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. The patient returns in 10 days and has only partial improvement in the size of the lesion. Which of the following is the most appropriate advice for 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.  The patient returns in 10 days and has only partial improvement in the size of the lesion.  Which of the following is the most appropriate advice for this patient?

Quizplus · Accepted Answer

Explanation: Initial response to salicylic acid may take 2-3 weeks to become apparent. Patients are usually assessed at 2-3 week intervals for resolution. Treatment is continued for 1-2 weeks after clinical resolution to eradicate the virus and prevent recurrence. Some patients may require treatment for several weeks or months. Liquid nitrogen cryotherapy also often requires repeat treatment at regular intervals of 2-3 weeks. It is too soon to determine treatment failure in this patient, and he still needs continued treatment with salicylic acid before considering alternate options. (Choices A, B, and E) Topical imiquimod is an immunomodulator that induces local cytokines. It is used more commonly for anogenital warts but can be used for plantar warts that do not respond to or tolerate initial therapy (salicylic acid, liquid nitrogen). Patients who do not improve with medical therapy may need referral to a dermatologist for other options or surgical excision. (Choice D) Discarding and replacing footwear can prevent recurrence of plantar warts after successful treatment, but this patient first needs treatment with salicylic acid to eradicate the virus. Educational objective: The initial response to salicylic acid treatment for plantar warts may take 2-3 weeks to become apparent. Patients are usually assessed at 2-3 week intervals and treatment is continued for 1-2 weeks after clinical resolution to eradicate the virus and prevent recurrence. 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