Description

The human papillomavirus (HPV) can infect the skin and mucous membranes. Common warts, filiform warts, epidermodysplasia verruciformis, mosaic warts and plantar warts represent clinical manifestations of infection with HPV. Giant warts in the hands are very rare in immunocompetent adults and sometimes by their extension or atypical location represent a diagnostic and therapeutic challenge. The giant tumours caused by HPV are more common in the anogenital region where they are known as Buschke-Loewenstein tumours. No risk factor has yet been identified for giant warts in immunocompetent patients.

The authors report this rare case of a giant wart with a linear configuration (figure 1) in an immunocompetent 40-year-old adult in whom clinical presentation resembled a verrucous epidermal naevus. Other differential diagnoses such as cutaneous adnexal neoplasms and squamous cell carcinoma have to be thought. HPV lesions of long duration and subjected to various treatments tend to lose their histology (figure 2) and most of the times HPV DNA cannot be detected by PCR in the histological specimen1 (as was the case). This fact, associated with the nodular and hyperkeratotic nature of these lesions may explain the poor response to various therapies performed before and a not so marked response to imiquimod. The patient was initially treated with imiquimod during 12 weeks to reduce the size of the lesions and subsequently serial excision of the resistant nodes was carried out.

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Figure 1

Long-standing verrucous nodules, with linear distribution, simulating Blaschko's lines.

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Figure 2

Histopathological examination: hyperplasia of all layers of the epidermis with areas of parakeratosis, papillomatosis and presence of koilocytes.