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Joe R. Monroe, PA-C, MPAS, DEPARTMENT EDITOR

Persistent warts in an adolescent with severe atopy

Joe R. Monroe, PA-C, MPAS

The author practices in the dermatology department of the Warren 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 16-year-old girl is referred to dermatology by her pediatrician for the removal of “warts” that have been present on her fingers for years. Many attempts at treatment, including use of OTC (salicylic-acid based) products and liquid nitrogen, have all been unsuccessful. Liquid nitrogen had debulked the warts temporarily, but they had grown back rather rapidly.

The patient admitted to being quite atopic, reporting that she had seasonal allergies and asthma and had had eczema as a child. The physical examination showed what were clearly warts, in a periungual distribution, on 6 of 10 fingers (see Figure 1). The warts averaged more than 2 cm in width and were several millimeters thick.

Which of the following would be an inappropriate next step?

Liquid nitrogen treatment
Referral to dermatology
Oral treatment with cimetidine, 300 mg tid, as adjunctive therapy
Topical treatment with dinitrochlorobenzene (DNCB)

Discussion

Further treatment with liquid nitrogen not only would be extraordinarily painful but also would be quite ineffective for such persistent and bulky warts. Referral to dermatology is probably the best choice because a specialist is more likely to have a number of weapons to bring to bear on the problem. Putting the patient on cimetidine for a minimum of 2 months does have some modest support in the literature, but only as an adjunctive therapy for warts.

DNCB is a potent topical sensitizer that can be used as follows: first the patient can be made allergic to it, and then it can be placed on the warts themselves, so that they are attacked by the body’s immune system. A form of immunotherapy, such treatment with DNCB has been used successfully for many years, mostly in dermatology practices. DNCB can be compounded in cream form, in either a 0.25% or a 0.50% strength, and dispensed through the office. This treatment is totally painless, but it does involve some work on the patient’s part to apply it at home, and it typically takes 1 to 2 months to work.

A key factor in this case is the patient’s atopic state, which renders her susceptible to all manner of skin infections, including infections with viruses (human papillomavirus, molluscum, and herpes), fungi, and bacteria. The immune systems of such patients are of relatively little help in fighting off such infections, which is why something such as liquid nitrogen—normally an excellent treatment choice for warts—is less likely to do the job by itself.