Management of Pathology-Confirmed Verruca Vulgaris
For a patient with biopsy-confirmed verruca vulgaris, the appropriate next step is observation for spontaneous regression, as 30% resolve within 6 months and 60% within 2 years, with treatment reserved for symptomatic lesions or those that fail to regress. 1
Natural History and Observation Strategy
- Most verruca vulgaris cases spontaneously regress without intervention, making watchful waiting the most appropriate initial approach for asymptomatic lesions 1
- The pathology has already confirmed the diagnosis, eliminating the need for further diagnostic workup
- Adults experience much slower clearance than children, with persistence for 5-10 years being common, whereas children often clear within 1-2 years 2
When to Initiate Treatment
Treatment should be considered in the following scenarios:
- Symptomatic lesions causing pain or functional impairment 1
- Cosmetically concerning locations such as the face or hands where patients desire removal 1
- Lesions that fail to regress after a reasonable observation period 1
- Periungual or subungual locations that may cause nail deformity 3
Treatment Options When Indicated
Chemical or physical destruction methods include: 1
- Cryotherapy with liquid nitrogen - first-line destructive method
- Salicylic acid-based products - over-the-counter option for gradual removal
- Tretinoin (retinoic acid) cream - topical alternative
- Surgical excision - definitive treatment, particularly for recalcitrant lesions 3, 4, 5
- Laser ablation or electrocautery - alternative destructive methods 6
Important Caveat About Destructive Methods
More aggressive destructive treatments may cause pain that inhibits daily activities, so balance efficacy against potential morbidity 1. Cantharidin combined with podophyllotoxin-salicylic acid has been reported effective in adults but is associated with pain and blistering 1.
Special Considerations for Oral Lesions
If the verruca vulgaris is located in the oral cavity (which is rare): 7, 4
- Complete surgical excision is the standard of care due to the risk of dysplasia, particularly in immunosuppressed patients 6, 5
- Oral verruca vulgaris most commonly occurs on the palate, followed by lip, tongue, and buccal mucosa 4
- Prompt surgical removal is warranted because HPV has been linked to squamous cell carcinoma in oral and oropharyngeal areas 5
Critical Pitfalls to Avoid
- Do not over-treat benign confirmed lesions - unnecessary excision causes avoidable morbidity when spontaneous regression is likely 6
- Do not miss atypical features - if the lesion develops progressive growth, ulceration, bleeding, induration, or pain during observation, immediate re-biopsy is required to exclude malignancy 6, 8
- Immunosuppressed patients require closer monitoring as HPV lesions persist longer and carry higher malignancy risk 6
Follow-Up Protocol
- Re-evaluate periodically during observation to monitor for spontaneous regression or development of concerning features 6
- Any change in size, color, texture, or development of symptoms warrants reconsideration of treatment or re-biopsy 6
- For giant, chronic, or recalcitrant lesions present for years, surgical excision provides definitive treatment with excellent aesthetic and functional outcomes 3