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Joe R. Monroe, PA-C, MPAS, DEPARTMENT EDITOR
Multiple “warts” on the lower legs of a
52-year-old woman
Joe R. Monroe, PA-C, MPAS
The author practices in the dermatology department of the Springer Clinic, Tulsa, Okla, and is the founder and President of the Society of Dermatology Physician Assistants. He has indicated no relationships to disclose relating to the content of this article.
A 52-year-old woman presents with multiple lesions on her legs, which she calls warts. These have gradually appeared over the past 2 to 3 years. They have persisted despite the patient’s use of a salicylic-acid-based OTC wart treatment and her primary care provider’s use of liquid nitrogen. Her mother and one sibling have the same lesions. The patient is in good health otherwise.
 Examination reveals innumerable epidermal tan-to-gray warty papules on both of the patient’s legs. These appear as though they had been “stuck on” the surface of the skin and, as the patient reports, can easily be peeled off. The lesions change the farther down the leg one looks, becoming more numerous, drier, and whiter, especially on the dorsal foot (see Figure 1).
The correct name for these extremely common lesions is
- Flat wart
- Dermatofibroma
- Actinic keratoses
- Stucco keratoses
Discussion
The correct answer is stucco keratoses, which are simply a variant of seborrheic keratoses, which seem to have a predilection for the extremities. As with seborrheic keratoses, stucco keratoses develop with age and are not associated with any syndromes. They are thought to increase in number and prominence farther down the leg because these areas produce less sebum. Stucco keratoses are far more common, drier, and more papular than flat warts. Stucco keratoses also afflict a much older patient population than warts do. Dermatofibroma is an incorrect choice because these lesions are by nature firm, compact, and intradermal; they can appear anywhere on the body, even though they do seem to appear most often on the legs. Actinic keratoses are relatively uncommon on the legs and feet and are not as dry and warty as stucco keratoses. Occasionally, biopsy is necessary for such lesions since squamous cell carcinomas are common on the leg. Stucco keratoses, unlike squamous cell carcinomas and actinic keratoses, will show no atypia. Stucco keratoses will also demonstrate orthokeratosis, not the parakeratosis seen with actinic keratoses and squamous cell cancers.
Treatment of stucco keratoses is with liquid nitrogen, but this is a somewhat laborious process. The treatment is time-consuming and painful, and the pain can be considerable by the time 20 to 30 lesions are treated. Each site will blister to some degree, which will likely leave a blemish that will take weeks to months to clear. Finally, more lesions are certain to appear in the same areas no matter what treatment is used. Presented with these facts, most patients do not request treatment and are content simply to know that they do not have warts. |
