How would you treat his slightly tender lesion?

A 68-year-old male presented with a 10-year history of a lesion on his palm that had failed cryosurgery. There is no history of bleeding and only slightly tender when he bumps it. The solitary lesion appears to be around 1.5 cm with a keratotic rim and some hyperkeratosis within the lesion and at the external border.

How would you diagnose the lesion?

A. Actinic keratoses

B. Wart

C. Disseminated superficial actinic porokeratoses

D. Bowen’s disease or squamous cell carcinoma in situ

E. Lichen keratosis

Answer: Wart

Biopsy confirmed the diagnosis of a wart. Actinic keratoses would not be expected on the palm in the absence of significant UV exposure, such as hand photochemoterhapy. A giant disseminated superficial actinic porokeratosis is a reasonable thought, but should present on sun-exposed surface. Bowen’s disease could arise from human papillomavirus conversion and is not unreasonable. Lichenoid keratoses does not present in this fashion and also should appear on sun-exposed surfaces. 

These pesky lesions are as difficult to treat as plantar warts, but with patient and persistence, it can be accomplished.