Giant Verruca Vulgaris on Scalp: A Case Report

Prilly Pricilya Theodorus

, Novriyani Masuku

, Hanny Tanasal

RSUD Dr. M. Haulussy – Ambon, Indonesia

Departemen Dermatovenereologi RSUD Dr. M. Haulussy – Ambon, Indonesia

*Corresponding author

Keywords: Verruca vulgaris, histopathology, electrocauterization.

Abstract: Verruca Vulgaris (VV) or also called Common warts is a skin conditions that forms verrucose papules as a

result of skin and mucosa proliferations that caused by Human Papilloma Virus (HPV). Authors reported a

case of Giant Verruca Vulgaris on scalp in 18 years old male teenager, the lesion located in the left parietal

that continuously increasing in size within two weeks. Lesion has a cauliflower-like appearance with

nummular shape as big as 4x4x0,5cm and grayish-brown colored with verrucous surface on it.

Histopathology findings’ showed that the tissue perform a papillomatosis growth, epidermal hyperplasia,

acanthosis, hyperkeratosis and parakeratosis, hypergranulosis with rough clod of keratohyaline, it also

showed the upper epidermis has small core of coil cell, and hyperchromatic that surrounded by empty

cytoplasm. The diagnose of VV were based on the clinical and histopathology findings. The selected

treatment was electrocauterization (scar tissue presence after healing process).

1 INTRODUCTION

Warts are benign neoplasms caused by infection of

epidermal cells with papillomaviruses (Miller et al,

2013). The thickening of the dermal cells with

scaling and an upward extension of the dermal

papillae containing prominent capillaries give them

their warty of verrucous appearance (Miller et al,

2013; Androphy et al, 2012; Akram et al, 2015).

Verruca Vulgaris or usually called Common warts is

skin condition that usually comes with verrucous

papules as a consequence of skin and mucosal

proliferation that caused by Human Papilloma virus

(HPV) (Cipto, 2015; Patrick et al, 2018). The main

cause for VV is HPV type 2, followed by type 1 or 4

(Cipto, 2015). Incubations period vary from weeks

to years, and 60% of the cases has spontaneous

remission within 2 years without leaving scar tissue,

if so, it is probably because of the treatment’s

method (Stockfleth, 2009). VV can be found in all

ages, especially in children, adolescents, and young

adults (Patrick et al, 2018; Beber et al, 2018).

HPV’s transmission can occur from direct

contact (skin-to-skin) by microabrasion in the

superficial skin or through infected objects (e.g nail

clipper) and environmental surroundings (swimming

pool, because penetration is better when the skin is

in wet condition or broken) (Akram et al, 2015;

Stockfleth, 2009; Beber et al, 2018). HPV infection

mechanism can also occur through autoinoculation,

wherein virus enter the epidermis through

epithelium defect. Common predisposition factors

are trauma, finger sucking, skin rubbing, and the

presence of skin maceration (Haroen et al, 2008).

Physical examination usually presented with

solid verrucous papule, keratotic, with the size

ranging from a pin head to bigger than a centimeter,

but the average size is usually around 5mm, and the

lesion could go bigger as it goes confluent (Cipto,

2015; James et al, 2016). Variety of other shape such

as cauliflower has tendency to appear on the neck

and head, especially on scalp (warts usually bigger

in size and exophytic) and beard area (in men appear

because of shaving, as in women, they appear on

legs) (Stockfleth, 2009; Beber et al, 2018).

Predilection sites are fingers and hands (in areas that

usually exposed to trauma that produce abrasion,

e.g; elbow, knee, face, and fingers) and could be

spread elsewhere (Stockfleth, 2009; Beber et al,

2018; Sterling, 2016).

In immunocompromised

patient lesions tend to be more extensive and hard to

treat (Patrick et al, 2018; Bart, 2013).

Histopathology examination is performed to

support the diagnosis and to eliminate hesitation in

Theodorus, P., Masuku, N. and Tanasal, H.

Giant Verruca Vulgaris on Scalp: A Case Report.

DOI: 10.5220/0009988303430347

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 343-347

ISBN: 978-989-758-469-5

343

diagnosing a case (Miller et al, 2013; Androphy et

al, 2012; Cipto, 2015; Stockfleth, 2009).

There are

different types of treatment modalities to treat VV,

but recurrences are common with all treatment

modalities (Androphy et al, 2012).

Children with

common warts may not require treatment as

spontaneous regression is frequent (Androphy et al,

2012).

The management of warts depends on the

degree of physical and emotional discomfort, the

extent and duration of lesions, the patient’s

immunologic status, the patient’s desire for therapy,

and the risk of contagion to other persons (Androphy

et al, 2012).

In this case report, authors reported a case of

Giant Scalp Verruca Vulgaris in 18 years old male

teenager. The lesion grew in nummular shape at the

left side of parietal region that continuously

increasing in size within 2 weeks. The aim of this

case report to show that manifestation of VV can

occur in any part of the body (apart from the

predilection site) and may develop in variative size.

