual Film
o Wart-Off
o Dr. Scholl’s Wart Medication
o Medi-Plast
* It comes either as a liquid to paint on the wart or as a plaster to be cut out and placed on the wart tissue.
* The area with the wart should be soaked in warm water for 5-10 minutes.
* The wart should then be pared down with a razor. A simple razor works fine for this, then throw it away.
* Do not shave far enough to make the wart bleed.
* Apply the salicylic acid preparation to the wart tissue.
* Do not apply it to other skin because of salicylic acid's potential to injure normal tissue.
* Follow directions on the package for how long to apply the acid.

Cryosurgery
* Liquid nitrogen or cryotherapy is used to deep freeze the wart tissue.
* With liquid nitrogen applied to the wart, the water in the cells expands, thus exploding the infected tissue.
* The exploded cells can no longer hide the human papillomavirus from the body's immune system.
* The immune system then works to destroy the virus particles.
* Periungual area may scar if cryotherapy with liquid nitrogen is used improperly.
* Scarring could lead to permanent nail disfiguration.

Laser Therapy
* Laser therapy: Lasers are simply very intense light sources.
* This light has an enormous amount of energy that heats the tissue enough that it vaporizes.

Shave Removal
* Shave removal and electrodessication of the base may be necessary when other treatment methods fail.
* This would involve numbing the region around the wart and shaving the wart flat with the surface and light electrodessication of the base.

Prognosis:
* Most warts will disappear without treatment anywhere from 6 months to 3 years.
* Warts may recur after treatment and require additional treatments.
Prevention:
* Avoid touching warts on others or touching them on yourself (refrain from rubbing a warty finger across your face).
* Children needs to avoid biting or chewing warts.
* Wear shower shoes in the gym locker room to lower your risk of picking up the virus that causes plantar warts from the moist environment.

When to Refer
* If you feel uncomfortable treating warts.
* Warts that are resistant to your treatment
* Unsure of diagnosis

Warts Diagnosis and Treatment.ppt

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Dermal and Subcutaneous Tumors

Dermal and Subcutaneous Tumors

Mastocytosis
Urticaria pigmentosa
* Local and systemic accumulations of mast cells
* Persistent pigmented itchy skin lesions
* Urticate on mechanical or chemical irritation
* c-KIT mutation
* Birth to middle age, ½ < 6 mo
* Macules, papules, nodules, plaques, vesicles
* Lesions persist and gradually become chamois- or slate-colored
* Darier’s sign, pruritis
* Severe symptoms may result from massive liberation of histamine from mast cells after ingestion of known mast cell degranulators
* Spontaneous resolution is likely in those pts whose disease began in childhood

Solitary mastocytoma
* May be present at birth, may develop during the first weeks of life
* Brown macule that urticates upon stroking
* Smooth or peau d’ orange
* Dorsum of the hand near the wrist
* Edema, urtication, vesiculation may be observed
* Generalized eruption, childhood type
* Pseudoxanthomatous mastocytosis
* Diffuse cutaneous mastocytosis
* Generalized eruption, adult type
* Erythrodermic mastocytosis
* Telangiectasia macularis erupta perstans
* Systemic mastocytosis
* Familial urticaria pigmentosa
* Giemsa, azure A, or polychrome toluidine blue
* Local anesthetic adjacent to the lesion, without epi
* Dx is bx confirmed
* Histamine metabolites methylhistamine and methylimidazole acetic acid

Prognosis and treatment
* In all forms without systemic involvement the prognosis is good
* Solitary lesions usually involute within 3 years
* H1 and H2 blockers
* PUVA
* Intralesional and topical steroids
* Avoid physical stimuli

Abnormalities of neural tissue
Solitary neurofibroma
* Soft, flaccid, pinkish white, 2-20 mm
* Invaginates on pressure, “buttonholing”
* Solitary or multiple
* Distinctive histopathologic findings, fibrils, cellular proliferation, and degenerative changes
* Sx excision

Granular cell tumor
* Well-circumscribed, solitary firm nodule, with a brownish red or flesh tint
* Usually solitary, 10-15 % multiple
* 1/3 of cases have occurred on the tongue
* May occur anywhere on the body
* Grows slowly
* Cells stain positively with vimentin, neuron-specific enolase, S-100, and myelin protein
* Malignant granular cell tumor is rare

