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Warts Diagnosis


Pigmented Lesions

Pigmented lesions present particular problems. Several studies have shown that even the most experienced dermatologist makes mistakes when it comes to differentiating the various pigmented lumps and bumps. Moles and seborrhoeic warts are the commonest pigmented lesions but these have to be distinguished from malignant melanoma, dermatofibroma, pigmented basal cell carcinoma (rodent ulcer) and angiomas of different types. Probably the greatest difficulty is experienced in identifying lesions that are suspected of being malignant melanoma. As already indicated, the diagnosis may be difficult and what follows must only be regarded as brief notes and hints on the topic. If there is any doubt the patient must be referred without delay to a specialist with experience of these lesions.

Diagnostic pointers

Moles As malignant melanoma may arise from an existing mole or from previously normal nonpigmented skin, the patient's statement as to what was previously at the site of the presenting lesion is not often much help. The following points may, however, be of use:

  1. Ordinary moles gradually mature and later degenerate and disappear so that they become much less numerous in the elderly.
  2. Inflammation in moles can be very difficult to distinguish from malignant melanoma. It is particularly common on the face in hairy moles whose hairs have been plucked; the mole enlarges suddenly, becomes red and tender, and may discharge.
  3. Rapid increase in size and depth of color in a pre-existing lesion must always be taken seriously.
  4. Changes in the surface texture including erosion and crusting may be indicative of malignancy.
  5. Pigmentation of surrounding skin and/or satellite nodules are also bad signs.

Seborrhoeic warts

These develop on most people as they become older and are often misdiagnosed as malignant melanoma.

  1. Their distinguishing feature is their wartiness which is not a feature of malignant melanoma.
  2. Seborrhoeic warts don't usually occur singly.
  3. They occur particularly over the chest, shoulders, back and face.
  4. They often seem as if they are stuck on the skin surface or are plaque-like.
  5. Their pigmentation is usually lighter than that of moles and is uniform.

Basal cell carcinoma

This may be quite darkly pigmented - especially the nodular sort and can confuse the unwary. They generally occur on the face and usually have the pearly sheen of ordinary basal cell carcinomas despite their pigmentation.

Histiocytoma (dermatofibroma)

This is a common type of fibrous nodule that mostly occurs on the limbs of middle-aged and elderly people. They are often pigmented (though not deeply) and are firm or even hard and seem deeply set in the skin. Occasionally they have a slightly warty and scaling surface. These lesions can also be confused with malignant melanoma.

Vasular Malformations

Angioma Another sort of skin lesion that can be quite difficult to distinguish is the small vascular malformation or angioma. The blood in these may suddenly clot and turn black, sometimes causing alarm in inexperienced doctors.

Pyogenic granuloma A red, shiny or eroded nodule may suddenly appear which consists of a mass of young capillaries. These are inappropriately called pyogenic granulomas (inappropriately, because they are neither pus-forming - pyogenic - nor due to granulomatous inflammation). Unfortunately malignant melanoma can look just like pyogenic granuloma especially if it is rapidly growing and nonpigmented.

Warty Lesions When most people talk of warts they mean viral warts, and this is how I shall use the term here. Warts are probably the commonest tumour of all; most of us have some warts at some stage and most disappear without specific treatment. The sites most often affected are the hand and fingers, the soles of the feet, the genitalia and the face - but they can occur virtually anywhere. Warts have different clinical appearances depending on the particular type of wart virus involved, the anatomical site infected and the resistance of the subject concerned:

  1. On the hands viral warts are usually either proper warty nodules or small flat papules. The latter are either whitish-grey or pink and are known as plane warts.
  2. On the soles, warts are either hard callous nodules or large plaques consisting of a mass of faceted papules (mosaic warts).
  3. Warts on the face or on the genitalia often project straight out like horny spines or look like small cauliflowers. These are known as filiform warts.

Diagnostic problems When large numbers of warts occur on the hand or feet of youngsters there is usually no difficulty in diagnosis. Some problems may arise in older subjects when the differentiation between viral warts, seborrhoeic warts, solar keratoses and even squamous cell carcinoma may be difficult. Squamous cell carcinoma should be suspected if the lesion is large and indurated. Hyperkeratotic warty and ulcerated types both occur. Particular care should be taken with solitary warty lesions in elderly subjects. Although they may look like ordinary warts such lesions may actually be squamous cell carcinoma.

On the face, clusters of pink plane warts around the mouth and chin may look like acne or rosacea - such misdiagnoses are not as uncommon as you might think. Plane warts on the face tend to be uniform in appearance and not as inflamed as the lesions of acne and rosacea

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