Can verruca vulgaris (common wart) appear for the first time in adulthood, as in a 36-year-old patient with no previous history of similar lesions?

Can Verruca Vulgaris First Appear in Adulthood?

Yes, verruca vulgaris can absolutely first appear during adulthood, including in a 36-year-old patient, as HPV infection can occur at any age despite being more common in childhood. 1

Epidemiology Supporting Adult-Onset Disease

The British Association of Dermatologists guidelines explicitly state that while warts are most common in childhood, infection can occur at any age 1. This is a critical point that resolves your clinical confusion—there is no age cutoff beyond which verruca vulgaris cannot develop for the first time.

Key Epidemiological Facts:

• Warts affect 5-30% of children and young adults, but adult-onset is well-documented 1
• The incubation period varies from 6 weeks to a year after HPV exposure, meaning recent infection can manifest as new lesions in adults 2
• Warts in adults tend to persist much longer than in children (5-10 years is not uncommon), whereas children often clear within 1-2 years 1

Clinical Presentation in Adults

Verruca vulgaris presents as benign epithelial proliferations that are typically painless, multiple in number, and occur on any epithelial surface, most commonly on hands, feet, and around nails 1. In your 36-year-old patient:

• The lesions appearing "a few years ago" fits the natural history of adult warts, which persist longer than childhood warts 1
• Adult cases have been documented even in middle age, including a 50-year-old with giant periungual verruca vulgaris present for 2 years 3 and a 42-year-old with oral verruca vulgaris present for 3 years 2

Diagnostic Confirmation Algorithm

To confirm the diagnosis and exclude mimics:

1. Pare down the lesion—this should reveal pinpoint bleeding as capillary loops of elongated dermal papillae are exposed 1

2. Rule out red flag features requiring immediate biopsy within 2 weeks: 4, 5

   • Pruritus (itching is NOT characteristic of verruca vulgaris and suggests lichen planus or inflammatory dermatoses) 4
   • Progressive growth beyond initial observation period 4, 5
   • Ulceration or spontaneous bleeding 5
   • Change from soft to indurated/fixed consistency 5
   • Pain or functional impairment 5

3. If atypical features exist, biopsy immediately to exclude:

   • Squamous cell carcinoma 1, 4
   • Verrucous carcinoma 4
   • Actinic keratoses 1
   • Other keratotic lesions 1

Critical Pitfall to Avoid

Do not dismiss adult-onset verruca vulgaris as impossible or assume it must be something else solely based on age. The evidence clearly shows HPV infection causing verruca vulgaris occurs across all age groups 1. However, lesions of long duration (like your patient's "few years") may lose characteristic histopathologic features and HPV may not be detectable by PCR, requiring multiple histopathologic sections to avoid misdiagnosis 3.

Management Considerations

For confirmed verruca vulgaris in adults:

• Spontaneous clearance is much slower in adults than children—persistence for 5-10 years is not uncommon 1
• Treatment options range from conservative (observation, topical agents) to aggressive (surgical excision, CO2 laser) 6
• Complete surgical excision is the standard of care for atypical presentations or when biopsy is needed 4