History
A 51-year-old patient under the care of the haematologists is referred to the dermatol-ogy clinic with a 6-year history of multiple papules and nodules on her fingers. The lesions have slowly been increasing in size and number over the last two years and are mainly asymptomatic. The lesions were treated with liquid nitrogen by her GP but they were unresponsive. She had been diagnosed two years previously with stage B chronic lymphocytic leukaemia (CLL). She has received several courses of chlorambucil, fludara-bine and cyclophosphamide to which she partially responded and is being considered for alemtuzumab (Campath – antiCD52) biological therapy in the future.
Examination
She has multiple hyperkeratotic flesh-coloured papules and nodules, mainly over the dorsi of her fingers and hands (Fig. 77.1) The lesions are warty in nature and firm on palpation. The surrounding skin is normal.
Questions
• Why does she have multiple lesions on her hands?
• What treatment options are possible for her skin lesions?
Medicine
This woman has been suffering from multiple viral warts on her hands for many years. The warts result from an infection with human papilloma virus (HPV) in the cutane-ous keratinocytes. HPV is specific to humans and is passed by direct skin contact and through fomites. HPV infects the basal keratinocytes; when these infected cells leave the basal layer they become highly differentiated, triggering viral genome replication. Consequently, when the keratinocytes reach the epithelial surface, viral particles are released with the sloughed-off cells into the environment where they can survive for many months.
HPV infections are common in the general population but are more frequently found in patients who are immunosuppressed, when warts are often multiple. CLL causes down-regulation of immune surveillance and an increased susceptibility to all manner of infections. In addition, chemotherapy depletes patients’ white cell populations render-ing them more vulnerable to infections. These patients are unable to clear the HPV and subsequently develop multiple recalcitrant warts.
Although cutaneous warts are not harmful in themselves they can cause a considerable amount of distress to patients both psychologically and socially. Patients frequently feel embarrassed by their warts and can often feel stigmatized by others.
Most treatments for HPV are locally destructive (cryotherapy with liquid nitrogen, sali-cylic acid, electrodessication, CO2 laser) and then the host’s immune cells ‘mop-up’ the residual virus released; however, when the host’s immune system is suboptimal, locally destructive treatments are frequently ineffective.
Although not licensed to treat cutaneous warts, treatment options include immunothera-py with imiquimod 5% cream (daily with Elastoplast occlusion) or diphencyprone (DPC) fortnightly. DPC is a highly sensitizing chemical – patients are rendered allergic to it by painting a small amount on their forearm skin, then increasing percentages are applied directly to the warts to recruit immune cells into the local tissue. Cure rates of 60 per cent are reported in immunosuppressed patients after 6 months of treatment. This patient was treated with DPC immunotherapy to good effect. Topical bleomycin has also been used with some success to treat recalcitrant warts in this group of patients.
KEY POINTS
• If a patient presents with multiple HPV warts, then consider immune deficiency.
• Warts will eventually resolve spontaneously in the majority of patients.
• Management of warts includes local destructive modalities and immunotherapy to the skin.
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