2 CASE REPORT

A 18 years old male teenager came to

Dermatovenereology policlinic at Dr.M. Haulussy

General Hospital in December 6

2018. He stated

that he had a lump at the left side of his head that

continuously grow bigger within 2 weeks. The lump

cause no itching sensation, pain, and no prior trauma

on the site of the lesion. During history taking,

patient stated that he had no contact with anyone

surround him that has the same complain as he does.

The lesion has never been treated before. Physical

examination showed a grayish-brown cauliflower-

like wart on the left side of the parietal with

nummular size as big as 4x4x0,5cm and verrucous

surface and a slight of blood on right side of the

lesion. Laboratory test showed normal result and

non-reactive to anti-viruses (HIV, HbsAg, anti-

HCV).

Histopathology finding showed that the tissue

perform a papillomatosis growth, epidermal

hyperplasia, acanthosis, hyperkeratosis and

parakeratosis, hypergranulosis with rough clod of

keratohyaline, it also showed the upper epidermis

has small core of coil cell, and hyperchromatic that

surrounded by empty cytoplasm. Papilla dermis

showed dilated capillaries that contains erythrocyte.

The dermis layer contains sebaceous glands, hair

follicle, eccrine gland, and perivascular lymphocyte

infiltration. The treatment comprise

electrocauterization with local anesthesia (scar tissue

presence after healing process), analgetic

(mefenamic acid 500mg t.i.d / p.o), wound compress

with gauze using normal saline 0,9% (1x10 minutes

before topical application), oral antibiotic

(cefadroxile 500mg b.i.d / p.o for 5 days), topical

antibiotic (fusidic acid 2 times a day/ TP), and

multivitamin (vitamin B complex and vitamin C q.d

/ p.o for 5 days).

Picture 1. First clinical picture.

(reference: private documentation of Prilly in 2018)

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

344

Picture 2. Biopsy result (a) zoomed 40x (b) zoomed 400x.

(reference: Doc. of Pathology Anatomy Dept of Dr. M. Haulussy General Hospital in 2018)

Picture 3. (a)Post cauterization (b)Post healing process (scar)

(reference: private documentation of Prilly in 2019)

3 DISCUSSION

The diagnosis of VV in this case were based on

history taking, physical examination, and

histopathological finding. In history taking, authors

found a 18 years old male teenager with a lump on

the back of his head that increasing in size within 2

weeks. According to literature, VV is one of the

manifestation that occur due to the presence of HPV

infection.

VV can also be seen in any part of the

body, happens in both male and female, and

manifests in variety of age range, but mostly occur

in children (during school age) and adolescents.

HPV can be transmitted through direct contact and

autoinoculation.

2,4,6

The incubation period vary from

couple of weeks to years.

6,12

In physical examination, a wart was found in the

left parietal region with nummular shape as big as

4x4x0,5cm, with verrucous surface in it that covered

in greyish-brown color and slight of blood at the

right edge of the lesion. In case such as VV, lesion

could be distinguished from normal skin because it

interrupts the normal skin lines. This reflects the

convoluted epidermal surface (papillomatosis),

hyperkeratosis, and often punctate bleeding into the

stratum corneum.(Cipto,2015)

Generally, wart’s size

vary from 1-10mm up to larger than a

centimeter.(James et al,2016;Jr JGM et al 2013)

Lesion of VV tends to be exophytic, multiple,

and irregular with rough nodules that arise in body

part that often gets trauma or rubbed and has

abrasion. Predilections site are those who often

exposed to trauma, such as hands, fingers, elbow,

knee and could spread elsewhere in the body. Warts

can also appear in other unusual predilection site

like the beard area, vermillion, and scalp could also

(as for scalp, lesion tends to be bigger and

exophytic).(Cipto,2015)

Initial diagnosis of this case was Giant Scalp

Verruca Vulgaris with Seborrheic Keratosis (SK)

and Epidermodysplasia Verruciformis (EV) as the

differential diagnosis. Similar case report for Giant

VV has been reported before in 2008 by Haroen et

all, with different site of lesion. The lesion was

located in dorsal pedis and has been going on for so

A B

Giant Verruca Vulgaris on Scalp: A Case Report

345

many years that it had developed keratinization.

(Haroen et al, 2008).

In order to confirm the diagnosis, authors run for

skin biopsy for histopathological testing and the

result matched to Verruca Vulgaris. The result

showed acanthosis (epidermal thickening),

hyperkeratosis, papillomatosis, parakeratosis, and

dilated vessels in the upper dermis (this cause blood

to enter the stratum corneum and can be clinically

visible, therefore the stratum corneum contains

parakeratotic nucleus and blood). (Akram et al,

2015;Androphy et al, 2012; Beber at al, 2018).

;Cipto,2015;Patrick et al,2018).

The differential diagnosis with SK was removed

because lesion in SK perform as papule with smooth

or verrucous surface, covered in light brown to dark

brown or similar to the skin tone (especially in

dorsum manus), and happens in the

elderly.(Sterling,2016)

As for EV, the disease

usually inherited genetically in a way that it’s either

autosomal dominant or recessive inheritance, and

can’t be found in general population like Verruca

Vulgaris. ( Beber at al, 2018)

Therapies consist personal care hygiene and

avoidance of direct contact with infected person.

