Usefulness of dermoscopy in anogenital warts: A descriptive study of 30 cases

Abstract

Dermoscopy applications are expanding beyond skin tumours to include various other cutaneous disorders, such as inflammatory and infectious dermatoses. Anogenital warts (AGW) are the most common sexually transmitted infection.¹ Our objective is to describe the dermoscopic characteristics of AGW.

We conducted a monocentric prospective study in the dermatology department of Farhat Hached Hospital in Sousse, Tunisia, from 1 January to 31 August 2023. All clinically diagnosed cases of AGW were included. Each patient underwent a clinical examination, a dermoscopy and a biopsy.

Thirty patients were included in the study, with a mean age of 34.24 years (ranging from 3 to 63 years). The male-to-female ratio was 3.28:1. Among the males, 52.17% of warts were located in the penile area and 43.47% in the perianal area. For females, all warts were located in the vulvar area. The papular warts represented 53.33% of the described lesions, condyloma acuminata 40% and Buschke−Lowenstein tumours were observed in two patients (6.66%). The dermoscopic pattern was mosaic-like (Figure 1a). In 53.33% of cases, corresponding clinically to the papular warts. A finger-like pattern (Figure 1b) was seen in 13.33% of cases, a cerebriform pattern in 13.33% of cases and a knob-like pattern (Figure 1c) in 10% of cases. In two female patients aged 18 and 55, the dermoscopy revealed finger-like structures but with separated bases and clinicopathological correlation concluded to vestibular papillomatosis. In a male patient with HIV, dermoscopy showed a cerebriform pattern (Figure 1d) in all warts, and in one wart, it revealed a whitish structureless area, a yellowish keratin area and polymorphous vessels. Malignancy was suspected, and a biopsy guided by dermoscopy confirmed invasive well-differentiated squamous cell carcinoma (SCC). All patients underwent biopsies confirming the diagnosis excepting two female patients with vestibular papillomatosis. However, HPV typing was performed for only five patients due to limited availability. It showed low-risk HPV 6 and 11 in three male patients and negative for two other patients.

AGW are a major risk factor for multiple malignancies, including cancers of the cervix, vagina, vulva, oropharynx, anus, penis and skin.² AGW are mostly diagnosed with the naked eye, but early-stage diagnosis can be challenging.³ Three principal dermoscopic patterns have been described, though none is specific. Consistent with our findings, the mosaic pattern is the most common. It resembles common warts, with a whitish network surrounding central dotted or glomerular vessels.⁴ This pattern is associated with papular warts and can coexist with other patterns.

The finger-like and knob-like patterns are more commonly reported with exophytic condyloma acuminata. They are characterized by whitish, finger-like or knob-like papillae with varying heights and fusion at their bases. Inside the papillae, elongated and dilated vessels are more prominent at the periphery, caused by nitric oxide produced by HPV.⁵

The cerebriform pattern is reported in pigmented keratotic lesions and mimics seborrhoeic keratosis.⁶ The association of two patterns, most commonly finger-like and knob-like structures, has been reported.⁷ Dermoscopy is also useful in differentiating (AGW) from vestibular papillomatosis and pearly penile papules, which show more irregular projections with tapering ends and separated bases.⁸ Other differential diagnoses include Fordyce's spots, molluscum contagiosum, lymphangiomas and angiokeratomas, which are easily identifiable with dermoscopy. The dermoscopy of invasive SCC reveals keratin and vascular features. Keratin appears as white-to-yellow structureless areas, white circles and white clods. As seen in our patient, dermoscopy is invaluable for detecting malignant transformation and guiding the biopsy.⁹

In conclusion, dermoscopy is crucial for AGW, aiding both in differential diagnosis and the early detection of SCC, particularly in immunocompromised patients.

Marouane Ben Kahla: Conceptualization; writing—original draft. Lina Bessaad: Investigation; resources. Nadia Ghariani Fetoui: Supervision; review and editing. Maha Lahouel: Investigation; resources. Sarra Saad: Investigation; resources. Mohamed Ben Rjab: Investigation; resources. Jacem Rouatbi: Investigation; resources. Haifa Mkhinini: Investigation; resources. Zeineb Nfikha: Investigation; resources. Dorra Chiba: Investigation; resources. Cyrine Chelli: Investigation; resources. Oumayma Ben Rejeb: Investigation, writing review. Najet Ghriani: Investigation; resources. Badreddine Sriha: Investigation; resources. Nadia Ben Lasfar: Investigation; resources. Sana Mokni: Review. Amina Aounallah: Review. Mohamed Denguezli: Supervision; validation; writing—review and editing.

The authors declare no conflict of interest.

All patients in this manuscript have given written informed consent for participation in the study and the use of their deidentified, anonymized, aggregated data and their case details (including photographs) for publication. Ethical Approval: not applicable.