Neuroma cutis
* Three true neuromas exist in the skin and mucous membranes: traumatic neuroma, multiple mucosal neuromas, and solitary palisaded encapsulated neuromas
* Traumatic neuromas occur commonly on the fingers, tender and painful
* Multiple mucosal neuromas occur as part of multiple mucosal neuroma syndrome
* solitary palisaded encapsulated neuromas occur commonly on the face, resembles BCC

neurothekeoma
* Nerve sheath myxoma
* Benign tumor of nerve sheath
* Mitotic figures and nuclear atypia are sometimes observed
* Intradermal or subcutaneous
* Histologically are divided into two subtypes: myxoid and more common cellular variant

schwannoma
* neurilemmoma
* Usually a solitary nerve sheath tumor
* Most often seen in women
* Occur almost exclusively along the main nerve trunks of the extremities
* Soft or firm nodules, may be painful
* May be multiple
* May be assoc. with NF-1 or NF-2
* Occur in many other organs
* excision

Infantile neuroblastoma
* The most common malignant tumor of childhood
* Cutaneous nodule are most often seen in the younger patients
* Blue nodules the when rubbed form a halo of erythema
* Periorbital ecchymoses and heterechromia
* Good prognosis for patients with skin involvement, spontaneous remission

ganglioneuroma
* Rarely described in the skin as an isolated entity
* Arise most often in von Recklinghausen’s neurofibromatosis
* Occur in childhood

Nasal glioma
* Cephalic brainlike heterotopias
* Rare, benign congenital tumors
* Easily confused with hemangiomas
* Firm, reddish blue lesion on the nasal bridge
* No connection with the subarachnoid space
* Radiography and neurosurgical consultation
* Does not involute spontaneously

Cutaneous memingioma
* Psammoma
* Results from the presence of meningocytes outside the calvarium
* Small, hard, fibrous, calcified nodules occurring along the spine, in the scalp, and on the forehead
* Usually seen within the first year
* No distinctive appearance, dx by histo

Encephalocele and Meningocele
* Primary defect in the neural tube
* Present in infancy along the midline
* Compressible masses that may transilluminate or enlarge with crying
* Midline masses require intensive radiologic and neurosurgical evaluation before biopsy

chordomas
* Slow-growing, locally invasive
* Firm, smooth nodules in the sacralcoccygeal region or at the base of the skull
* Arise from notochord remnants
* May metastasize late in their course
* Wide excision and postoperative radiation therapy

Abnormalities of Fat Tissue
lipomas
* Subcutaneous tumors composed of fat tissue
* Most commonly found on the trunk
* Also neck, forearms and axillae
* Soft, single or multiple, lobulated and compressible
* Growth to size and remain stationary
* again be careful of sacrococcygeal lipomas
* Lesion may be left untreated or excised
* Solitary lesions reaching greater than 10 cm should be investigated for malignancy
* Multiple lesion may be painful if growing rapidly
* Madelung’s disease, benign symmetric lipomatosis
* Dercum’s disease, assoc with weakness and psychiatric disturbances
* Familial multiple lipomatosis, AD inheritance
* Bannayan-Riley-Ruvalcaba syndrome
* MEN 1
* Frohlich’s syndrome
* Gardner’s syndrome

angiolipoma
* A painful subcutaneous nodule just slightly above the level of the skin
* Has all other typical features of a lipoma
* Seen in young adults who have multiple painful lumps in the skin
* Multiple subcutaneous angiolipomas have no invasive or metastatic potential

Neural fibrolipoma
* Overgrowth of fibro-fatty tissue
* Occurs along a nerve trunk and often leads to compression
* Slowly enlarging subcutaneous mass with tenderness and decreased sensation or parasthesia
* Median nerve is most commonly involved
* MRI, no effective treatment

Spindle-cell lipoma
* Asymptomatic, slow growing subcutaeneous tumor
* Predilection for the back and neck and shoulders of older men
* Consists of lobulated masses of mature adipose tissue

Painful Piezogenic pedal papules
* Transitory, soft, sometimes painful papules on the sides of the heels
* Elicited by weight-bearing and disappearing when this is stopped
* Occur in at least 75 % of normal individuals
* Suitable supportive shoes may alleviate discomfort
* May occur on the wrist

