Verruca plantaris presenting as a foot abscess following a roofing nail puncture: A diagnosis requiring a high index of suspicion: Case report

Puncture injuries of the foot are a common presentation in orthopedic and emergency practices and account for a large proportion of foot trauma seen in young individuals. These injuries commonly result from stepping on sharp objects and are often managed conservatively with simple wound care. However, complications such as foreign body reactions, soft tissue infection, and osteomyelitis are well-documented consequences. Verruca vulgaris, also known as the common wart, is one of the most common skin conditions and must be distinguished clinically from other hyperkeratotic conditions, including bone pathology such as tumors that can exert pressure on the skin, cause callus formation, and mimic a wart. A high index of suspicion for underlying verruca or malignant degeneration should be maintained when evaluating patients with persistent pain following puncture wounds or failure to improve with treatment, particularly involving the hand or foot. This case report presents a 21-year-old male with a verruca of the left plantar heel following a puncture wound from a roofing nail six weeks earlier, associated with painful, indurated, hyperkeratotic skin at the puncture site. Initial management at home included wound cleansing and topical antibiotic ointment. After failure to improve, the family administered Dr. Scholl’s Freeze Away Wart Remover cryotherapy without resolution, and the patient attempted surgical exploration. The family requested evaluation at our practice due to concern for an abscess, as the patient became unable to ambulate on the heel or work. Surgical treatment was requested due to pain and difficulty performing his occupation as a laborer. Physicians must remain mindful of verruca plantaris, in addition to infection, in patients presenting with worsening pain after penetrating trauma. Recognition that verruca plantaris may present as a painful mass following a deep puncture wound, an association not previously described to our knowledge, may prevent delays in diagnosis or unnecessary treatment.