Dermatology MCQ - Inflammatory Dermatoses - Murray Williams warts

A 12-year-old boy presents with multiple, small, 1-2 mm, flat-topped, skin-colored papules that are densely grouped into a single, well-defined plaque on his chin. The lesions have a slightly verrucous surface under close examination. What is the most specific morphological term for this presentation of verruca vulgaris?

A. Filiform Warts
B. Mosaic Warts
C. Digitate Warts
D. Murray Williams Warts
E. Plane Warts

Correct Answer: D. Murray Williams Warts

Explanation:

• The presentation is characteristic of Murray Williams Warts. This term describes a specific, localized cluster of numerous, densely packed, small, flat-topped or minimally elevated warts that coalesce into a single, circumscribed plaque. They are a morphological variant of common warts (verruca vulgaris) caused by human papillomavirus (HPV). The description of a dense cluster on the face (chin) forming a plaque is the key identifier.

• Why the other options are incorrect:

  • A. Filiform Warts: These present as single, long, narrow, finger-like projections, commonly on the face, neck, and eyelids. They are not clustered into a plaque.

  • B. Mosaic Warts: These are plaques formed by the coalescence of many small, tightly packed warts, but they are typically found on the palms and soles. The location on the chin makes this diagnosis less likely than Murray Williams warts.

  • C. Digitate Warts: These are similar to filiform warts, characterized by multiple, finger-like, horny projections arising from a common base.

  • E. Plane Warts (Flat Warts): These are caused by HPV types 3 and 10 and present as slightly elevated, flat-topped, smooth papules. They are usually multiple and disseminated, but they do not typically coalesce into a single, dense, verrucous plaque in the way that Murray Williams warts do.

Key Points for Exams

• Definition: A specific clinical pattern of verruca vulgaris, not a pathologically distinct entity.

• Clinical Features:

  • Location: Most commonly on the face (especially around the mouth and chin) and the dorsal hands.

  • Morphology: A solitary, well-defined plaque composed of innumerable tiny, aggregated warts. The surface has a characteristic "cobblestone" or "verrucous" appearance.

• Prognosis: Like other common warts, they can be persistent but are benign. Spontaneous resolution is possible but may take months to years.

• Management: Treatment can be challenging due to the dense cluster and location on the face, where scarring is a concern.

  1. First-line: Topical Salicylic Acid can be attempted but may be difficult to confine to the plaque.

  2. Other Topical Agents: Imiquimod or 5-Fluorouracil can be used as immunomodulatory and antiproliferative options.

  3. Physical Destruction: Cryotherapy is effective but must be performed carefully to avoid hypopigmentation or scarring. Curettage or light electrodesiccation under local anesthesia are other options.

  4. Important Consideration: The goal is to treat the entire plaque as a single unit rather than targeting individual warts within it.