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The clinical features were consistent with a filiform wart, which is caused by human papillomavirus and common on the face. Filiform warts may occur on mucosal surfaces, including the nasal mucosa, lips, or eyelids. Most are benign and resolve within 2 years without treatment, but others can be symptomatic. Larger filiform warts may develop the clinical features of a cutaneous horn and mimic a squamous cell carcinoma.

Patients often want the wart removed for functional or cosmetic reasons. Although, there are many treatments available for warts, none have success rates that exceed about 70%. The most common options for treatment include topical salicylic acid in a liquid or plaster, cryotherapy, intralesional immunotherapy with candida antigen, excision, and topical acid.

The location of this patient’s wart limited the treatment options to cryotherapy or snip excision and cautery. The patient opted for cryotherapy. In this process, a hemostat or heavy gauge tweezer is dipped in liquid nitrogen and allowed to cool. Then, without anesthesia, the clinician pinches the lesion gently with the instrument and holds it until the freeze horizon extends to the base. This is then repeated. Each cycle may take 10 and 15 seconds. A benefit of this technique (which is also useful for skin tags and lesions close to the eye) is the ability to avoid overspray of liquid nitrogen and thus, minimize collateral tissue damage. It is also quick and bloodless.

The FP performed cryotherapy on the wart and advised the patient to expect the lesion to become more inflamed over the next 2 to 3 days and then peel off within 1 to 2 weeks. The FP also instructed the patient to return in a week or 2 so that the FP could evaluate whether additional treatment would be necessary. In general, non-genital warts require 2 to 3 individual treatments to clear, but a smaller and pedunculated wart like the one seen in this case tend to clear more easily.

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Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained).

Kathleen Usmani, CPNP

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