In vivo and ex vivo dermoscopy of lesions from implantation of human papillomavirus in tattoos: report of two cases

Abstract The number of individuals with tattoos has been increasing worldwide, alongside with reports of complications varying from reactions to the injected pigments to infections caused by agents inoculated in the pigmentation process. The diagnosis of such unwanted events can be obtained through complementary non-invasive methods, preserving the maximum of the tattoo design. The authors present two cases of patients with warts on tattooing, and correlate their clinical aspects to in vivo and ex vivo dermoscopy, and to the findings in the histopathological examination, aiming to determine patterns that aid the diagnosis of these lesions without performing biopsy.

Amelanotic acral melanoma misdiagnosed as verruca plantaris

Abstract: 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.

PLECT or PPLECT? Granulomatous pyoderma gangrenosum in the differential diagnosis of the verrucous syndrome

Abstract: Pyoderma gangrenosum (PG) is an uncommon neutrophilic dermatosis, with variable clinical features, nonspecific histopathology and multifactorial pathogenesis, posing a challenging diagnosis for the dermatologist. Pyoderma gangrenosum is a diagnosis of exclusion and should be included in the differential diagnoses of the verrucous syndrome. We report a granulomatous variant affecting the face.

Pilomatrixoma quístico con verruga vulgar intraquística: reporte de un caso / Cystic pilomatrixoma with intracystic vulgar wart: case report

El pilomatrixoma es una neoplasia anexial benigna, que habitualmente se presenta como pápula o nódulo subcutáneo, de crecimiento lento y asintomático. Es más frecuente en niños. El diagnóstico se basa en hallazgos clínicos, y la ecografía es útil como examen complementario. El tratamiento es su resección quirúrgica. Se presenta un caso infrecuente de pilomatrixoma quístico con verruga vulgar intraquística en un paciente adulto.

Pilomatricoma is a benign adnexal tumor, usually presenting as a slow growing asymptomatic subcutaneous papule or nodule. It is more common in children. The diagnosis is based on clinical findings, and ultrasound is useful as a complementary workup tool. Its treatment is surgical excision. We present a rare case of a cystic pilomatricoma with an intracystic verruca vulgaris in an adult patient.

Acquired lymphangiomas mimicking multiple hallux warts

Abstract: Lymphangioma is an uncommon benign vascular tumour that involves lymphatic vessels. It can be acquired or, most frequently, congenital. The acquired form presents with dilated lymphatic channels due to an obstruction. These lesions have no risk of malignant transformation, but they have a high rate of recurrence whether removed. We present a case of a 52-year-old woman with acquired lymphangiomas mimicking warts. She came to our observation for some keratotic lesions on her feet. Clinically, we found three warts on the sole of her left foot, but we also noticed the presence of swelling and papillomatous wart-like papules on both halluces. The hallux papules were studied by performing an excisional biopsy and were found to be lymphangiomas.

Verruga umbilical / Umbilical wart

Las verrugas vulgares son proliferaciones epiteliales benignas, causadas por la infección del virus papiloma humano. Suelen afectar a niños y adolescentes comprometiendo frecuentemente manos y rodillas. Existen múltiples tratamientos pero ninguno infalible, y si bien se preconiza la conducta expectante, existen casos en los que se debe realizar tratamiento. Presentamos el caso de un escolar de sexo masculino con verruga umbilical, una localización infrecuente, tratada exitosamente con electrocoagulación.

Common warts are benign epithelial growths caused by infection with human papillomavirus. They usually affect children and adolescents often compromising hands and knees. There are many treatments but none infallible, and while it is recommended an expectant behaviour, there are cases in which treatment should be performed. We report the case of a 12 year old white male with an umbilical wart, an unusual localization, treated successfully with electrocoagulation.