Nevus lipomatosus superficialis
* Soft, yellowish papule or ceribriform plaques, usually of the buttock or thigh, less often the ear or scalp
* A wrinkled surface characterizes this tumor
* Onset prior to age of 20
* Nevus lipomatosus superficialis

Folded skin with scarring
* Rare, aka Michelin Tire Baby Syndrome
* There are numerous deep, conspicuous, symmetrical, ringed creases around the extremities
* The underlying skin may manifest a smooth muscle hamartoma, a nevus lipomatosis, or elastic tissue abnormalities
* AD, sporadic or an isolated finding assoc with congenital facial and limb abnormalities

Diffuse lipomatosis
* Characterized by an early age of onset, by the age of 2, diffuse infiltration of muscle by and encapsulated mass of mature lipocytes
* Progressive enlargement and extension
* Usually involves a large portion of the trunk or extremity

Hibernoma
(lipoma of brown fat)
* A form of lipoma composed of finely vacuolated fat cells of embryonic type
* Have a distinctive brownish color and a firm consistency
* Benign and usually occur singly
* Chiefly in the mediastinum and the interscapular region
* Onset usually in adult life

Pleomorphic lipoma
* Occur for the most part on the backs and necks of elderly men
* Occasional lipoblast-like cells and atypical mitotic figures may require differentiation from a liposarcoma
* Behave in a perfectly benign manner`

Benign lipoblastomatosis
* Frequently confused with a liposarcoma
* Affects exclusively infants and young children, 90% < age 3
* Commonly involves the soft tissues of the upper or lower extremity
* A circumscribed and a diffuse form can be distinguished
* TOC- complete local excision

liposarcoma
* One of the less common mesenchymal neoplasms of the soft tissue
* Usually arise from intermuscular fascia
* Do not arise from preexisting lipomas
* Usual course is an inconspicuous swelling of the soft tissue with gradual enlargement
* When a fatty tumor becomes greater than 10 cm DX should be considered
* Upper thigh is the most common site
* Adult males are mostly affected
* May be well or poorly differentiated
* Tx is adequate radical excision
* For metastatic liposarcomas, radiation therapy may be effective

Abnormalities of smooth muscle
leiomyoma
* Smooth muscle tumors
* Characterized by painful nodules
* Singly or multiple
* Benign
* Treatment is directed toward the removal of the pain source
* Simple excision is best
* Solitary cutaneous leiomyoma
* Multiple cutaneous leiomyomas
* Solitary genital leiomyoma
* angioleiomyoma

Grouped leiomyomata of the back
Congenital smooth muscle hamartoma
* Typically a skin colored or slightly pigmented patch or plaque with hypertrichosis
* Often present at birth
* Usually seen on the trunk, lumbosacral area in 2/3
* Michelin tire baby syndrome may result from a diffuse smooth muscle hamartoma
* Clinically may mimic a mastocytoma, pseudo-Darier’s sign is seen in 80%
* No treatment is necessary

leiomyosarcoma
* Of soft tissue origin are extremely rare
* May occur as metastasis from internal source
* Appears in the dermis as a solitary nodule, good prognosis
* Subcutaneous lesions have a guarded prognosis, with fatal hematogenous metastases in 1/3
* WLE or Mohs

Miscellaneous tumors and tumor-associated conditions
Cutaneous endometriosis
* Brownish papules in the umbilicus or lower abdominal scars after gynecologic surgery
* Tender or painful lesions
* Bluish black from cyclic bleeding
* Usually misdiagnosed as malignant metastases
* Surgical excision
* Preoperative tx with danazol or leuprolide may reduce size

teratoma
* May develop in the skin but are most common in the ovaries or testes
* No characteristic clinical features
* Tissue representing all three germ layers are present
* Occasionally malignancy may occur

Metastatic carcinoma
* 5 to 10% of patients with cancer develop skin metastases
* Usually present as numerous firm, hard, or rubbery masses
* Predilection for chest, abdomen or scalp
* Sister Mary Joseph nodule, metastatic tumor localized to the umbilicus, most common primary sites include the stomach, large bowel, ovary and pancreas
* A poor prognosis is usually the rule
* The involvement of the skin is likely to be near the area of the primary tumor
* Breast cancer is the type most commonly metastatic to the skin in women and melanoma followed by lung cancer in men
* Metastatic lesions are uncommon in children

