Excision of Verruca Vulgaris Does Not Cause Cancer
Surgical excision of a common wart (verruca vulgaris) does not increase the risk of malignancy, and you should proceed with standard excisional treatment for this patient's thumb lesion. 1
Evidence Against Malignant Transformation from Excision
The concern that "cutting a wart causes cancer" is a medical myth without scientific basis. The evidence clearly demonstrates:
- Complete excision is the recommended treatment for verruca vulgaris, particularly for recalcitrant or giant lesions that fail conservative therapy 2, 3
- No malignant transformation has been reported from surgical excision of verruca vulgaris in the medical literature 1
- Verruca vulgaris is caused by low-risk HPV genotypes (commonly HPV-2, -4, -27, -57) that do not have oncogenic potential 1, 4
Appropriate Treatment Approach for This Patient
Excision Technique
- Use a scalpel for complete excision with a narrow margin (2-5 mm) of normal-appearing skin around the clinically visible wart 1
- Avoid tissue-destructive methods like electrocautery or laser for the initial excision, as these compromise histopathological examination 1
- Include the base of the lesion in the excision to prevent recurrence from residual infected epithelium 1
Specimen Handling
- Send the entire excised specimen for histopathological examination to confirm the diagnosis and rule out other conditions 1
- Request that margins be assessed histologically to ensure complete removal 1
- Document the exact anatomic location and size in your operative note 1
Important Diagnostic Considerations
When to Suspect Alternative Diagnoses
While verruca vulgaris is the presumed diagnosis, certain features warrant heightened suspicion for other conditions:
- Lesions unresponsive to multiple treatment modalities over years may represent misdiagnosed squamous cell carcinoma, particularly in immunosuppressed patients 1, 5
- Underlying bone involvement should be considered if the lesion is fixed to deeper structures or if there is bony prominence—this could represent an osteochondroma with overlying hyperkeratotic skin mimicking a wart 6
- Immunosuppressed patients (transplant recipients, patients with hematologic malignancies) have higher rates of HPV-related squamous cell carcinoma that can clinically resemble verruca vulgaris 1, 5
Histopathological Confirmation is Essential
- Long-standing warts may lose characteristic histopathologic features, making diagnosis challenging 2
- Multiple tissue sections should be examined if the clinical presentation is atypical 2
- HPV typing can be performed if there is diagnostic uncertainty, though this is rarely necessary for typical presentations 4
Common Pitfalls to Avoid
Do not use destructive methods (cryotherapy, electrocautery, laser) as the initial treatment for atypical or long-standing lesions without first obtaining tissue for histopathology 1, 6. This patient's 2-year history of a 5mm tall cylindrical lesion warrants histological confirmation.
Do not assume all hyperkeratotic digital lesions are warts—the differential diagnosis includes squamous cell carcinoma (especially in sun-exposed or chronically damaged skin), keratoacanthoma, and even underlying bone tumors with secondary skin changes 1, 6.
Recurrence after excision typically results from incomplete removal of infected epithelium at the base, not from the act of cutting itself 1, 2. Ensure adequate depth of excision to include the full thickness of the lesion.
Patient Counseling Points
You can confidently reassure your patient that:
- Surgical excision is the standard of care for recalcitrant verruca vulgaris and does not cause cancer 2, 3
- The excision allows for definitive diagnosis and typically provides excellent functional and aesthetic results 2
- Recurrence rates are low when complete excision is achieved 1, 2
- The specimen will be examined microscopically to confirm the diagnosis and ensure no other concerning features are present 1