WARTS, MOLES t3 CORNS* HOWARD

NEW

W ARTS and moIes are worthy of serious attention by the physician and shouId not be considered as

mere cosmetic defects to be treated by the beauty parIors. Corns are of much Iess importance and seIdom require the aid of a physician. The recognition of warts, moles and corns is usuaIIy easy, though it is difEcuIt at times to distinguish between certain types of warts and moIes. In spite of the great frequency of these Iesions we have much to Iearn of their causation. The majority of warts appear to be infectious though no specific organisms have as yet been discovered. Common warts at Ieast have been experimentaIIy produced by a fiItrabIe virus. As to the cause of moIes, we mereIy know that they show a marked hereditary and famiIia1 tendency. The rea1 cause of moIes, as of a11 other birth- marks, is unknown. Corns constitute a reaction to pressure and tend to remain as Iong as this continues. The chief interest in this subject is the treatment, which wiI1 be considered at some Iength.

WARTS (VERRUCAE)

There are severa varieties of warts which present very dissimiIar appearance, some of them (flat warts, pIantar warts) often faiIing to be recognized as such by the average physician. A discussion of this subject wiI1 not incIude the verrucous changes that occur in certain skin diseases such as tubercuIo&, nor wiI1 it incIude the infectious disease seen in parts of South America, known as verruga peru- ana. Six types of warts wiI1 be considered: common, GIiform, pIantar, Aat, acuminate and seniIe warts.

I. The common wart (verruca vuIgaris) is the famiIiar type occurring most often on the back of the hands or fingers of

FOX, M.D.

YORK

chiIdren. Like other types of warts it is a benign epitheIia1 neopIasm and not an inflammatory affection. It is true, however, that warts may at times become sec- ondariIy inflamed as shown by a reddish areoIa and tenderness. Common warts vary in size from a pin head to a smaI1 bean and may become more or Iess conff uent. They are sharpIy defined, have a rough mammiIIated surface which may become very hard in Iesions of Iong standing. The b ase may be somewhat constricted and aImost peduncuIated. They may be singIe or muItipIe. WhiIe seen most often on the hands, they often occur in the nai1 foIds and aIso on the face, scaIp or any region, incIuding the mucous membranes. The common wart may be associated with other types of warts and in rare instances may be the starting point of maIignancy. WhiIe chiIdren are most often affected, the disease is aIso seen in young ad&s, Iess often in Iater years.

A variation from the cIassic common warts is known as the digitate wart, which consists of a “group of separated finger- Iike projections arising from a common base” (Pusey). This Iesion differs from the ordinary type in its greater hyper- trophy of the papiIIae.

In treating common warts it should not be forgot’ten that they eventuaIIy disappear SpontaneousIy. They have been known to disappear apparentIy from the menta1 effect of suggestion. At any rate their duration is extremeIy variabIe and capri- cious. It is therefore proper to avoid scarring as far as possibIe in their remova1, especiaIIy as the majority occur on exposed parts of the body. Massive doses of roentgen rays or radium, with cIose screening of the surrounding skin, wiI1 cure a minority of common warts. This method

* Submitted for pubIication February 20, 1929.

418

New SER~B VOL. VI, No. 4 Fox-Warts, MoIes, Corns American Journal of Surgery 419

of treatment, if successfu1, is ideaI, as it is painIess, causes no scarring and affords no opportunity for infection. In a few cases of muItipIe warts on the back of the hands and fingers, I have seen the Iesions disappear rapidIy after a singIe dose of I “skin unit” roentgen rays, appIied without screening the individua1 Iesions. When irradiation faiIs I prefer to use eIectro- desiccation (monopoIar Oudin current). With this method care must be taken to use a smaI1 spark which wiI1 not extend beyond the Iesion to be treated. LocaI anesthesia may be used, especiaIIy for warts affecting the nail foIds, where this method of treatment is decidedIy painfu1. Great care must be used not to overtreat an anes- thetized Iesion and produce unwarranted scars. Caustic’potash is a favorite remedy of some of my coIIeagues, the surrounding skin being protected with Vaseline. I have not been successfu1 with carbon dioxide snow, though freezing by Iiquid air, which is now easiIy obtainabIe, is highIy recommended by Irvine. The Iatter uses this remedy intermittentIy for three minutes with success. SaIicyIic acid has Iong been used for warts, though my experience with this keratoIytic agent has not been very satisfactory. I wouId cer- tainly never recommend nitric acid, on account of its weII-known tendency to produce keIoida1 scars.

2. The $filiJorm wart (verruca fiIiformis) is a thin, ffexible, thread-Iike body which consists of one or of severa hypertrophied papiIIae. This type of wart may be singIe or muItipIe and occurs most frequentIy on the neck and face, often about the eyeIids. It is easiIy removed by a sharp curette, after which the base shouId be cauterized with siIver nitrate stick.