Paraneoplastic syndromes
* Some cancers produce findings in the skin that indicate to the clinician that an underlying internal malignancy may be present
* Bazex’s syndrome, characterized by violaceous erythema and scaling of the fingers, toes, nose, and aural helices.
* Secondary to a primary malignant neoplasm of the upper aerodigestive tract

Bazex’s syndrome
* Necrolytic migratory erythema, seen with glucagon-secreting tumors of the pancreas
* Erythema gyratum repens, erythema with characteristic wood-grain-pattern scales, is almost always associated with and underlying malignancy
* Hypertrichosis lanuginosa aquisata, most common with lung and colon ca
EGR
Hypertrichosis lanuginosa
* The sign of Lesser-Trelat, the sudden appearance of multiple pruritic seborrheic keratosis, associated with and internal malignancy
* Trousseau’s sign, migratory thrombophlebitis, pancreatic ca
* Pityriasis rotunda
* Tripe palms
* Several others with less frequency

carcinoid
* Characterized by distinctive involvement of the lungs, heart, gastrointestinal tract and the skin
* Cutaneous flushing lasting 5-10 minutes
* Involves the head and neck producing a scarlet color
* Cyanosis may be present
* Episodic flushing continues for months or years
* The release of excessive amounts of serotonin and bradykinen into circulation produces attacks of flushing of the skin, weakness, abdominal pain, nausea and vomiting, sweating, palpitation, diarrhea and collapse
* Tumor arises from the argentaffin Kulchitsky chromaffin cells of the appendix or terminal ileum (gi, lungs, ovaries, testes)
* The diagnosis may be established by finding high levels of 5-hydroxyindolacetic acid (5-HIAA) in the urine
* Tx- primary tumor should be removed, and excision of metastatic lesion should be considered
* Chemotherapy

Dermal and Subcutaneous Tumors.ppt

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Female Genital Cutting

Female Genital Cutting
By:Safa Magid

Female Genital Cutting(FGC)
* Also known as: female circumcision & female genital mutilation
* Female circumcision is the term preferred by cultures who practice this custom

FGC -Definition
* Procedure involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious, or other non-therapeutic reasons.

WHO Classification of FGC
* Type 1: Excision of prepuce w/ or w/o excision of all of the clitoris
* Type 2: Clitoridectomy and partial or total excision of labia minora
* Type 3: Infibulation, includes removing all or part of ext. genitalia and re-approximation of remnant labia majora, leaving a small interoitus for passage of urine and menstrual blood

* Type 1 and Type 2 are the most common forms
* Type 1 and Type 2 account for 80% of the cases
* Infibulation accounts for 15% of the cases

FGC
* Currently ~ 130 million women and girls have had the procedure
* An estimated 2 million girls worldwide are at risk per year

FGC in the US

* Data from 2000 census suggests:
228,000 women and girls are with or at risk for FGC in the United States
* CA, NY, and MD have the most female immigrants and refugees from countries where FGC is prevalent.
* Occurs mostly in 28 sub-Saharan African countries
* FGC is practiced by Christians, Muslims, and adherents to traditional African religions
* Also practiced in Middle East and Asia

Origins and History
* Origins remain unclear
* FGC practiced in Pre-Islamic Arabia, ancient Rome, and Tsarist Russia
* Female circumcision was discovered in ancient Egyptian mummies in 200 B.C.
* Practiced in the United States until the 1970’s to tx hysteria, lesbianism, and erotomania

FGC and Religion
* Christianity:
FGC is not an obligatory religious requirement
* Islam:
FGC is not an obligatory religious requirement

FGC-Procedure
* Performed between the ages of 5-10, or prior to marriage
* Performed by a member of community who is not a healthcare worker
* Often performed w/o anesthesia
* However in metropolitan areas the use of anesthesia is more common

