Verrucae planae juveniles B07

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 23.04.2021

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Synonym(s)

Flat warts; Intermediary warts; Juvenile warts; Plane juvenile warts; Tarpaulin warts; Warts plane juvenile

History
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Besnier and Doyon 1881

Definition
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Flat warts, mainly occurring in children and adolescents, harmless, self-limited, infectious disease caused by human papilloma viruses. They can suddenly erupt and spread over larger areas. Spread to the face and legs often occurs through autoinoculation during shaving.

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Pathogen
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Human papillomavirus types 3, 10, 28, 29, 49.

Etiopathogenesis
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Infection by human papilloma viruses. The occurrence of these warts in UV-exposed areas is probably determined in the genome of the triggering viruses. In the closely related HPV type 77, a UV-activatable promoter region (see protooncogenes below) has been identified.

Manifestation
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Mainly in children and adolescents; less frequently in early adulthood.

Localization
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Mainly occurring on the forehead, temples, cheeks, perioral, back of the hand and fingers, rarely localized on the mucous membranes.

Clinical features
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Flat, raised, asymptomatic, roundish or polygonal, light brown or somewhat reddish, slightly consistent, solitary papules, which also merge into small plaques, with a dull surface. The small, non-follicular elevations with their frosted surface are prominent, especially in laterally incident light. They are predominantly irregularly scattered. Inflammatory reddening of the warts often signals immunologic rejection reactions in the wart parenchyma.

Often, however, a linear arrangement (induced by inoculating scratching effects - Köbner phenomenon) can be found. Caused by the same type of virus, plane warts are found on the back of the hand of adolescents or adults (so-called intermediate warts).

Histology
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Acanthosis, papillomatosis, plexus hyperkeratosis, focal parakeratosis, ballooning epithelia in the stratum granulosum and in the upper parts of the stratum spinosum.

Differential diagnosis
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Lichen planus: polygonal structure, itching, surface shiny, rarely in the facial area

Lichen nitidus: comparable with Lichen planus

Verruca seborrhoica: no eruptive occurrence, surface matt brown, never shiny

Milia: whitish, small globular, firm consistency, deep set.

Syringomas: in principle syringomas can occur on all parts of the body surface, especially when they are eruptive. Preferably they are found on the lower eyelids, less frequently on the upper eyelids (eyelid syringoma). Further on the neck, chest, axillary folds, groin, vulva/scrotum rarely on the extremities. Especially in adults.

General therapy
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High spontaneous healing rate, therefore restrained use of the various, especially surgical, therapy options.

External therapy
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  • Apply keratolysis with ointment containing vitamin A acid (e.g. Cordes VAS, Isotrex, Aknemycin plus) 1-2 times/day lesionally. In case of burning and reddening of the facial skin reduce to 1 time a day. Cave! Do not use during pregnancy or while breastfeeding.
  • Possibly in combination with UV-radiation. Cave! Reduced average erythema dose. Further keratolysis e.g. with 1-5% salicylic acid.
  • Successes with 5% Imiquimod cream (e.g. Aldara) applied 3-4 times/week overnight (therapy duration: 3-4 weeks) are described (off-label use!).
  • In individual cases the use of photodynamic therapy is just as successful.

Operative therapie
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Careful scraping with a sharp spoon. Cave! Only superficial curettage to avoid scarring. Cryosurgery, electrocoagulation or ablation with the pulsed dye laser or Erbium-YAG laser are also possible.

Progression/forecast
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After months or years of progression, usually spontaneous, scarless healing.

Note(s)
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The warts on the backs of the hands, which are caused by the same virus types and are only slightly more prominent, are called intermediate warts.

Case report(s)
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  1. A sixteen-year-old girl presented with extensive flat juvenile warts on her forehead and cheeks. She was informed about her clinical picture. Subsequently, a local therapy with a combination preparation (erythromycin/tretinoin) followed. The therapy was indicated as follows: dab the lesions with the solution 3 times a week. The patient initially noticed an inflammatory reaction with a slight burning sensation of the treated skin areas. Within three weeks the warts healed completely. The patient remained recurrence-free in the following period.
  2. A 35-year-old patient reported surprisingly developed brownish spots on the right cheek. They were limited to the right cheek only, about 20-30, disseminated brown and red, 0.2-0.4 cm large spots and flat plaques with a slightly rough surface. No itching. The treatment was performed as before. After a mild inflammatory treatment reaction with a slight burning sensation, the flat warts healed completely within 4 weeks. The patient remained recurrence-free in the following period.

Literature
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  1. Choi YS et al (1993) The effect of cimetidine on verruca plana juvenilis: clinical trials in six patients. J Dermatol 20: 497-500
  2. Karakashian GV et al (1989) Frigipoint: a new cryosurgical instrument. J Dermatol Surg Oncol 15: 514-517
  3. Rübben A (2011) Clinical algorithm for the therapy of cutaneous, extragenital HPV-induced warts. Dermatologist 62: 6-16
  4. Skinner RB Jr (2003) Imiquimod. Dermatol Clin 21: 291-300
  5. Stulberg DL et al (2003) Molluscum contagiosum and warts. On Fam Physician 67: 1233-1240
  6. Tan OT et al (1993) Pulsed dye laser treatment of recalcitrant verrucae: a preliminary report. Lasers Surg med 13: 127-137

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Last updated on: 23.04.2021