Disseminated viral warts

Today I saw a 24 y/o patient complaining of warts. He had them for over 10 years now. His right arm was almost completely covered in them; both hands were also badly affected. He has no history of previous illness (besides the warts), takes no medications, denies any illicit drug use or sexual promiscuity. 

If it were just a few warts then it would be a simple case.  But since they’re so many, and so widespread, the suspicion for a possible complication of something else pops up. For example HIV, Syphilis, or a rare condition that causes warts to grow out of proportion like that.

I ordered a syphilis test and a HIV test to confirm. The next step, after receiving the results, would be a dermatologist referral. The problem in treating this is that they're too many. Usually they can be burned, frozen or treated with podophyllin. This would be extremely difficult for various reasons: 1) to be burned you need localized anesthesia...in this case he would need MANY injections or a complete arm blockade and I don't think that is feasible for this. 2) Freezing them would also be very painful and lengthy. 3) Podophyllin is applied in small drops to each wart and can cause irritation, contact dermatitis, and in some rare cases nausea, vomiting, diarrhea, seizures and coma. Imagine the risk in treating so many warts. 

The following picture is not from the patient, but his are similar, just a lot more.

The following picture is from a somewhat similar disease called Epidermodysplasia Verruciformis: (EV) is an extremely rare disorder of warts, the pathogenesis of which is poorly elucidated. Individuals with EV have a severe and apparently congenital susceptibility to infection with HPV that may be inherited in an autosomal recessive fashion. EV is clinically characterized by widespread warts that appear in childhood— typically flat warts as well as lesions that are scaly, red/brown macules— which do not revert and often develop into skin cancers. The HPV strains specific to the scaly (scary!) warts that characterize EV are HPV-5 and HPV-8.

The following is a link to a video of a man with this disease.

Video of EV patient