Filiform Wart

Filiform warts are slender, finger like projections of keratinised skin caused by human papillomavirus types 1, 2, 4 and 7. They favour the face, especially the eyelids, lips, nose and neck, and grow outward with a narrow base.

• Common in adults and children; spread by shaving and autoinoculation.
• Lesions near the eye can cause chronic conjunctivitis or keratitis through viral shedding.

Thread like skin coloured projections 2 to 10 mm long, single or multiple, usually on the face, eyelid margin, lips, neck or beard area.

• Usually painless; may snag on clothing or bleed on shaving.
• Differential diagnosis: skin tag, cutaneous horn, seborrhoeic keratosis, molluscum contagiosum, squamous cell carcinoma, verruca vulgaris, trichofolliculoma, sebaceous hyperplasia.
• Complications: bleeding, secondary infection, eyelid conjunctivitis or keratitis, spread to new sites, recurrence, scarring or pigment change after treatment.

Clinical.

• Biopsy for cutaneous horn, persistent, ulcerated or rapidly growing lesions, and in the immunosuppressed.
• Eyelid lesions: slit lamp examination for conjunctival or corneal involvement.
• HIV test in extensive or resistant lesions.

Treat if bothersome or cosmetically distressing, or when at the eyelid.

• Supportive: avoid picking and shaving over lesions, keep the area clean, do not share razors.
• Pharmacological: salicylic acid 17 percent or low strength preparations applied with care on facial skin (avoid the eye); imiquimod 5 percent cream three times weekly for up to 8 to 16 weeks; fluorouracil 5 percent cream twice daily for resistant lesions on the face with care; intralesional Candida antigen 0.1 mL for multiple lesions.
• Procedures: snip or shave excision with local anaesthesia under 1 percent lidocaine, curettage with electrodessication, brief cryotherapy 5 to 10 seconds (most effective), laser ablation. Eyelid lesions: refer to ophthalmology or oculoplastic specialist.
• Special groups: pregnancy, use procedures and avoid fluorouracil and imiquimod; children, simple excision or cryotherapy with topical anaesthetic; HIV, optimise antiretroviral therapy and treat all lesions; darker skin, light cryotherapy to avoid hypopigmentation.
• Red flags: eyelid margin lesion with red eye, bleeding, ulceration, rapid growth, pigment, hard base, non response after 3 treatments.
• Follow-up: review at 4 weeks and 3 months; biopsy persistent or atypical lesions.