Can a 2-Year History of Itchy and Scaly Verrucous Lesions Be Considered Verruca Vulgaris?
A 2-year history of itchy and scaly verrucous lesions is atypical for verruca vulgaris and warrants immediate biopsy to exclude other diagnoses, particularly squamous cell carcinoma or verrucous carcinoma, as verruca vulgaris is typically asymptomatic and does not present with pruritus. 1
Key Clinical Features That Argue Against Verruca Vulgaris
Pruritus is not a characteristic feature of verruca vulgaris. The British Association of Dermatologists guidelines describe verruca vulgaris as well-circumscribed, hyperkeratotic lesions that are typically asymptomatic. 1 The presence of itching suggests an alternative diagnosis such as:
- Lichen planus - which presents with scaly, pruritic lesions that can be confused with plane warts 1
- Inflammatory dermatoses - which commonly present with pruritus and scaling 1
- Verrucous carcinoma or squamous cell carcinoma - particularly concerning given the 2-year duration 2
Duration Raises Concern
The 2-year persistence is a red flag requiring immediate evaluation. While verruca vulgaris can persist for months to years, the combination of prolonged duration with atypical symptoms (itching and scaling) mandates exclusion of malignancy. 1
- Lesions of long duration may lose characteristic histopathologic features of verruca vulgaris 3
- Giant or chronic verruca vulgaris can be misdiagnosed, and differential diagnosis must be verified by biopsy 3
- Progressive growth over time is a red flag feature requiring immediate biopsy 4
Diagnostic Algorithm
Immediate biopsy is indicated based on the following red flags present in this case:
- Duration exceeding typical observation period - Any lesion persisting beyond 2-3 weeks of observation warrants referral 4
- Atypical symptoms - Pruritus is not consistent with verruca vulgaris 1
- Scaly appearance - While verruca vulgaris shows hyperkeratosis, the description of "scaly" combined with itching suggests alternative diagnoses 1
The biopsy should be performed within 2 weeks to avoid delayed diagnosis of oral squamous cell carcinoma or verrucous carcinoma. 4
Critical Differential Diagnoses to Exclude
Verrucous papillary lesions include a spectrum from benign to frankly malignant entities:
- Verrucous carcinoma - Shows combined exophytic and endophytic growth patterns, unlike the purely exophytic pattern of benign lesions 2
- Oral verrucous hyperplasia - A potentially malignant disorder that is clinically and histologically difficult to distinguish from verrucous carcinoma 2
- Squamous cell carcinoma - Must be excluded in any persistent keratotic lesion, particularly with atypical features 1
Why This Likely Is NOT Verruca Vulgaris
Classic verruca vulgaris presents with specific features absent in this case:
- Asymptomatic nature - Verruca vulgaris does not cause itching 1
- Well-circumscribed growth with white pebbly or papillary surface - caused by HPV 2 and 4, occurring via autoinoculation from fingers to mouth 1, 5
- Prominent hyperkeratosis with heavy granular layer and koilocytes on histology 1
- Most commonly seen in children on hands and fingers, uncommon in the mouth 1
Recommended Management
Do not treat empirically as verruca vulgaris. Proceed directly to excisional biopsy for the following reasons:
- Multiple sections should be examined histopathologically to avoid misdiagnosis, as lesions of long duration lose characteristic features 3
- Complete surgical excision serves both diagnostic and therapeutic purposes 4, 6
- Delayed biopsy of any lesion with red flag features risks missing malignancy 4
If biopsy confirms verruca vulgaris despite atypical presentation, complete surgical excision remains the standard of care due to the 2-year duration and atypical symptoms. 6