Medical treatment has some option to perform,

including topical medication (e.g; Cantharidin, 5-

fluorouracyl, Imiquimod, Salicylic acid 25-50%,

Tricloroacetate 25%, and phenol solution),

destructive agents method (keratolytic), destructive

surgery method (e.g; cryosurgery,

electrocauterization, and CO

laser), and

intralesional treatment (interferone and Bleomycin).

(Androphy et al,2012; Cipto,2015Jr JGM et

al,2013;Patrick et al,2018)

The existence of multiple treatment modalities

reflects the fact that none is uniformly effective or

directly antiviral. (Androphy et al, 2012) Literature

stated that most treatments for verrucae involve

physical destruction of the infected cells and

immunotherapy, but recurrences are common with

all treatment modalities. (Androphy et al,2012;

Bansal,2015;Cipto,2015). In this case,

electrocauterization was considered to be more

effective to eliminate the wart and to avoid patient’s

potentially non-compliance to the long course of

topical treatment.The drawback side of

electrocauterization is that it may cause scar tissue,

pain, and can isolate the virus that it will cause

recurrence. Authors did not perform HPV DNA

identification because the limitation of modality in

authors domicile. The last day of follow up showed

the post treatment lesion has been healed with scar

tissue remaining.

4 CONCLUSION

The diagnosis of Giant Scalp Verruca Vulgaris were

made based on clinical and histopathological

findings. Selected therapy was electrocauterization

which was used to destruct the lesion, authors

considered it to be more effective than topical

application that it might decrease patient’s

compliance. Patient also were given oral antibiotic

and topical antibiotic (applied on the lesion post

electrocauterization) and also multivitamin. The last

day of follow up showed the lesion has been healed

with scar tissue remaining.

REFERENCES

Akram S, Zaman H. 2015. Warts and verrucas :

assessment and treatment. Pharm J. 7867(294): [6p.].

[Accessed on March 21

2019]. Available from :

https://www.pharmaceutical-

journal.com/learning/learning-article/warts-and-

verrucas-assessment-and-

treatment/20068680.article?firstPass=false.

Androphy EJ, Kirnbauer R. 2012. Human papilloma virus

infections. Dalam: Goldsmith LA, Katz SI, Gilchrest

BA, Paller AS, Leffel DJ, Wolff K. Fitzpatrick’s

dermatology in general medicine. 8

Ed. Vol.II. New

York: McGraw-Hill; p.2421-33.

Bansal R. 2015. Essentials in dermatology, venereology &

leprosy. 1

Ed. Nepal: Jaypee Brothers Medical

Publishers. p. 76-82.

Bart B. 2013. Viral infections of the skin. In: Soutor C,

Hordinsky MK. Clinical dermatology. 1

Ed. New

York: McGraw-Hill Education. p. 88-96.

Beber AAC, Benvegnú, Dallazem LND, Lages LN. 2018.

Viral Infections. In: Bonamigo RR, Dornelles SIT.

Dermatology in public health environments. 1

Ed.

Switzerland : Springer Nature; p. 174-227.

Citpo H. 2015. Veruka vulgaris dan veruka plana. In:

Menaldi SLSW. Ilmu penyakit kulit dan kelamin. 7

Ed. Jakarta: Badan Penerbit FKUI; p.131-2.

Haroen MS, Purba HM, Kartadjukardi E, Sularsito A.

2008. Giant verruca vulgaris: a case report. Med J

Indones. 2(18): 135-8. [Accessed on March 21

2019].

Diunduh dari: http://mji.ui.ac.id/journal/index.php/

mji/article/view/347

James W, Berger T, Elston D. 2016. Andrew’s disease of

the skin. 12

Ed. Philadelphia: Elsevier; p.399-403.

Jr JGM, Miller JJ. 2013. Lookingbill & Marks’ principles

of dermatology. 5

Ed. Philadelphia: Elsevier; p. 55-8.

Patrick Bacaj and David Burch. 2018. Human

papillomavirus infection of the skin. Arch Pathol Lab

Med. 6( 142): 700-705. [Accessed on March 25

2019

]. Diunduh dari :

https://www.archivesofpathology.org/doi/full/10.5858/

arpa.2017-0572-RA.

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

346

Sterling JC. 2016. Human papilloma virus infections. In:

Griffiths C, Barker J, Bleiker T, Chalmers R, Creamer

D. Rook’s textbook of dermatology. 9

Ed. Vol.I.

Oxford: Wiley. ch. 25.43-61.

Stockfleth E. 2009. Human papilloma virus infections. In:

Burgdorf WHC, Plewig G, Wolf HH, Landthaler M.

Braun-Falco’s dermatology. 3

Ed. German:

Springer; p.64-73.

Giant Verruca Vulgaris on Scalp: A Case Report

347