Cutaneous Warts (Verruca Vulgaris)
The most likely diagnosis is cutaneous warts (verruca vulgaris), based on the characteristic presentation of numerous small papules on the hands that bleed with minor trauma—a pathognomonic feature of warts when pared or struck. 1
Clinical Features Supporting This Diagnosis
The presentation is highly characteristic of verruca vulgaris for several key reasons:
Pinpoint bleeding with trauma is pathognomonic for warts and distinguishes them from other papular conditions like corns, calluses, or psoriatic plaques 1
Well-circumscribed, flesh-colored growths with a white pebbly or papillary surface are classic features favoring verruca vulgaris over psoriasis or lichen planus 1
Location on the hands is one of the most common sites for verruca vulgaris, which typically appears on hands, arms, and legs 2
Chronic duration of several months is consistent with common warts, which can persist for extended periods (5-10 years in adults) with minimal inflammation 1
Mild pruritus can occur with warts, though it is not a prominent feature 1
Key Distinguishing Features from Other Diagnoses
Why Not Psoriasis (Option D)?
Absence of silvery scale is a critical distinguishing feature—psoriasis characteristically presents with thick silvery scales, which are not described in this case 1
Psoriatic plaques are typically more indurated, sharply demarcated, and covered with thick scale rather than having a pebbly surface 3
While psoriasis can occur on the hands, the bleeding pattern differs—psoriasis shows diffuse bleeding when scraped (Auspitz sign), not pinpoint bleeding from papillary structures 1
Why Not Lichen Planus (Option C)?
Lichen planus typically presents with flat-topped, violaceous papules with Wickham striae, not flesh-colored pebbly lesions 1
The distribution and morphology do not fit the classic presentation of lichen planus
Why Not Atopic Dermatitis (Option A)?
Atopic dermatitis presents with erythematous, scaly, excoriated patches with intense pruritus and lichenification in chronic cases, not discrete papules that bleed with trauma 3
The mild pruritus described is inconsistent with the severe itching characteristic of atopic dermatitis 3
Why Not Tinea Infection (Option E)?
Tinea infections typically present with annular, scaly plaques with central clearing and an advancing erythematous border, not multiple discrete papules 1
Fungal infections do not cause pinpoint bleeding with trauma
Clinical Pearls and Diagnostic Considerations
Hyperkeratotic changes can obscure the underlying viral etiology in long-standing warts on the hands and feet, particularly at sites of mechanical stress 1
Multiple sections may need histopathologic examination in chronic lesions, as long-duration warts can lose characteristic features and HPV may not be detectable by PCR 2
The mechanical trauma at hand sites promotes hyperkeratotic changes that can make clinical diagnosis more challenging 1
Verruca vulgaris is caused by various HPV subtypes (most commonly types 2 and 4, with types 1,3,26,29, and 57 less frequent), though the specific subtype does not influence treatment response 4
Management Approach
Complete surgical excision is the standard of care for established HPV-associated lesions on the hands, particularly when they persist and cause diagnostic confusion. 1
Alternative treatment options include:
Cryotherapy, electrocautery, or laser ablation (pulsed dye laser at 595 nm or long-pulsed Nd:YAG laser) 1, 5
Intralesional Candida antigen injection has shown 80% response rates (39% complete, 41% partial) and is well-tolerated with minimal adverse events 6
Observation for 2-3 weeks is only appropriate for small, soft, stable lesions—definitive treatment is required for established lesions like those described 1