Atypical Presentation of Verrucous Lesions

Key Clinical Features

• The British Association of Dermatologists guidelines describe verruca vulgaris as well-circumscribed, hyperkeratotic lesions that are typically asymptomatic, and the presence of itching suggests an alternative diagnosis such as lichen planus or inflammatory dermatoses 1, 2
• Pruritus is not a characteristic feature of verruca vulgaris, and its presence, combined with scaly appearance, suggests alternative diagnoses 1, 2

Diagnostic Considerations

• The American Academy of Otolaryngology-Head and Neck Surgery suggests that verruca vulgaris is most commonly seen in children on hands and fingers, and is uncommon in the mouth 4
• The presence of atypical symptoms, such as pruritus, and scaly appearance, warrants immediate biopsy to exclude other diagnoses, particularly squamous cell carcinoma or verrucous carcinoma 1, 2

Management Recommendations

• The British Association of Dermatologists recommends complete surgical excision as the standard of care for verruca vulgaris, even if biopsy confirms the diagnosis despite atypical presentation 3, 6
• Delayed biopsy of any lesion with red flag features, such as prolonged duration and atypical symptoms, risks missing malignancy, and biopsy should be performed within 2 weeks 3