[Question #4554] Wart or ?

28 months ago
I'm a 50 year old male with no history of HPV. I shave my genitals frequently and 7 out of 10 times get "normal" folliculitis (red bumps,  whiteheads) which do not  concern me.  But...

Two months ago, I shaved and as usual had a few bumps afterward (appearing within 2-3 days, as usual). One of them has remained. About 1 mm, initially reddish/inflamed but now flesh colored. It has 1 one but 2 hairs that come out, 1 more or less in the middle, 1 somewhat to the side but still within the raised bump.  (I have since shaved twice, each time with 2 hair follicles eventually coming out.) I've read docs saying warts don't grow hair, but I had done the vinegar test and it clearly turned white, so I decided to get it checked, even though I know vinegar isn't a clear diagnostic., and anyway I don't like the appearance. Went to ZoomCare and seen by an MD Derm. He thought it was a wart despite the clearly visible hair - said that was a "coincidence". (Only 1 of the 2 had fully sprouted at the time.) He wanted to do cryo right there, but said biopsy was also an option if I wanted to be sure.  Chose biopsy, which isn't until next week.  

Did I do the right thing by requesting a biopsy in this case?  When I get the biopsy, is there anything special to request (like PCR vs regular)? I have diagnosed OCD, pretty bad, with health-related concerns and didn't want an HPV Dx if that's not what it is, and I'm suspicious because of the timing (shaving), the presence of the hair that grows back, etc.  If photos help, I can link those somehow if that's allowed.
28 months ago
I forgot to mention the location.  This is on my scrotum, which is where I always tend to get the folliculitis.

And I see I made a typo in my original post, but you probably figured it out.  I meant to say "It has not 1 but 2 hairs that come out..."

Thanks.
Edward W. Hook M.D.
Edward W. Hook M.D.
28 months ago
Welcome to the Forum. I'll be glad to comment nd hope that you will find my comments helpful.  The lesion you describe certainly sounds far more likely to be folliculitis or a cyst (benign cysts also commonly occur on the scrotum) rather than a wart. As you point out, the presence of a hair, as well as the fact that you have had similar lesions before all make it more likely than not that this is folliculitis.  I would discount the vinegar test which is VERY often misleading and certainly is not diagnostic of HPV to the exclusion of other lesions.  

I also appreciate your acknowledgement of your OCD which helps me to understand why you even care that it might be a wart.  As you no doubt know, we consider warts to be a cosmetic nuisance more than anything else.  Thus if I noted such a lesion, I would do nothing.  The decision to have it biopsied is, of course, yours but I would suggest you consider what you will do with the result if it is positive.  

Whatever the lesion is, cryo would have probably made it go away.  OTOH, it is really important to find out if it is HPV, a biopsy is the right test.  Typically microscopic examination of the biopsy is sufficient to distinguish warts from other sorts of skin lesions.  If it is a wart, there are specific tests that the pathologist can do to tell you what sort of HPV is causing it.  

I hope my comments are helpful to you.  EWH
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28 months ago
Thanks for your supportive reply, Dr. Hook.

I realized that some of the references I had found reassuring because they said warts do not have hair were in fact yours and Dr. HHH's from another site (e.g., https://www.medhelp.org/posts/STDs/hair-on-gential-wart/show/738618 and https://www.medhelp.org/posts/STDs/Are-these-Genital-Warts/show/245149 and others).  

Given you both are  unequivocal about the hair situation, is it even possible that a biopsy would say my situation was HPV, given there are 2 hair follicles coming out of this bump? If a biopsy did say it was HPV, what could that even mean? Would the biopsy be a false positive? Could a cyst or whatever be confused with a wart by a lab? 

Given that the dermatologist only _visually_ diagnosed this as a wart, I almost feel obligated to do the biopsy now, if for no other reason than to correct the diagnosis that is now on my chart which gives me concerns about how to tell a partner (despite everyone's likelihood of HPV exposure anyway - it's still more of an issue now, it feels).  But like you asked, I don't know how I could even interpret a positive biopsy result. It's confusing to a lay person given the many references saying this can't be a wart because of the two hairs clearly in the bump, but a doctor who looked at it said he didn't care about the hair, he thinks it's a wart.  What a struggle.

Thanks again.

PS: Did you mean to say "OTOH, _if_ it is really important to find out..." rather than 
"OTOH, it is really important to find out if it is HPV, a biopsy is the right test."?  I interpreted it as the former, given the context.
Edward W. Hook M.D.
Edward W. Hook M.D.
28 months ago
Your follow-up questions suggest that your OCD is taking over your line of thought.  Questions such as "is it even possible that a biopsy would say my situation was HPV, given there are 2 hair follicles coming out of this bump?" are just not productive.  In science and medicine you can never say never.  That said, it would be most unusual for a wart to have hairs growing out it.  