Oral verruca vulgaris: a rare case with transformation of papilloma to well differentiated oral squamous cell carcinoma

Variety of verrucous and papillary lesions affect the oral mucosa. These are either benign or reactive, for example, papilloma, verruca vulgaris, fibroepithelial polyp and verruciform xanthoma, which usually present with little diagnostic difficulty. However, dysplastic and malignant verrucous present with much greater diagnostic challenges. There is evidence of some carcinomatous changes in oral lesions with some pre existing predisposing factors. The common wart or verruca vulgaris are lesions of childhood. These are benign, elevated, firm nodules with characteristic papillomatous surface projections. The most common site of occurrence is the fingers. Oral lesions are relatively rare, and are usually caused by auto inoculation from lesions on the fingers and hands. This report describes a lesion which was histopathologically diagnosed as oral verruca vulgaris that occurred in a middle-aged woman without any history of wart like lesions elsewhere in the body. But later on expanded in size, became indurated involving entire lower lip, labial sulcus, alveolar ridge and floor of the mouth. It was histopathologically confirmed as well differentiated oral squamous cell carcinoma

Caracterização clínica e histopatológica e tipagem do papilomavírus humano das verrugas vulgares nos receptores de transplante renal / Clinical and histopathological characterization and typing of the human papillomavirus in common warts of kidney transplant recipients

Os pacientes receptores de transplante renal apresentam elevada prevalência de lesões cutâneas por HPV. Foram estudados 20 receptores de transplante renal com diagnóstico de verruga vulgar. A detecção do HPV foi realizada pela polimerização em cadeia (PCR) com os primers MY09/MY11 e RK91. A tipagem do HPV foi feita por meio da restrição enzimática e do sequenciamento automatizado. Identificamos a presença do HPV em 10 pacientes (50 por cento) e os tipos identificados foram: HPV-2, 27, 29, 34 e 57.

The prevalence of skin lesions caused by the human papillomavirus (HPV) is high in kidney transplant patients. Twenty recipients of kidney transplants with a diagnosis of common warts were evaluated. HPV detection was performed by polymerase chain reaction (PCR) using the MY09/MY11 and RK91 primers. HPV typing was performed by restriction fragment length polymorphism analysis and direct sequencing. The presence of HPV was identified in 10 patients (50 percent) and the types identified were HPV-2, 27, 29, 34 and 57.

Comparação entre a eficácia da cimetidina e do sulfato de zinco no tratamento de verrugas múltiplas e recalcitrantes / Efficacy comparison between cimetidine and zinc sulphate in the treatment of multiple and recalcitrant warts

FUNDAMENTOS: Verrugas são proliferações epiteliais na pele e mucosas causadas por diversos tipos de HPV. Elas podem involuir espontaneamente ou aumentar em número e tamanho de acordo com estado imunitário do paciente. A cimetidina e o sulfato de zinco têm importante efeito no sistema imune, sendo usados como imunomoduladores no tratamento de diversas doenças. OBJETIVO:Comparar a eficácia terapêutica de cimetidina e sulfato de zinco no tratamento de verrugas cutâneas de difícil tratamento. MÉTODOS: Estudo prospectivo duplo-cego randomizado. Dezoito pacientes com verrugas múltiplas foram divididos em dois grupos, um recebeu cimetidina 35mg/kg/dia (máximo 1.200mg/dia), e o outro, sulfato de zinco 10mg/kg/dia (máximo de 600mg/dia) por três meses. RESULTADOS: Dos 18 pacientes do estudo, nove receberam cimetidina, e nove, sulfato de zinco; apenas um do grupo do sulfato de zinco não completou o tratamento devido a náuseas e vômitos. Cura foi obtida em cinco pacientes tratados com sulfato de zinco, e apenas um não obteve alteração das lesões. Do grupo da cimetidina cinco não apresentaram modificação, e quatro apresentaram diminuição inferior a 30% das lesões iniciais. CONCLUSÕES: Sulfato de zinco na dose de 10mg/kg/dia parece ser mais efetivo que cimetidina para o tratamento de crianças e adultos com verrugas múltiplas e de difícil manejo. A pequena casuística deste trabalho não permite, entretanto, conclusão categórica.

Background: Warts are epithelial proliferations on the skin and mucous membrane caused by various types of HPV. They can decrease spontaneously or increase in number and size according to patient's immune status. Cimetidine and zinc sulphate have important effects on the immune system and are used as immunomodulators in the treatment of various diseases. Objective: To compare the efficacy of cimetidine and zinc sulphate in the treatment of multiple and recalcitrant warts. Methods: A random double-blind prospective study. Eighteen patients with multiple warts were divided into two groups: one took 35mg/Kg/day of cimetidine (maximum 1200 mg/day) and the other 10 mg/Kg/day of zinc sulphate (maximum 600 mg/day) for three months. Results: Among the 18 patients who participated in the study, nine took cimetidine and nine zinc sulphate. Just one patient in the zinc sulphate group did not complete treatment due to nausea and vomiting. Five patients who were treated with zinc sulphate were cured and only one did not show modifications in lesions. Among the group who was treated with cimetidine, five did not show modifications in lesions and four showed decrease from baseline below 30%. Conclusions: 10 mg/Kg/day zinc sulphate dose seems to be more effective than cimetidine for the treatment of children and adults with multiple and difficult-to-handle warts. However, the small number of patients did not enable any definitive conclusion.

