Oral cavity & oropharynx

Benign epithelial tumors & processes

Verruca vulgaris


Editorial Board Member: Lisa Rooper, M.D.
Deputy Editor-in-Chief: Kelly Magliocca, D.D.S., M.P.H.
Molly Housley Smith, D.M.D.

Last author update: 2 June 2023
Last staff update: 2 June 2023

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PubMed Search: Verruca vulgaris oral

Molly Housley Smith, D.M.D.
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Cite this page: Smith MH. Verruca vulgaris. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/oralcavityverrucavulgaris.html. Accessed March 29th, 2024.
Definition / general
  • Benign epithelial proliferation of squamous mucosa
  • Associated with human papilloma virus (HPV) types 2 and 4
Essential features
  • Associated with low risk strains of HPV
  • Mostly found on the skin but uncommonly may be seen in the oral cavity
  • Similar to cutaneous lesions both histopathologically and microscopically (Dent Clin North Am 2014;58:385)
  • Histopathological features include exophytic epithelial growth with prominent hyperkeratosis, inward cupping of the rete pegs, koilocytes and hypergranulosis within the superficial epithelial aspects
Terminology
  • Oral wart
  • Common wart
ICD coding
  • ICD-10:
    • D10.0 - benign neoplasm of lip
    • D10.1 - benign neoplasm of tongue
    • D10.2 - benign neoplasm of floor of mouth
    • D10.30 - benign neoplasm of unspecified part of mouth
    • D10.39 - benign neoplasm of other parts of mouth
    • D10.4 - benign neoplasm of tonsil
    • D10.5 - benign neoplasm of other parts of oropharynx
Epidemiology
Sites
  • Lips, palate, anterior tongue most common but can affect any intraoral location
  • 50% affect the hard palate in Venezuelan population (J Oral Pathol Med 1993;22:113)
Pathophysiology
  • HPV is thought to gain access to epithelial cells via microabrasion or trauma (Head Neck Pathol 2019;13:80, Rev Med Virol 2015;25:2)
  • Virus infects the basilar epithelial stem cells via endocytosis
  • Cell division occurs during wound / trauma repair, populating the basal cell layer with transiently amplifying cells with HPV genomes
  • There is slow division of the infected basal stem cells with little or no viral gene expression within the basal layer (Rev Med Virol 2015;25:2)
  • Transformation of verruca vulgaris to HPV related squamous cell carcinoma is not possible since low risk HPV strains lack oncogenic properties (Rev Med Virol 2015;25:2)
Etiology
Clinical features
Diagnosis
  • Histopathologic examination of excisional specimen
  • Presence of HPV has been detected via immunohistochemical staining, electron microscopy, in situ hybridization and polymerase chain reaction studies; however, these studies are unnecessary for diagnosis (J Oral Pathol Med 1993;22:113)
Prognostic factors
Case reports
Treatment
Clinical images

Contributed by Molly Housley Smith, D.M.D. and Michael Piepgrass, D.M.D., M.S.
Well circumscribed papillary lesion

Well circumscribed papillary lesion

Prominent keratin horn

Prominent keratin horn

Gross description
  • White, exophytic, papillary growth
Microscopic (histologic) description
  • Similar to cutaneous counterpart (Head Neck Pathol 2019;13:80)
  • Prominent surface keratinization (often orthokeratin with superficial parakeratin tufts)
  • Inward cupping of the rete pegs
  • Exophytic / papillary fronds which form church spire-like peaks
  • Hypergranulosis with coarse keratohyalin granules and potential eosinophilic intranuclear viral inclusions within the granular cell layer
  • Koilocytosis within the superficial epithelial layers
Microscopic (histologic) images

