LAUSR

In this issue of the BJD, Hogendoorn et al. introduce a new tool to characterize cutaneous warts, the Cutaneous WARTS (CWARTS) diagnostic tool. In recent years, there have been several attempts in dermatology to standardize tools for classification and scoring of different cutaneous disorders, among them, the Psoriasis Area Severity Index (PASI), the Eczema Area and Severity Index (EASI), the Frontal Fibrosing Alopecia Severity Index (FFASI), the International Hidradenitis Suppurativa Severity Score System (IHS4) and the recent Actinic Keratosis Area Score Index (AKASI). The basic principle is to overcome the inter-observer variability in clinical evaluation so that these tools can be used for several purposes: to enhance the clinical diagnosis, predict the most appropriate treatment and evaluate its efficacy, and compare various therapies across different clinical studies. Cutaneous warts, one of the most diffuse dermatological disorders, may present different morphological aspects, and no validated classification system exists so far. The new proposed CWARTS tool suggests that cutaneous warts be characterized and classified on the basis of the evaluation of two objective characteristics, size and periungual location, and nine features subjected to individual interpretation: arrangement, level, aspect, border, colour, and the presence of white skin flakes, black dots, border erythema and callus. In their study, aimed at validating these subjective features through the evaluation of interand intra-observer agreement, the authors observed a moderate to strong agreement for seven of them, thus suggesting the possible implementation of this tool in clinical practice. The CWARTS is actually limited to common, plantar and periungual warts, and new versions can be implemented to include other variants of cutaneous warts (flat, filiform) as well as genital warts. Besides being a simple classification system, its use could be expanded to identify, for example, a correlation between the morphological characteristics of the warts and the human papillomavirus subtype or a possible evolution or treatment response and in this regard the authors are performing specific studies. An important future step will be, as the authors suggest, to investigate inter-observer agreement between photographs and clinical assessment: in such cases, it would be interesting to evaluate how palpation or the induction of pressure on the lesion, which in clinical practice represent important diagnostic clues, might affect the final evaluation. Lastly, the introduction of a severity score to assign to each clinical feature might turn this classification system into a more practical and objective tool to be utilized in treatment monitoring. In conclusion, the CWARTS tool represents a promising and valid attempt at creating a standardized assessment of cutaneous warts with great potential in daily practice as well as in clinical trials.