Características del cuerno cutáneo: revisión de 26 años / Characteristics of cutaneous horns: review of 26 years

El cuerno cutáneo es un diagnóstico clínico que describe una lesión hiperqueratósica con forma de cuerno.El presente estudio determina las características del cuerno cutáneo según sexo, rango de edad, localización anatómica, diagnóstico histológico y presencia de malignidad en una serie de 93 casos. El promedio de edad de la muestra fue de 67,9 años. El 59,1 por ciento de las lesiones se localizó en la cara, especialmente en las mejillas. El 61,3 por ciento de los cuernos cutáneos fue benigno y el 38,7 por ciento fue no-benigno, siendo el 25,8 por ciento lesiones malignas in situ y el 12,9 por ciento, malignas. No existió diferencia según sexo. El total de las lesiones malignas se presentó en la cabeza. El diagnóstico histológico más frecuente fue el de verruga vulgar (28,0 por ciento). La lesión maligna más frecuente fue el carcinoma espinocelular (10,8 por ciento), más común en mayores de 70 años. La prevalencia de lesiones malignas in situ o malignas fue de 66,7 por ciento en mayores de 70 años versus 15,7 por ciento en menores de 70 años (p < 0,001).La importancia del cuerno cutáneo radica en la patología que le subyace. En mayores de 70 años la probabilidad de tener una lesión no-benigna (maligna in situ o maligna) es mayor que en pacientes más jóvenes.

Cutaneous horn is a clinical diagnosis that describes an hyperkeratotic lesion with shape a horn.This study describes the characteristics of cutaneous horns according to sex, age, localization, histological diagnosis and the presence of malignancy in a series of 93 cases.The mean age of the sample was 67.9 years. 59.1 percent of the lesions were localized on the face, especially on the cheeks. 61.3 percent of cutaneous horns were benign and 38.7 percent were non-benign. 25.8 percent were malignant in situ and 12.9 percent malignant lesions. There was no difference among sexes. All malignant lesions were localized on the head. The most common histological diagnosis was warts (28.0 percent). The most common malignant lesion was squamous cell carcinoma (10.8 percent), which was more frequent in patients older than 70 years. In patients older than 70 years, the prevalence of malignant in situ or malignant lesions was 66.7 percent, versus 15.7 percent in younger patients (p < 0,001).The importance of cutaneous horns is the nature of its underlying disease. In patients older than 70 years, the probability of having a non-benign lesion (malignant in situ or malignant) is higher than in younger patients.Key words: Cutaneous horn, cutaneous biopsy, squamous cell carcinoma.

Long-Pulsed Nd:YAG Laser Treatment of Warts: Report on a Series of 369 Cases

Various treatment methods have been adopted in the management of warts; however, there is still no consensus on first-line treatment. This study was designed to evaluate the efficacy of long-pulsed Nd:YAG laser in the treatment of warts. Over the course of 1 yr, 369 patients with recalcitrant or untreated warts were exposed to a long-pulsed Nd:YAG laser. The following parameters were used: spot size, 5 mm; pulse duration, 20 msec; and fluence, 200 J/cm2. No concomitant topical treatment was used. In all, 21 patients were lost during follow up; hence, the data for 348 patients were evaluated. The clearance rate was 96% (336 of the 348 treated warts were eradicated). The clearance rate of verruca vulgaris after the first treatment was very high (72.6%), whereas the clearance rate of deep palmopantar warts after the first treatment was low (44.1%). During a median follow-up period of 2.24 months (range, 2-10 months), 11 relapses were seen (recurrence rate, 3.27%). In conclusion, long-pulsed Nd:YAG laser is safe and effective for the removal or reduction of warts and is less dependent on patient compliance than are other treatment options.

Pathological studies on Bovine papilloma virus-fern interaction in hamsters.