Contributed by Molly Housley Smith, D.M.D.
Prominent cupping of rete pegs

Prominent cupping of rete pegs

Hypergranulosis and koilocytosis

Hypergranulosis and koilocytosis

Hyperorthokeratosis

Hyperorthokeratosis

Hypergranulosis

Hypergranulosis

Eosinophilic viral inclusions

Eosinophilic viral inclusions

Videos

Verruca vulgaris versus seborrheic keratosis pathology

Sample pathology report
  • Hard palate, excisional biopsy:
    • Verruca vulgaris (see comment)
    • Comment: Microscopic examination reveals a well defined proliferation of keratinized stratified squamous epithelium forming papillary projections above the surrounding mucosa. The epithelium is covered by a dense and thickened layer of orthokeratin. Prominent granular cells and koilocytes are noted. Cytologic atypia is not appreciated.
Differential diagnosis
  • Oral squamous papilloma:
    • Clinically identical to verruca vulgaris
    • HPV types 6, 11
    • Lack the prominent hypergranulosis and koilocytosis in the superficial epithelial layers
    • Variable keratinization (Head Neck Pathol 2019;13:80)
  • Condyloma acuminatum:
    • HPV types 6, 11, 16, 18
    • Labial mucosa, soft palate, lingual frenum
    • Often demonstrates a fleshy, broad based clinical appearance
    • Bulbous rete pegs and blunted papillary projections
  • Multifocal epithelial hyperplasia (Heck disease):
    • HPV types 13, 32
    • Multiple / generalized, often coalescing, sessile lesions (Head Neck Pathol 2019;13:80)
    • Exhibits mitosoid bodies
    • Higher frequency in Inuit and Indian populations of North, Central and South America, Greenland and North Canada, as well as in descendants of Khoisan in South Africa (J Oral Pathol Med 2013;42:435)
    • Living in crowded, unhygienic environmental conditions is a risk factor (Dent Clin North Am 2014;58:385)
  • Verruciform xanthoma:
    • Similar clinically, although may have a yellow hue
    • Demonstrates foamy xanthoma cells within papillary projections
    • More likely to occur on gingiva (Head Neck Pathol 2019;13:80)
    • Inward cupping of the rete pegs is not apparent
  • Proliferative verrucous leukoplakia:
    • May be confused with verruca vulgaris on small, incisional biopsies
    • Patients with verrucous leukoplakia often demonstrate multiple, flattened or slightly raised, well demarcated white plaques
    • Often affects marginal gingiva
    • Also demonstrates prominent granular cell layer and church spire keratin peaks
    • Inward cupping of the rete pegs is not apparent
  • Verrucous carcinoma:
    • Not associated with HPV
    • Rete ridges show downward, pushing growth
    • Inward cupping of the rete pegs is not apparent
Board review style question #1


The lesion shown above is found on the tongue. What is the diagnosis?

  1. Condyloma acuminatum
  2. Squamous papilloma
  3. Verruca vulgaris
  4. Verrucous carcinoma
Board review style answer #1
C. Verruca vulgaris. The microscopic images show a well circumscribed, papillary epithelial proliferation with inward cupping of the rete ridges, prominent koilocytosis and prominent keratohyaline granules, which are all features of verruca vulgaris. Answers A and B are incorrect because condyloma acuminatum and squamous papilloma both lack prominent hypergranulosis while condyloma acuminatum exhibits broad, blunted papillary projections rather than the thin, hyperkeratotic projections seen above. Answer D is incorrect because verrucous carcinoma demonstrates broad, pushing rete ridges and lacks circumscription.

Comment Here

Reference: Verruca vulgaris
Board review style question #2

A patient presents with a white lesion on the hard palate. Microscopic examination shows a well defined proliferation of stratified squamous epithelium forming exophytic papillary fronds. The epithelium is covered by a thickened layer of dense orthokeratin, which forms church spires and hypergranulosis and koilocytosis are appreciated. The rete ridges demonstrate prominent inward cupping. What is the diagnosis?

  1. Condyloma acuminatum
  2. Proliferative verrucous leukoplakia
  3. Verruca vulgaris
  4. Verrucous carcinoma
Board review style answer #2
C. Verruca vulgaris. Verruca vulgaris is characterized by a papillary epithelial proliferation with hypergranulosis, inward cupping of the rete ridges and koilocytosis, as described in the question. Answer A is incorrect because condyloma acuminata are not bright white clinically and lack prominent hypergranulosis. Answer B is incorrect because proliferative verrucous leukoplakia may look very similar to verruca vulgaris on small biopsies but proliferative verrucous leukoplakia is not well circumscribed clinically and not isolated. Additionally, proliferative verrucous leukoplakia does not show circumscription and inward cupping of the rete ridges histopathologically. Answer D is incorrect because verrucous carcinoma is traditionally larger clinically and demonstrates a pushing pattern of invasion without circumscription.

Comment Here

Reference: Verruca vulgaris
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