A 28-year-old woman comes to the physician for evaluation of a rash on her left foot. A week ago, she noticed multiple lesions on the sole of her foot that are painful with walking or standing. The patient has no other medical conditions. Her only medication is an oral contraceptive. She has no history of tobacco or alcohol use. She works as an accountant. The patient has had 2 sexual relationships in the past 3 years and has been sexually active with her current boyfriend for the past 6 months. Her temperature is 36.1 C (97 F), blood pressure is 128/76 mm Hg, and pulse is 78/min. Skin examination is shown below. The remainder of her physical examination is within normal limits. Which of the following is the most likely etiology for this patient's findings?

Question

A 28-year-old woman comes to the physician for evaluation of a rash on her left foot.  A week ago, she noticed multiple lesions on the sole of her foot that are painful with walking or standing.  The patient has no other medical conditions.  Her only medication is an oral contraceptive.  She has no history of tobacco or alcohol use.  She works as an accountant.  The patient has had 2 sexual relationships in the past 3 years and has been sexually active with her current boyfriend for the past 6 months.  Her temperature is 36.1 C (97 F), blood pressure is 128/76 mm Hg, and pulse is 78/min.  Skin examination is shown below.  The remainder of her physical examination is within normal limits.  Which of the following is the most likely etiology for this patient's findings?

Quizplus · Accepted Answer

This patient's skin lesions are consistent with warts (cutaneous verrucae), which are the most common cutaneous manifestation of human papillomavirus (HPV) infection. HPV can cause warts in various locations including the plantar, palmar, or genital areas. Plantar warts occur most commonly in young adults and patients with decreased cellular immunity (eg, AIDS, organ transplant patients). The virus usually enters through tiny cuts or skin abrasions after direct contact with an HPV-infected individual. Patients can develop lesions weeks to months later; these appear as hyperkeratotic papules on the sole of the foot (sometimes with thrombosed capillaries and visible skin lines) that can be painful with walking or standing. Diagnosis is made clinically based on the appearance and location of the lesions. (Choice A) Calluses are hyperkeratotic lesions that usually occur next to bony prominences on the feet or sometimes on the hands. Calluses may sometimes cause pain and discomfort and occur in response to repeated shear or frictional forces. Calluses (Choice C) Lichen planus presents as purple flat-topped papules or plaques that are pruritic, planar, or polygonal. The lesions most commonly occur on flexural surfaces of the extremities, trunk, and genitalia. Lichen planus (Choice D) Molluscum contagiosum is a common condition caused by a poxvirus. It typically presents as single or multiple skin-colored papules with a central punctum (umbilicus or central pit). Molluscum contagiosum (Choice E) Seborrheic keratosis usually appears after age 50 as solitary or multiple well-circumscribed hyperpigmented lesions. They can have a "stuck-on" or warty appearance and usually occur on the trunk, face, and upper extremities. Seborrheic keratosis (Choice F) Squamous cell carcinoma typically presents with erythematous lesions that are scaly, ulcerate, or grow irregularly. It should be suspected in patients with a slow-growing and non-resolving lesion in sun-exposed areas. Squamous cell carcinoma Educational objective: Plantar warts are due to human papillomavirus (HPV) infection and most commonly occur in young adults and immunocompromised individuals. The lesions appear as hyperkeratotic papules on the sole of the foot that can be painful when walking or standing. References: Cutaneous human papillomavirus infection: manifestations and diagnosis (http://www.ncbi.nlm.nih.gov/pubmed/24643180)

A 28-Year-Old Woman Comes to the Physician for Evaluation of a Rash