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Saturday, January 01, 2011

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Case Note

Case Note: Tan ‘spots’ on the face

History

A 24-year-old healthy female, with no significant past medical history, presents for management of an increasing number of facial tan 'spots'.

Initial evaluation

  • Healthy-appearing female
  • Bilateral cheeks and neck with numerous tanned, flat-topped and slightly hyperkeratotic papules
  • Image 1
    Image 1

Enter your diagnosis

Diagnosis

  • A diagnosis of verruca plan (flat warts) is rendered

Initial Treatment

  • Recommendations:
    • Application of tretinoin 0.1%* cream at night. Begin by applying twice-weekly and increase to daily use as tolerated
    • Photoprotection of affected areas
  • Follow-up in 6 weeks
*Not FDA approved for treatment of flat warts

Follow-up evaluation strategy

6-week follow-up evaluation:

  • Improved (fewer lesions, many resolved, lesions flatter and smaller in size)
  • No evidence of topical retinoid toxicity (erythema, xerosis)
Further recommendations:
  • Continue application of tretinoin cream
  • Follow-up in 6-week intervals (requires total 6 months to eradicate all lesions)

General discussion

Verruca plana (flat warts) almost universally involute spontaneously over several months to years, with no sequelae. Therapy should be bland and non-scarring, as this is the expected result from spontaneous involution.

Any treatment plan should start with topical application of tretinoin 0.1% or 0.25% (cream or gel), which should be applied twice-daily for 4-6 weeks to induce mild-to-moderate irritation. This will clear warts in approximately 50% of patients. Alternative treatments include the use of tazarotene cream 0.1%* twice-daily, imiquimod cream* 3.75% or 5% daily or, for patients with fewer lesions, light cryotherapy with or without topical retinoid therapy.

Patients should also take steps to prevent the spread of the lesions. In particular, avoidance of shaving over the affected area with a razor is recommended until the lesions are cleared, although use of electric razors may reduce this risk. Patients should also avoid sun exposure during the summer months, opting to use a sunblock with UVA and UVB protection on a daily basis.

Subsequent treatment options include 5-fluorouracil 5%* cream twice-daily (not recommended for infants <6 years or pregnant women), cantharidin application to larger warts that are fewer in number (avoid application around the eyes) and immunotherapy.

For immunotherapy, consider dinitrochlorobenzene, squaric acid dibutylester or diphencyprone, however, be aware that any resulting dermatitis often looks worse than the warts themselves and may prove difficult to remedy, as use of steroids to suppress inflammation are not recommended. Other agents that elicit an appropriate immune response include intralesional candida antigen, which may be used adjunctively to the topical therapies mentioned above. Finally, consider cimetidine (50 mg/kg/day) as an adjunct to immunotherapy to enhance the response.

Flat warts are commonly confused for inflammatory dermatoses. In such cases, topical steroids potentially encourage their spread, especially in patients with atopic dermatitis. They are also frequently misdiagnosed as acne and in patients who are affected by both, topical retinoids are an ideal choice.

In general, electrosurgery should be avoided for flat warts, as scarring may occur, except when the procedure is performed by the most expert hands. Very gentle, low-voltage (2-5V) hyfrecation can be attempted to several test lesions, to assess a response and determine whether undesired sequelae such as scarring or dyspigmentation occur.

Finally, it is also worth noting that for certain patients (those with HIV infection and other forms of immunosuppression), flat warts can be severe, with many lesions spread over large parts of the body. In addition, patients with the autosomal recessive disorder, epidermodysplasia verruciformis, have innumerable flat warts and a higher incidence of cutaneous carcinomas.

*Off-label use

Further reading

Gibbs S, Harvey I. Topical treatments for warts. Cochrane Database Syst Rev 2006;3:CD001781.

Kwok CS, Holland R, Gibbs S. Efficacy of topical treatments for cutaneous warts: a meta-analysis and pooled analysis of randomized controlled trials. Br J Dermatol 2011;165:233-246.

Loo SK, Tang WY. Warts (non-genital). Clin Evid 2009:pii1710.

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