3. The plantar wart (verruca pIantaris) is seen on the bearing surface of the feet (toes, baII of foot and hee1). From a casua1 gIance it resembIes a corn or smaI1 caIIus. CarefuI inspection however shows it to consist of grouped fiIiform hypertrophies with a hard eIevated border. PIantar warts are aIways painfu1, often extremeIy

so, and interfere seriousIy with waIking or dancing. They are singIe or muItipIe and may be associated with other types of verrucae. They are unquestionabIy com- municabIe and often affect a Iarge number of boys or girIs in boarding schooIs. It seems probabIe that they are carried from one to another by waIking barefoot in the gymnasium or swimming ~001.

The best treatment for pIantar waqts in my opinion is by the roentgen rays, this method being successfu1 in the majority of cases. It is my practice to give one exposure

of 3 “skin units” of unfiItered rays, screening the individua1 Iesion with Iead foi1 as cIoseIy as possibIe. With this dosage it is not advisabIe to pare the Iesions previous to irradiation. I have never seen any iI effects from this method, though it is not aIways successfu1 and may have to be repeated once or twice after intervaIs of five or six weeks. When the roentgen rays fai1, the Iesions may be excised or removed by eIectrodesiccation or other destructive methods. The advantages of treatment by the roentgen rays are that there is no pain, no danger of infection and the patient is not compeIIed to remain off his feet for a week as after excision.

4. The flat wart (verruca pIana juve- niIis), as its name wouId impIy, is seen most often in chiIdren, though it aIso occurs in adoIescent girIs and young women and in men upon the bearded region. The Iesions are usuaIIy muItipIe and may be numerous, one or two hundred being present at times. Fiat warts are of pinhead size with smooth or sIightIy scaIy surface and round or poIygona1 base. They are mostIy discrete but may coaIesce to form smaI1 patches. The coIor is that of normaI skin or sIightIy yeIIowish. Fiat warts are often unrecog- nized as such and may be mistaken for Iichen pIanus, though this disease is rareIy seen on the face. These Iesions, Iike other types of warts, are capricious in their course but aIways disappear spontane- ousIy, after months or at times years. They cause no subjective symptoms and may be associated with other warts. Their

420 American Journal of Surgery Fox-Warts, MoIes, Corns

cause is unknown, though it is probabIy an infectious agent.

In the treatment of ffat warts, it is

FIG. I. Acuminate warts (condylomata acuminata). They may be SatisfactoriIy treated by electric cautery under IocaI anesthesia.

aIways advisabIe to try interna adminis- tration of protiodide of mercury, originaIIy suggested by C. J. White. This resuIts in a cure of the majority of cases, at Ieast in chiIdren, though in my experience it has not been successfu1 in men. The drug is used in doses of $6 to $i grain, after meaIs. The lesions may be easily removed by a sharp curette, a method which I aIways use’for the bearded region in men but hesi- tate to use in chiIdren. The roentgen rays are not successfu1 in this type of verruca.

5. The acuminate wart, or so-caIIed “ venerea1 wart” (verruca acuminata), is aIso known as pointed condyIoma in con- tradistinction to broad condyIoma of syphiIis. It consists of fiIiform excrescences which often coaIesce and form Iarge cauIi- ff ower-Iike growths which are more or

Iess tufted and are constricted at the base. They occur on the suIcus or corona of the penis, or on any part of the vuIva and may invoIve Iarge areas incIuding the anus, perineum, intergIutea1 foId and thighs. There is often a fouI-smeIIing discharge and some soreness on motion.

Acuminate warts are auto-inocuIabIe and extremeIy persistent if not treated. They occur where there is heat, moisture and irritating discharge and are seen chieffy in uncIeanIy persons. They were formerly thought to be due to gonorrhea1 infection. They are probabIy due to the action of various organisms though the cause is unknown. Their differentiation from broad condyIoma of syphilis may sometimes be diffIcuIt. Acuminate warts are pointed with Iong Niform projections, whereas the condyIomata of syphiIis are flatter and arise from ffat papuIes.

For the treatment of smaI1 acuminate warts, either the cautery or eIectrodesicca- tion is satisfactory. Large Iesions are best removed by excision under genera1 anes- thesia. At times the Iesions shrink and disappear under various appIications such as permanganate of potash (I :2000) or Iactic acid, 0.5 per cent. LocaI appIications are, however, rather unsatisfactory.

6. The senile wart (verruca seniIis), often caIIed seborrheic wart, is a ffat, scaIy or warty non-pruritic Iesion of varying size occurring especiaIIy on the scaIp, face, trunk and back of the hands. The Iesions are often muItipIe and may be extremeIy numerous, especiaIIy on the neck, back and chest. The color is some shade of yeIIowish brown. SeniIe warts occur in middIe and oId age and are com- parativeIy harmIess. OccasionaIIy they may be the starting point of maIignancy though Iess often than are ffat senile kera- toses of the face.

SeniIe warts are most easiIy removed by a sharp curette foIIowed by the appIication of siIver nitrate stick. They may aIso be satisfactorily treated by the roentgen rays, radium, eIectrodesiccation or other destruc- tive methods.