Early pathological changes of Bovine papilloma virus (BPV-2)-fern (Pteridium aquilinum and Onychium contiguum fern) interaction in hamsters were studied. In bracken-exposed cattle, BPV induces malignancy in gastrointestinal and urinary bladder mucosa. Cutaneous warts were transmitted successfully in hamsters approximately after 3 months post inoculation while urinary bladder tumour of enzootic bovine haematuria cases were not transmitted. Histologically, tumour was diagnosed as fibroma. Onychium produced more pronounced effects than bracken fern which was characterized by significant reduction in body weight and testicular atrophy. BPV-fern interaction was not appreciable during early period of tumour induction and requires long-term studies for 12 to 18 months.

Citologia anal para rastreamento de lesões pré-neoplásicas / Anal cytology for screening of pre-neoplasic lesions

OBJETIVO: Avaliar se a citologia anal com escova pode servir para rastreamento das lesões clínicas e subclínicas provocadas pelo HPV. MÉTODOS: Colhemos citologia anal, com escova, do canal anal de 102 doentes HIV-positivo com queixas proctológicas. Eram 86 homens e 16 mulheres com média etária de 37 anos. Destes, 33 negavam infecção pelo HPV, 14 haviam tratado verrugas, 28 tinham condilomas externos, sete apresentavam lesões internas e 20 os tinham em associação. O material foi enviado para exame de papanicolaou e coloração pela hematoxilina-eosina. Avaliamos as contagens de linfócitos T CD4+ para observar se o estado imunológico determinou as displasias mais avançadas. RESULTADOS: Somente um exame não pôde ser aproveitado. Os demais revelaram padrões celulares que variaram da normalidade até NIAa, incluindo a presença do HPV. Ocorreram 30 NIAs de baixo e 13 de alto grau em todos os grupos de doentes, com ou sem infecção pelo HPV. Em um dos doentes com NIAa e sem história prévia de infecção pelo HPV, e com úlcera no canal anal, a biópsia revelou carcinoma espinocelular invasivo. As médias de células T CD4+ nos portadores de NIA de baixo grau foi 281/mm³ e naqueles com NIAa foi 438/mm³. A análise estatística mostrou diferença significante, revelando que, ao contrário do esperado, displasias menos acentuadas acometem doentes com contagens menores de linfócitos T CD4+. Esse fato demonstra que a imunidade sistêmica isolada parece não interferir na gênese dessas lesões, sugerindo que aspectos da imunidade local devam ser estudados. A avaliação estatística feita com a tabela 2x2 revelou sensibilidade de 74 por cento e especificidade de 61 por cento. CONCLUSÃO: Acreditamos que a citologia anal possa servir para esse rastreamento, selecionando os doentes para colposcopia anal e biópsias.

BACKGROUND: High grade intra-epithelial neoplasias (HAIN) are probable precursors of anal carcinoma, with association to high-risk types of Human Papillomavirus (HPV). This progression could be related to severity of the dysplasia and, albeit not yet confirmed, treatment of these lesions would prevent the evolution to cancer. Standardization and improvement of screening methods should therefore be essential to treat or prevent precursor lesions, mainly in patients at risk such as seropositives to Human Immunodeficiency Virus (HIV). The aim of this study was to evaluate if anal cytology, with a cytobrush, could be useful to screen clinic and pre-clinic lesions provoked by HPV. METHODS: Brushes were used to obtain smears from the anal canal of 102 HIV-positive patients with proctologic complaints. There were 86 males and 16 females with a mean age of 37 years. HPV infection was denied by 33 patients, 14 had treated anal warts in the past, 28 had condylomas in the anal verge, seven had internal clinical lesions and 20 had both internal and external condylomas. The smears were submitted to Pappanicolaou and hematoxilin-eosin stains to identify cytological changes including HAIN. T CD4+ lymphocyte counts were also evaluated to check if the immunologic status caused more advanced dysplasia. RESULTS: One smear only proved insufficient. All the others revealed cellular patterns varying from normality to HAIN. Low grade AIN (LAIN) occurred in 30 and HAIN in 13 patients. One patient with HAIN, without a history of HPV infection in the past, presented an anal canal ulcer which at biopsy was diagnosed as invasive squamous-cell carcinoma. T CD4+ cells averaged 281/mm³ for LAIN patients and 438/mm³ for HAIN patients. Analyses disclosed a statistical difference, showing that despite expectations, more advanced dysplasias occurred in patients with higher counts of T CD4+ cells. This fact demonstrated that isolated systemic immunity did not...