INTRODUCTION Also known as a viral wart, or a viral papilloma, this lesion is a papilloma caused by an epidermal infection with the human papillomavirus, which is spread by direct contact and fomites. Immunocompromised patients are more susceptible to infection. Verruca vulgaris is more common in children and young adults between the ages of 5 and 20 years. They may occur anywhere on the skin, including the eyelids. Two common variants exist: Verruca filiformis or filiform warts (which include the subgroup known as digitate warts) and verruca plana, or flat warts.
CLINICAL PRESENTATION These lesions begin as small tan or gray papules that slowly enlarge to become elevated papules with an irregular hyperkeratotic, papillomatous surface. The filiform variety is the most common variety on the face and eyelid, and is distinguished by columnar, hyperkeratotic projections. The digitate variety has several such spikes joined at the base. Lesions along the eyelid margin may induce a mild papillary conjunctivitis due to shedding of virus particles into the tear film. Patients also may develop a superficial punctate keratitis, and may have pannus formation. Primary conjunctival lesions may also occur.
HISTOPATHOLOGY Verruca vulgaris is characterized by marked hyperkeratosis and acanthosis. Papillomatosis is prominent in the filiform variant of verruca vulgaris. Parakeratosis, often arranged as vertical tiers, overlies the papillomatous projections. The granular cell layer is usually prominent, and the cells contain coarse clumps of basophilic keratohyaline granules. Dilated capillary loops may be conspicuous in the core of the papillary projections.
DIFFERENTIAL DIAGNOSIS The differential diagnosis includes squamous papilloma, nevi, inverted follicular keratosis, cutaneous horns, and seborrheic keratoses.
TREATMENT Observation is recommended if no ocular complications occur, as these are benign lesions.
Treatment, if necessary, includes the use of cryotherapy, keratolytic agents, chemical cautery, electrodessication, local antimetabolite therapy, or complete surgical excision, as incomplete excision may cause multiple recurrences. Caution is advised to prevent spread of the virus that can occur when cutting across the stalk of pedunculated lesions, or leaving residual tumor behind.
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