NEW SERIES VOL. VI, No. 4 Fox-Warts, MoIes, Corns American Journal of Surgery 421

MOLES

The term mole is somewhat indefinite but usuaIIy refers to a smaI1 pigmented

sIightIy raised or may form a circum- scribed and partIy peduncuIated eIevation. The coIor usuaIIy varies from a Iight

FIG. 2. Pigmented moIes. Large lesion suitable for treat- ment by cautery, eIectroIysis or eIectrodesiccation. SmaIIer Iesions best treated by cautery.

nevus which may or may not be hairy. It aIso includes circumscribed, soft or firm elevations, which are not hyperpigmented. My conception of moIes wouId not incIude any type of vascuIar nevus. WhiIe a moIe is known as a birthmark it is not present at birth in the majority of cases and may not appear unti1 aduIt Iife. MoIes vary greatIy in size, shape and number and may be singIe or muItipIe. They may be IocaIized or may cover large areas of the body. Like other types of birthmark they may be uniIatera1 and at times Iinear. The Iatter type, known as nevus Iinearis, is a papiIIomatous and verrucous Iesion, at times covering Iarge areas of the body. It is not suitabIe to incIude it in this discussion.

The pigmented moIe may be flat,

FIG. 3. Pigmented and hairy moIe, not suitabIe for treatment on account of large extent.

yeIIowish-brown to a deep brownish bIack. The surface may be smooth or covered by a varying thickness of hair. The combination of pigment and hair is seen chieffy in the extensive Iesions and may cover as much as two thirds of the body, as in the so caIIed “bathing trunk nevus.”

The usua1 course of moIes is to become stationary after attaining a certain size and to remain without change throughout life. They rareIy cause subjective symp- toms and as a ruIe constitute mereIy a cosmetic defect.

I do not beIieve that moIes in genera1 are a great source of danger and they shouId not be removed in a whoIesaIe manner to avoid the possibiIity of Iater maIignancy. There are two exceptions to this ruIe: When a pigmented nevus is in a situation where it is exposed to constant trauma, as on the bearded region in men, it shouId be removed. The same appIies to a pig-

422 American Journal of Surgery Fox-Warts,

mented moIe which is definitely increasing in size. In genera1 the darkIy pigmented moles, especiaIIy when covered by hair, may be safeIy aIIowed to remain. There is a type which shouId be radicaIIy destroyed or at Ieast kept under carefu1 observation. This is the bIuish or sIate coIored, smooth moIe which is not appreci- abIy eIevatid. Such a Iesion, if irritated by constant trauma or by improper treat- ment, may be the source of nevocarcinoma, one of the most rapidIy fata types of maIignancy.

For the treatment of ffat pigmented moIes, it is proper to use eIectroIysis, eIectrodesiccation, the actua1 cautery or carbon dioxide snow, with or without IocaI anesthesia. For very smaI1 pigmented nevi I have found the cryocautery of Lortat- Jacob convenient. This apparatus has various sized appIicators by which the refrigeration can be confined to the desired area, whereas with a crayon of carbon dioxide snow, pressure is IikeIy to aIIow the snow to spread beyond the border of the Iesion. In smaI1 pigmented and hairy moIes, it is advisabIe to remove the hairs first by eIectroIysis, before using one of the above-mentioned destructive methods. Large hairy moIes are best treated by refrigeration or eIectrodesiccation. For the ordinary circumscribed eIevated moIes, whether pigmented or non-pigmented, I aImost invariabIy use the eIectric cautery, being carefu1 not to cause enough destruc- tion to resuIt in a depressed scar.

MoIes, Corns APRIL, 1929

CORNS

A corn (clavus) is the famiIiar cir- cumscribed lesion occurring usuaIIy on the outer aspect of the IittIe toe, Iess often on the back of the second toe. It is a keratotic thickening, roughIy conica in shape with the base Iooking outward and the apex extending inward and pressing on the nerves of the cutis. Corns are invariabIy painfu1 and may become inflamed and even uIcerate. There are two types, hard and soft. The former has been described. The Iatter is usuaIIy situated between the toes and is soft from maceration due to heat and moisture. In association with corns, there may be a bursitis beneath or nearby, popuIarIy known as bunion.

The treatment of an ordinary hard corn is unsatisfactory, as after remova it recurs when pressure is again appIied. A time honored remedy is saIicyIic acid in coI- Iodion or ointment. The best treatment is prophyIactic and consists in wearing properIy fitting shoes and hosiery. PaI- Iiative treatment consists of soaking in hot water and soap, after which the Iesion is pared and covered with adhesive strips or a protective ring-shaped pad. Soft corns may disappear when they are kept cIean and dry. They shouId be washed frequentIy with aIcoho1 and kept as dry as possibIe by dusting powder, such as taIcum. If this procedure is not successfu1 they may be destroyed by the cautery or by eIectrodesiccation.