Diagnosis: Plantar warts (verruca plantaris)
A 28-year-old male runner presents with painful mosaic lesions on the plantar surface of his foot, persisting for several months. Despite attempts at over-the-counter treatments, the lesions have become increasingly symptomatic, affecting his ability to train and compete.
The patient is a 28-year-old male runner who reports a 6-month history of painful lesions on the plantar aspect of his foot. He describes the lesions as multiple, clustered, and tender, especially during physical activity. On examination, there are several hyperkeratotic, dome-shaped papules with a rough surface, some coalescing into larger plaques, and characteristic black dots representing thrombosed capillaries.Location: Lesions are primarily located on the metatarsal heads and heel.Symptoms: Pain exacerbated by weight bearing and running.Appearance: Mosaic pattern with varying sizes of lesions.Other findings: No associated erythema or drainage noted.
The patient reports that the lesions began after he started training for a marathon, with frequent exposure to public showers and swimming pools. He has attempted self-treatment with topical salicylic acid and freeze therapy from an over-the-counter kit without significant improvement. There is no significant past medical history, and he denies any family history of similar lesions. He works as a software engineer and has no other notable exposures.Onset: Symptoms began approximately 6 months ago.Triggers: Increased training intensity and exposure to communal surfaces.Treatments: Over-the-counter salicylic acid and cryotherapy.Medical history: No significant past medical history.Social history: Active lifestyle, frequenting gyms and pools.
Acute / First-Line ManagementTopical salicylic acid: Apply 40% solution daily after soaking the affected area, covering with a bandage.Cryotherapy: Liquid nitrogen application every 2-3 weeks until resolution.Cantharidin: Application by a healthcare provider, followed by occlusion for 24 hours.Workup and Diagnostic ConfirmationClinical diagnosis based on characteristic appearance and history.Consider biopsy if atypical features are present or if lesions do not respond to treatment.Long-Term ManagementMonitor for resolution; repeat treatments as necessary.Educate on preventive measures: avoid walking barefoot in public areas.Referral to dermatology for persistent cases or surgical intervention if conservative measures fail.
Plantar keratosis: Typically presents as a single, well-defined lesion without the mosaic pattern; often lacks the characteristic black dots.Calluses: Thickened skin due to friction; usually painless and not located in a mosaic pattern.Common warts: Usually appear on non-weight-bearing areas; less likely to be painful and do not typically coalesce.Skin cancer: Atypical lesions may warrant biopsy; usually show irregular borders and color variations.Fungal infection: Tinea pedis can mimic warts but typically presents with scaling and is more diffuse.Foreign body reaction: Can present as localized hyperkeratotic lesions; history of trauma or foreign body exposure may be present.Acrokeratosis verruciformis: Rare, hereditary condition presenting with wart-like lesions, typically on the dorsal hands and feet.
High-Yield PearlsDiagnosis: Clinical diagnosis is often sufficient for typical presentations of plantar warts.Treatment: First-line treatments include topical salicylic acid and cryotherapy, with variable success rates.Prevention: Educating patients on avoiding communal surfaces can reduce transmission risk.Persistence: Warts may require multiple treatment sessions; persistence is common and can necessitate referral.Psychosocial impact: Consider the impact of pain and appearance on athletes and active individuals.Plantar warts can significantly affect quality of life, particularly in active individuals; effective management requires both treatment and preventive strategies.
Tags: plantar warts, runner