FGC Procedure
* Performed w/o surgical instruments. Razor blades or other instruments which may or may not be sterile are used
* Depending on socio-economic factors FGC may also be performed in a health care facility by qualified health personnel
* WHO is opposed to medicalization of all types of female genital mutilation.
* Reasons currently practiced:
o Rite of passage to womanhood
o Maintains chastity
o Ensure marriageablity
o Belief that it improves hygiene
o Social pressure to adhere to custom
o Belief that it is a religious requirement

Complications
* Prevalence of complications is unknown
* Rate of complications increase with severity of procedure( i.e. women with type III have > complications that women w/type I)
* A study of 120 Somalian women suggests rate of complications are inversely proportional to the age of the child when FGC was performed
* Women who had FGC btwn the ages of 5-8, had more complications than their 9-12 y.o counterparts
* Long and short term complications
* Some women with FGC do not experience complications

Short term complications
* Hemorrhage
* Severe pain
* Shock
* Infection
* Urine retention
* Ulceration of genital region injury to adjacent tissue
* HIV?-Possibly transmitted due to use of unsterilized equipment

Long Term Complications
* Cysts and abscesses
* Post-partum fistulaes: vesico-vaginal
* Keloid scar formation
* Damage to the urethra resulting in urinary incontinence
* Dyspareunia and sexual dysfunction
* Infertility
* Difficulties with labor.

Case Report

* 16 y.o female presents w/severe dysmenorrhea
* PE revealed the absence of a clitoris and fused labia majora with a 1cm opening
* Physicians initially thought pt had corrective surgery for ambiguous genitalia
* Later determined that while visiting Africa with her mother she had FGC performed
* Perinealography revealed:
o Filling of the vagina,urethra, and bladder simulating a urogenital sinus.
o Dilated vagina suggested obstruction
Perinealography

Case Report
* Defibulation procedure was performed
* The patients symptoms of dysmenorrhea eventually resolved

FGC and Obstetric outcomes
* WHO Study

FGC & Length of maternal hospital stay
* FGC and length of maternal hospital stay
o FGC Type I- RR: 1.15
o FGC Type II-RR:1.51
o FGC Type III-RR:1.98

FGC and Mental Health
* Anxiety
* Depression
* PTSD
* Feeling of incompleteness

Defibulation
* Corrective procedure
* Involves division of the fused labia majora with suturing of each labia for hemostasis
* Thus the infibulated scar, which is a flap obstructing the introitus and urethra, is removed
* WHO Indications for defibulation:
* Urinary retention
* Recurrent UTI’s or kidney infections
* Dysmenorrhea
* Dyspareunia or apareunia
* Prior to coitus
* Prior to labor
* It is also reasonable that defibulation can be performed to alleviate any mental health consequences for women who do not meet the WHO indications

Approach to patients with FGC
* Some physicians remain unfamiliar w/FGC & have expressed their shock during PE
* Some women report being reprimanded by physicians for having the procedure done
* Despite the fact the majority had FGC while they were children and were not given a choice

Patients perspective of FGC
* Many pts w/FGC who have immigrated to the West do not feel as if they abused
* Some feel that FGC was done “for them” and not an attack against them

Patients perspective of FGC
* 1st generation pts born in the West who had FGC while traveling abroad often have very different views than their foreign born counterparts
* HC workers may need to modify their approach depending on the pts perspective

Legality of FGC
* U. S. passed a law in March 1997:
* Made performing any medically unnecessary surgery on the genitalia of a girl younger than 18 years of age a federal crime.
* Reinfibulation was not included as a federal crime, so it may be performed with absorbable sutures in a running fashion if a woman chooses the procedure


Resources for pts and HC providers
* African’s Women’s Health Center
o Established in 1999 by Dr. Nawal Nour a Sudanese-American OB/GYN
o Goal of clinic is to provide culturally appropriate holistic care to African women who are refugees who may or may not have undergone FGC
o Defibulation is performed at this clinic

Resources for pts and HC providers
* WHO
* Website with information about FGC
* Includes fact sheet about FGC and guidelines for healthcare workers
* http://www.who.int/topics/female_genital_mutilation/en/
* http://www.who.int/reproductive-health/publications/rhr_01_18_fgm_policy_guidelines/index.html

Dedicated to all of my sisters who have had FGC.
To those who have suffered physical or mental consequences, I am inspired by your courage and strength.

References
Female Genital Cutting.ppt

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