A Case of Condyloma Acuminatum on the Nipple Detected via Dermoscopy

Abstract

Introduction Condyloma acuminatum (CA), also known as genital warts, is an anogenital warty growth caused by some types of the human papilloma virus (HPV). CA is usually found within the anal or genital area, but it occasionally presents in the oral, respiratory, conjunctival, nasal, or nipple region. We herein report a rare case of a 29-year-old Chinese woman with a tiny CA on her nipple, which was diagnosed through dermoscopy. With noninvasion and convenience, dermoscopy is valuable for the early diagnosis of tiny CA that is unable to be discerned by the naked eye. Case report A 29-year-old Chinese woman presented with a one-week history of a pink papule affecting her right nipple. The lesion was asymptomatic. Just two months ago, she had been diagnosed with CA caused by HPV-6 and HPV-18 and treated with carbon dioxide (CO2) laser in Chengdu Second People's Hospital. Physical examination revealed a pink papule with a size of millet at the center of her right nipple (Fig. 1A). Dermoscopy showed fingerlike patterns with hairpin and dotted vessels within the papillae (Fig. 1B). The acetowhitening test was positive, and real-time polymerase chain reaction (PCR) amplification positively detected HPV-18 sequences. In addition, a test for antihuman immunodeficiency virus antibody (HIV-Ab), the Treponema pallidum particle agglutination assay, and the tolulized red unheated serum test all produced negative results.Figure 1: Clinical and dermoscopic features of the lesion. (A) A pink papule with a size of millet at the center of the right nipple. (B) Dermoscopy shows fingerlike patterns with hairpin or dotted vessels within the papillae (×50).Based on these findings, we diagnosed this patient with CA on the nipple and started treatment with liquid nitrogen cryotherapy and topical 5% imiquimod cream. There has been no recurrence in the ensuing three months. Discussion CA is a sexually transmitted infection caused by certain types of HPV, most commonly HPV-6 and HPV-11. Suzanne et al.1 used PCR to assess the lesions of 472 patients with CA and detected a total of 14 HPV genotypes (6, 11, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59), of which HPV-6 and HPV-11 were the dominant types (94.7%) followed by HPV-16 and HPV-18. HPV-16 and HPV-18 accounted for 50% of the 22 CA patients, who were positive for a high-risk HPV genotype. Although CA usually occurs in the anal or genital area, it occasionally presents in the oral, respiratory, conjunctival, nasal, or nipple region. The anogenital HPV infection is almost acquired through sexual contact. The lesions are characterized by localized single or multiple papules without any symptoms in the early stage, which gradually develop into papillary, cristate, cauliflower-like, or crumby neoplasms. To date, a few cases of CA on the nipple have been reported. Wood2 reported the first case of CA on the nipple in 1978. Later, Kulke et al.3 cloned HPV-6 subtype from a CA located on the nipple, and Kowalzick et al.4 described a case of CA on the nipple associated with HPV-41. In 2014, Saeki et al.5 reported a case of CA on the nipple and areola that resembled seborrheic keratosis. This patient visited our clinic again for a new tiny papule on her nipple. If she had not been previously diagnosed with genital CA, we might have easily ignored such a tiny lesion. Then, dermoscopy showed typical wart manifestations, and HPV-18 sequences were positively detected by real-time PCR. However, there have been no reports of the correlation between HPV-18 and verruca vulgaris. In view of her history of CA caused by both HPV-6 and HPV-18, our patient was diagnosed with CA on the nipple. In most cases, clinicians familiar with the clinical manifestations of CA can easily make a diagnosis only based upon a physical examination. However, examination with a dermoscopy is helpful for diagnosing CA when the lesions are particularly small or atypical.6-7 The specific dermoscopic findings of CA include morphologic patterns (fingerlike, knoblike, mosaic-like) and multiple vascular features (glomerular/dotted, hairpin).6 As a noninvasive and convenient examination method, dermoscopy is valuable for the early diagnosis of tiny CA that is unable to be discerned by the naked eye.