Verruca and Papilloma

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Verruca plana.

Signs and symptoms: The term papilloma refers to a benign epithelial lesion of either the skin or mucosa. Papil-lomas affecting the eye primarily appear on the skin of the eyelid, but occasionally they may develop on the palpebral and bulbar conjunctivae. All papillomas have a characteristic configuration of lobular projections that can resemble mulberries or cauliflower. They may be flat or planar, or pedunculated. They may present singly or in multiple numbers.

Verrucae are papillomas of viral origin. They are sometimes referred to in the literature as viral papillomas, verruca vulgaris or viral warts. Verrucae may vary in pigmentation from yellow to pink to dark-brown or even black. At least two types of verrucae may be identified clinically. Verruca plana are generally round, flat-topped, slightly elevated lesions. Their surface is remarkably smooth compared with other papillomas. Verrucae digitata, as the name implies, present with numerous "finger-like" projections from a larger base.

Close inspection reveals that all verrucae are comprised of multiple filliform stalks of fibrovascular tissue. Often there are tiny red or black dots near the surface of these projections, representing thrombosed, dilated capillaries. Verrucae of the lids may become quite large, often becoming keratinized over time; associated cutaneous horns are not uncommon. Verrucae of the conjunctiva are less common and tend to maintain a more "fleshy" appearance.

Squamous papilloma is a generic term for any papilloma of non-viral origin. Most often these lesions represent a benign dermatological condition known as acrochordon, or "skin tag." Clinically, squamous papillomas present as round or oval, multilobular lesions. They may be sessile (attached by a base) or pedunculated, and like verrucae they may vary in pigmentation. Most commonly, the coloration approximates that of the patient's skin. Upon close examination, you may note a central vascular core to each lesion, which provides blood to the proliferating epithelium. The surface is typically roughened or granulated, reflecting the redundant epithelial cell growth.

Conjunctival caruncular papilloma.

Patients with verrucae tend to be typically between ages 5 and 20; fewer than 15% of patients are over 35.1 Squamous papilloma, on the other hand, is more common in those 30 and older, and the incidence increases with age. Patients with papillomas rarely present with symptoms beyond cosmetic concern, although in rare instances large lesions may induce mild lid dysfunction or discomfort. Patients who attempt to remove these lesions by picking at them may develop secondary, localized bacterial infections.

Pathophysiology: Papillomas represent benign overgrowths of normal epithelium, with varying levels of keratinization and pigmentation. Histopathologically, the lesions consist of multiple epithelial projections, the cores of which are vascularized, fibrous connective tissue. These are covered by acanthotic (the thickened prickle-cell layer of the skin) and hyperkeratotic epithelium.

Verrucae arise from viral infection, their cores representing inflammatory hypertrophy of tissue with viral inclusions. The causative agent in these lesions is the human papillomavirus (HPV), a double-stranded, non-enveloped DNA virus that is spread by direct contact. As with many viral diseases, immunocompromised patients are more susceptible to infection.

Squamous papillomas may have numerous etiologies, but most often they arise de novo as a normal senescent skin change. The onset is gradual rather than sudden. Lesions tend not to resolve spontaneously. Squamous papillomas may in rare instances represent precancerous lesions, so malignant conversion remains a consideration.

Management: Given their benign nature, both verruca and squamous papillomas warrant intervention only in cases of cosmetic concern, impaired lid function or discomfort. Obviously, if any signs of malignancy develop, biopsy and removal are essential. Typical management involves only patient reassurance, photodocumentation and periodic observation.

When warranted, papillomas may be removed via several methods. Less-invasive measures involve chemical cauterization and electrocautery. The former calls for applying bichloracetic acid to the surface of the lesion after coating the surrounding skin with petroleum ointment. This does not require injectable anesthetic, and results in necrosis and regression of the lesion within a week to 10 days. Electrocautery achieves the same effect, but it requires local anesthesia, and recurrence rates tend to be higher. Obviously, neither method is suitable for lesions on the lid margin or conjunctival surface, because of the risk to the ocular surface.

CO2 laser ablation can effectively remove lid papillomas. Most oculoplastic surgeons, however, opt for local surgical excision, the quickest and easiest way to permanently remove these lesions. Bleeding is the most significant problem, although topical astringents (for example, aluminum chloride) can help achieve hemostasis. Physicians must take care when surgically removing verrucae to prevent spread of the virus that can occur by cutting across the stalk of pedunculated lesions. The virus may also spread if not enough of the adjacent tissue is removed.

Clinical Pearls:

  • While the nomenclature regarding papillomas is sometimes confusing, it is important to remember that these are all benign epithelial lesions. Whether the origin is hyperplasia or viral infection, recognition and differentiation from malignant skin lesions is the first concern. Red flags for malignancy include: asymmetrical shape, irregular borders, abrupt changes in color or size, and crusting or bleeding with minimal manipulation.
  • Most commonly these lesions represent a purely cosmetic concern or are discovered on routine examination. Treatment is rarely indicated, although it should be offered if the patient is symptomatic.
  • Advise patients of the infectious nature of verrucae. These may spread to form satellite lesions around the eye, affect skin in different regions of the body, or be transferred to other individuals. Also realize that HPV may be spread by sexual contact. Ask patients if there are similar lesions elsewhere on the body, and if so refer the patient for a dermatologic consultation.

1. Odom RB, James WD, Berger TG. Andrew's Disease of the Skin: Clinical Dermatology, 9th ed. Philadelphia: WB Saunders 2000:509.

Other reports in this section

Eyelids & Eyelashes | Conjunctiva & Sclera | Cornea
Uvea | Vitreous & Retina | Optic Nerve & Brain | Oculosystemic Disease

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