Simple cases
Case 13
32-year-old man presents with new lesions on right foot.
History
How long have you had these lesions?
I noticed them 2 months ago.
Search for more diagnostic details with further questions.
Do you feel otherwise sick?
No, I feel great.
Search for more diagnostic details with further questions.
Are the lesions painful?
Yes, they hurt when I walk.
Search for more diagnostic details with further questions.
Does anyone with whom you have close contact have similar lesions?
My father died from skin cancer.
Could the disease be infectious or genetic?
Have you ever had anything like this before?
No, I was always healthy.
Could it be a recurrent disease?
Do you sweat a lot or wear rubber shoes?
I am a construction worker and have been wearing heavy rubber boots for the past 4 months. Everyone sweats a lot in them.
Search for more diagnostic details with further questions.
Lesion
Choose the right efflorescences:
False. The lesions are raised but not smooth.
A crust consisted on dried blood, pus or serum. This is not present here.
Urticaria is transient.
Once again, a raised lesion, but not smooth. Furthermore a nodule is >5mm.
Correct. We see localized massive exophytic hyperkeratosis.
Diagnosis
Choose the right diagnosis:
Hyperkeratotic lesions can be seen in the perianal region in syphilis but not on the back of the foot.
Scabies is pruritic, with papules, excoriations and a different distribution pattern.
A melanocytic nevus is usually pigmented and does not have excessive scale.
The lesions do not have peripheral scale and erythema, as is typical for tinea.
Correct. These are typical common warts (verrucae vulgares) caused by human papilloma virus infection.
Therapy
Choose the right therapy(ies):
Warts are diagnosed clinically. Biopsy is only appropriate in confusing cases.
While 50% of warts disappear in 2 years, this patient is having pain and deserves treatment.
Contraindicated. While radiation therapy was used decades ago for resistant warts, it is no longer acceptable.
No need for an x-ray and surely no need for toxic systemic treatment.
This is the usual first approach for a limited number of warts.
Test
The following questions are related to the current case. Try to solve them.
