A 30-year-old man comes to the physician for evaluation of a rash on his right thumb. He initially noticed a small lesion near the nail margin that has progressively worsened over the past 2-3 weeks. He has no other medical conditions and no history of tobacco or alcohol use. He works in the kitchen of a local restaurant. The patient has been sexually active with a single partner in the past year.
His temperature is 36.1 C (97 F), blood pressure is 128/76 mm Hg, and pulse is 78/min. Skin examination findings are shown below. The remainder of the physical examination is within normal limits.

Which of the following is the next best step in management of this patient?

Question

A 30-year-old man comes to the physician for evaluation of a rash on his right thumb.  He initially noticed a small lesion near the nail margin that has progressively worsened over the past 2-3 weeks.  He has no other medical conditions and no history of tobacco or alcohol use.  He works in the kitchen of a local restaurant.  The patient has been sexually active with a single partner in the past year.
His temperature is 36.1 C (97 F), blood pressure is 128/76 mm Hg, and pulse is 78/min.  Skin examination findings are shown below.  The remainder of the physical examination is within normal limits.

Which of the following is the next best step in management of this patient?

Quizplus · Accepted Answer

This patient's skin lesion is consistent with warts (cutaneous verrucae), which are the most common cutaneous manifestation of human papillomavirus (HPV) infection. The virus usually enters through tiny cuts or skin abrasions after contact with an HPV-infected individual and can cause warts in various locations including plantar, periungual, palmar, or genital areas. Periungual warts are most common in individuals who bite their nails or have occupations causing chronically wet hands (eg, dishwashers). Periungual warts begin weeks to months after viral exposure and are characterized by thick cauliflower-like skin around the nail plate. There can be loss of the cuticle, paronychia, and pain from nail separation. Diagnosis is made clinically by skin examination. Although warts in other areas can spontaneously regress, periungual warts often persist and require treatment. Topical salicylic acid is the preferred treatment in most patients and is given for 2-3 weeks until the dead wart tissue sloughs off. Treatment is continued for another 1-2 weeks to prevent recurrence and eliminate residual virus. paronychia (Choice A) Curettage and desiccation can effectively remove the wart but is usually reserved for patients who fail topical therapy. The procedure involves numbing the skin with an anesthetic (eg, lidocaine) prior to scraping the wart off. (Choice B) Imiquimod is a topical immunomodulator that likely induces local cytokine production against the virus. However, it is usually reserved for patients who fail initial topical therapy. (Choice C) Liquid nitrogen cryotherapy is a second-line treatment option for patients who fail treatment with salicylic acid. However, cryotherapy in the fingers, which have dense innervation, can cause severe pain and residual neuropathy. It can also injure the nail bed leading to dystrophic nails. (Choice E) Shave or snip excision is typically used for filiform warts and is less effective for periungual warts. Patients are typically given topical lidocaine before using scissors (snip) or a scalpel (shave) to remove the wart. filiform warts Educational objective: Periungual warts are characterized by thick cauliflower-like skin around the nail plate and can lead to loss of the cuticle, paronychia, and pain. They usually do not regress spontaneously. Topical salicylic acid is the preferred treatment for most patients. __________ References: Topical treatments for cutaneous warts. (http://www.ncbi.nlm.nih.gov/pubmed/22972052)

A 30-Year-Old Man Comes to the Physician for Evaluation of a Rash