A 47-year-old-man comes to the physician for a lesion on his foot. He has a 2-month history of an enlarging, painful, and thickened papule on the plantar surface of his left great toe. The patient attempted treatment for 2 weeks with a "corn pad" without relief. He has no prior history of similar lesions, and his past medical history is unremarkable.
Which of the following is the best next step in management of this patient?

Question

A 47-year-old-man comes to the physician for a lesion on his foot.  He has a 2-month history of an enlarging, painful, and thickened papule on the plantar surface of his left great toe.  The patient attempted treatment for 2 weeks with a "corn pad" without relief.  He has no prior history of similar lesions, and his past medical history is unremarkable.  
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient's presentation is consistent with plantar warts (verrucae), which are a form of cutaneous warts usually due to human papillomavirus (HPV). Plantar warts most often occur in young adults or in individuals with certain occupations (eg, meat, poultry, and fish handlers). More extensive disease occurs in patients with atopic dermatitis and conditions with decreased cellular immunity (eg, HIV, organ transplantation). Infection typically occurs via skin-to-skin contact and can have an incubation period of 2-6 months after exposure. The diagnosis of plantar warts is usually made clinically with visualization of single or multiple hyperkeratotic papules on the sole of the foot (as seen in this patient). Scrapings of hyperkeratotic debris can confirm the diagnosis by showing thrombosed capillaries (also called seeds). A shave or punch biopsy is rarely needed to confirm the diagnosis in uncertain cases (Choice B). Salicylic acid is preferred as initial treatment for plantar warts. Patients are instructed to prepare the affected area by soaking it in warm water for 10-20 minutes. The salicylic acid is then applied to the wart, taped in place with duct or athletic tape, and then kept dry for 48-72 hours. The patient should then remove the patch, pare the area down with a file or sandpaper, and then repeat the application. Liquid nitrogen cryotherapy is a reasonable alternative, but it can cause local burning and is usually avoided in dark-skinned individuals due to possible hypopigmentation. (Choice A) Daily application of duct tape alone has not been shown to effectively and consistently treat plantar warts. However, duct tape combined with salicylic acid has been effective in many patients. (Choice C) Snip or shave excision is usually preferred for filiform cutaneous warts, which usually appear as a solitary papule with finger-like keratotic projections. filiform cutaneous warts (Choice D) Topical miconazole cream is a treatment option for tinea pedis, which usually presents as chronic and progressive pruritic erosions or scales between the toes. tinea pedis Educational objective: Plantar warts usually present as single or multiple hyperkeratotic papules on the sole of the foot. Topical salicylic acid is the first-line therapy for plantar warts. Other options include liquid nitrogen cryotherapy. References: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae): a randomized controlled trial. (http://www.ncbi.nlm.nih.gov/pubmed/21652750)

A 47-Year-Old-Man Comes to the Physician for a Lesion on His