Photo Quiz: Wart or Mimic?

Noah S. Scheinfeld, MD, JD

During a routine examination, an asymptomatic wartlike lesion is noted near the axilla of a 35-year-old woman. The patient says that it has been present since childhood.

Case 1:

During a routine examination, an asymptomatic wartlike lesion is noted near the axilla of a 35-year-old woman. The patient says that it has been present since childhood.

Is this a wart . . . or something else?

Case 2:

A 70-year-old wheelchair-bound man who has had one leg amputated and lives in a skilled nursing facility complains of a "wart" on his amputation stump.

Does this look like a wart to you?

Case 1: This is an accessory nipple, which can occur along the milk line in both men and women. Unlike warts, these growths are soft and sometimes have a central dell.

Case 2: This patient has amputation stump hyperkeratosis, which is thought to be caused by the persistent rubbing that results from an ill-fitting prosthesis. These lesions are larger than warts and do not display the black "dots" that are characteristic of warts with thrombosed capillaries. Moreover, no human papillomavirus is found on polymerase chain reaction testing. Sometimes the keratotic tops of amputation stump hyperkeratoses can be peeled away like those of actinic keratoses.

Case 3:

A 25-year-old woman complains that these lesions on her foot are painful when she runs.

What do these look like to you?

Case 4:

This lesion has bothered a healthy 16-year-old boy.

Can you identify it?

Case 3: These are calluses, which can be distinguished from warts in 3 ways:

•Calluses do not contain the thrombosed capillaries (black dots) that are characteristic of warts.

•They do not interrupt the normal skin markings (dermatoglyphs), as warts do.

•Calluses are more painful on direct than on lateral pressure, while warts are more painful on lateral than on direct pressure.

Case 4: This is a common wart. The wart is keratotic and displays the characteristic interrupted skin lines (dermatoglyphs).

Case 5:

A 30-year-old man finds it difficult to shave around this lesion under his chin.

What can you tell him about this growth?

Case 6:

These rough, irregular papules arose under the nail of a healthy 16-year-old boy.

What does this look like to you?

Case 5: This is a filiform wart. These warts have fingerlike projections whose ends can be irregular or brushlike. Filiform warts resemble skin tags, but the latter are soft.

Case 6: This is a subungual/periungual wart, a keratotic papule that resists treatment. Subungual warts underlie and infiltrate the nail fold; periungual warts abut the nail fold. These warts are more difficult to eradicate than other types of warts because a nidus of infected tissue remains after chemical or surgical treatment, which allows for reextension of the wart.

Case 7:

What type of outbreak is seen here on the face of a healthy 33-year-old man?

Case 8:

What type of lesion is seen here in a healthy 30-year-old woman? The patient says that the hyperpigmented area has been present since birth.

Case 7: These are flat warts, slightly elevated, flat-topped papules that are usually smaller than 5 mm. They typically occur in shaved areas, such as the beard area in men and lower legs in women. Shaving may spread the outbreak. Flat warts are pink in pale-skinned persons and brown in darker-skinned persons.

Case 8: This is a congenital nevus. These lesions are softer than warts and sometimes cerebriform, although they can also be verrucous. However, they have no black dots. In the groin, congenital nevi may be mistaken for condylomata acuminata, seborrheic keratoses, or skin tags; a biopsy is sometimes required to confirm the diagnosis.

Case 9:

Can you identify this asymptomatic lesion on the neck of a healthy 14-year-old boy?

Case 10:

What are the growths seen here on the hands of a healthy 28-year-old man?

Case 9: This is an epidermal nevus. Unlike warts, epidermal nevi are usually soft. Typically, they are grouped or linear and do not have a potential for malignant degeneration. An epidermal nevus may be mistaken for a nevus sebaceus of Jadassohn (organoid nevus), which is often linear and occasionally becomes malignant. These nevi are red or orange in white persons and brown in black persons.

Case 10: This person has accessory digits. These growths occur on the lateral aspect of fingers, and their tops are keratotic rather than verrucous. They are sometimes confused with traumatic neuromas.