The correct answer is D: Destructive debulking followed by topical antiviral therapy
The lesions depicted are plantar warts, with one of them atypically large. The verrucous surface and black dots (which represent thrombosed small-caliber blood vessels) render the clinical diagnosis relatively easy.
Before topical treatment
After topical treatment
Aside from occasional reports of warts associated with lymphoma (in particular, Hodgkin disease and intestinal B-cell lymphoma), there is little epidemiologic data on the prevalence, severity, or treatment of warts arising in association with cancer.[1] This is most likely related to the disparity in at-risk demographic groups: warts are largely a disease of the young, and cancer is more common among the elderly.
Nonetheless, the author has noted many instances of severe, recalcitrant warts occurring in cancer patients, perhaps as a result of either the debilitating nature of the underlying disease state or the iatrogenic immunosuppression intrinsic to chemotherapy.
Even in the normal, immunocompetent host, no single topical or systemic therapy has demonstrated uniform superiority.[2,3] However, in the immunocompromised cancer patient, it would seem intuitive that treatments whose effect is based on immune response (eg, topical imiquimod(Drug information on imiquimod), intralesional injection of candida antigen, oral cimetidine(Drug information on cimetidine)) are less likely to be successful than either tissue destructive treatments (eg, CO2 laser ablation, cryosurgery, electrodesiccation, topical salicylic acid(Drug information on salicylic acid)) or directly anti-viral interventions (eg, topical, intralesional, or systemic cidofovir(Drug information on cidofovir); topical 5-fluorouracil; intralesional bleomycin(Drug information on bleomycin)).
In this particular case, the warts had already failed many standard therapies (such as cryosurgery and topical salicylic acid). Debulking was done using a CO2 laser. Nightly applications of 5% 5-fluorouracil cream (under occlusion) were started one week later, and in one month, clinical clearance was achieved (see illustration).
Obviously, amputation would be rather extreme, as would proton-beam surgery for a benign, albeit annoying condition. While some claim that application of honey may lead to wart resolution, there is scant, reliable and reproducible scientific evidence to this effect.
References
1. Bouhnik Y, Etienney I, Nemeth J, et al. Very late onset small intestinal B-cell lymphoma associated with primary intestinal lymphangiectasia and diffuse cutaneous warts. Gut. 2000;47:296–300.
2. Simonart T, Maertelaer VD. Systemic treatments fir cutaneous warts: A systematic review. J Dermatolog Treat. 2010;Nov 6 [Epub ahead of print].
3. Kwok CS, Holland R, Gibbs S. Efficacy of topical treatments for cutaneous warts: A meta-analysis and pooled analysis of randomized controlled trials. Br J Dermatol. 2011;Jan 11. [Epub ahead of print].