I suggest you save your "what if" questions until after your biopsy although I must say, I am still not sure why you feel out if the lesion you've noted is a wart of not. HPV is just not that big a deal.  Most unvaccinated adults have it and are non the worse for it.

With regard to your P.S.  my earlier statement should have read- "OTOH, if is really important to find out if it is HPV, a biopsy is the right test.  Typically microscopic examination of the biopsy is sufficient to distinguish warts from other sorts of skin lesions....."

If you have further specific questions, you have a single opportunity for further follow-up questions.  EWH
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28 months ago
Thanks, Doctor.   No further questions now, just thought I'd follow-up and let you know what I decided. 

Rather than get a biopsy on what was possibly a wart,  I went to a different dermatologist who said a biopsy wasn't really necessary and who just did cryo on the bump five days ago.  Given the history (i.e., how it came on right after shaving (typical for me), but didn't go away (not typical), and how it had two hair follicles visible, etc., she mentioned possibilities like sebaceaous something-or-other, keratosis, and a few other things she said might present like warts, but just to be sure she did cryo anyway.  For what it's worth, that was five days ago and in the place where it is healing, there are definitely still two hair follicles present, with a small deeper pit-like hole where the larger hair follicle is.  Don't know if that's from the cryo itself or just typical of some kind of folliculitis or what.  

I don't have any real question here, just thought I'd follow up and let you know what action I took.

Thanks for your help.
Edward W. Hook M.D.
Edward W. Hook M.D.
28 months ago
Thanks for the follow-up and glad to hear of your decision.  I like the way your 2nd dermatologist approached your problem and glad to hear that it is improving.  EWH---
27 months ago
Doctor Hook, to give you an update: 

I had cryo on the lesion I described (which appeared on my scrotum after shaving, had two very obvious and prominent hairs within the lesion, etc.)  

Cryo barely affected it at all, other than to make one of the two hair follicles disappear.  I had a shave biopsy that came back as a wart. 

The answers that I see everywhere on the internet that say warts do not/cannot have hair follicles is apparently not true, but because I believed them, I possibly infected others during the several months that lesion was present. Great.  

I’m not sure what to do/say now to past and future partners. 

In another twist, a woman who would like to start a potential relationship has  been diagnosed with precancerous cells as a current condition. If I pursue a relationship with her, I suppose I’m then very likely to get yet another strain of HPV?  
Edward W. Hook M.D.
Edward W. Hook M.D.
27 months ago
Thanks for the follow-up, I was about to close this thread.  I must say that I am surprised that the biopsy showed your lesion to be a wart.  Having said that, I do not feel that there is a need for disclosure to potential sex partners on risk regarding transmission.  Why? - because over 80% of sexually active unvaccinated adults already have HPV and when they do, the infection is of no consequence, resolving without therapy and going on to pre-cancerous lesions is less than 1% of cases.  When the infection does progress, it is readily discovered in women through following recommended sexual health screening (i.e. PAP smears) and in men is readily detected through dermatological consultation.   Except in the best of instances, when potential or actual partners are totally rationale and well informed, disclosure is far more likely to be disruptive and unnecessarily concerning (in large part because of the absolutely HUGE amount of misinformation present on the internet).

As for the situation with your potentially new partner, you may well have already had the infection and if not, the likelihood that you will acquire infection and then suffer consequences is very, very low.  while I do not know your circumstances, I would urge you not to let this widespread, innocuous infection have a negative impact on your future relations(s).  

Normally, this thread would now be closed.  I will however keep the thread open for a few hours in caae you have final questions or concerns.  EWH
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27 months ago
Thank you for your advice.

Yes, I was surprised it was a wart after all I had heard to the contrary.   I did not see the actual report, I only got a phone call saying it was a wart, and when I asked if they knew the type of HPV, I was told they did not try to type it.  I don't know if that meant there was any ambiguity in the diagnosis or not, or if it was so obvious it wasn't necessary to type.  

Edward W. Hook M.D.
Edward W. Hook M.D.
27 months ago
This will be a final reply as we are long past the number of replies which our Forum guidelines provide for.  I do not thing the type of virus present is terribly important.  If it bothers you, you can get it treated/removed in any number of ways.  If it does not both you, it is more likely than not to go away over time,  Either way, unless it starts to change it does not represent a major threat to your health. As for transmission to others, I have already outlined our stance on this above - no need to disclose as most people are already infected, when infected there is little harm or consequence as long as persons follow standard reproductive health reservations for screening (i.e. PAP smears, etc. for women, regular check-ups for men).  

Take care. EWH
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