WARTS (VERRUCAE
VULGARIS)
Warts (verrucae
vulgaris) are common, benign epidermal lesions associated with human
papillomavirus infection. They can appear anywhere on the body in a variety of
morphologies. Diagnosis is by examination. Warts are usually self-limited but
may be treated by excision, cautery, cryotherapy, liquid nitrogen, and topical
or injected agents.
Warts are almost universal in the population
and affect all ages but are most frequent in children and uncommon in the
elderly. Warts are caused by human papillomavirus (HPV) infection; at least 70
HPV types are linked to skin lesions. Trauma and maceration facilitate initial
epidermal inoculation. Spread may then occur by autoinoculation. Local and
systemic immune factors appear to influence spread; immunosuppressed patients
(especially HIV and renal transplant patients) are at particular risk for
developing generalized lesions that are difficult to treat. Humoral immunity
provides resistance to HPV infection, although cellular immunity helps
established infection to regress.
Symptoms and Signs
Warts are
named by their clinical appearance and location; different forms are linked to
different HPV types. Unusual manifestations are listed in Table 1: Viral Skin Diseases: Wart Variants
and Clinical Correlations
.

Table 1
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Common
warts (verrucae vulgaris) are caused by HPV 1, 2,
4, 27, and 29. Generally, they are asymptomatic but sometimes cause mild pain,
especially when they are located on a weight-bearing surface such as the bottom
of the feet. They are sharply demarcated, rough, round or irregular, firm, and
light gray, yellow, brown, or gray-black nodules 2 to 10 mm in diameter. They
appear most often on sites subject to trauma (eg, fingers, elbows, knees, face)
but may spread elsewhere. Variants of unusual shape (eg, pedunculated or
resembling a cauliflower) are most frequent on the head and neck, especially
the scalp and beard.
Filiform
warts are long, narrow, frondlike growths usually
on the eyelids, face, neck, or lips. They too are usually asymptomatic. This
morphologically distinct variant of the common wart is benign and easy to
treat.
Flat
warts, caused by HPV 3, 10, 28, and 49, are smooth,
flat-topped, yellow-brown papules most often on the face and along scratch
marks; they are more common in children and young adults and develop by
autoinoculation. They generally cause no symptoms but can be difficult to
treat.
Palmar
and plantar warts, caused by HPV 1, are warts on
the palms and soles flattened by pressure and surrounded by cornified
epithelium. They are often tender and can make walking and standing
uncomfortable. They can be distinguished from corns and calluses by their
tendency to pinpoint bleeding when the surface is pared away. Classically,
warts hurt with “side to side” pressure, and calluses hurt with direct
pressure; in reality, this is not a reliable sign.
Mosaic
warts are plaques formed by the coalescence of
myriad smaller, closely set plantar warts. As with other plantar warts, they
are often tender.
Periungual
warts appear as thickened, fissured
cauliflower-like skin around the nail plate. Patients frequently lose the
cuticle and are susceptible to paronychia. These warts are more common in
patients who bite their nails.
Genital
warts manifest as discrete flat to broad-based
smooth to velvety papules on the perineal, perirectal, labial, and penile
areas. Infection with high-risk HPV types (most notably types 16 and 18) are
the main causes of cervical cancer. They are generally asymptomatic.
Diagnosis
is based on clinical appearance; biopsy is rarely needed. A cardinal sign of
warts is the absence of skin lines crossing their surface and the presence of
pinpoint black dots (thrombosed capillaries) or bleeding when warts are shaved.
Differential diagnosis includes corns (clavi), lichen planus, seborrheic
keratosis, skin tags, and squamous cell carcinomas. DNA typing is available in
some medical centers but is generally not needed.
Many warts
regress spontaneously; others persist for years and recur at the same or
different sites, even with treatment. Factors influencing recurrence appear to
be related to the patient's overall immune status as well as local factors.
Patients who subject themselves to local trauma (eg, athletes, mechanics,
butchers) can have recalcitrant and recurrent HPV. Genital HPV infection has
malignant potential, but (except in immunosuppressed patients) malignant transformation
has not been generally observed in HPV-induced skin warts.
Treatment
is aimed at eliciting an immune response to HPV. In most instances, this is
achieved by applying an irritant (eg, salicylic acid Some
Trade Names
MEDIPLAST
PROPA PH
STRI-DEX
Click for Drug Monograph
[SCA], trichloroacetic acid, 5- fluorouracil Some Trade Names
ADRUCIL
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, podophyllum resin, tretinoin Some Trade Names
RETIN-A
Click for Drug Monograph
, cantharidin).
MEDIPLAST
PROPA PH
STRI-DEX
Click for Drug Monograph
[SCA], trichloroacetic acid, 5- fluorouracil Some Trade Names
ADRUCIL
Click for Drug Monograph
, podophyllum resin, tretinoin Some Trade Names
RETIN-A
Click for Drug Monograph
, cantharidin).
These
compounds can be used in combination or with a destructive method (eg,
cryosurgery, electrocautery, curettage, excision, laser). Direct antiviral
effects can be achieved with bleomycin Some
Trade Names
BLENOXANE
Click for Drug Monograph
and interferon-α2b, but these treatments are reserved for the most recalcitrant warts. Topical imiquimod Some Trade Names
ALDARA
Click for Drug Monograph
5% cream induces skin cells to locally produce antiviral cytokines. Topical cidofovir Some Trade Names
VISTIDE
Click for Drug Monograph
, HPV vaccines, and contact immunotherapy (eg, squaric acid dibutyl ester and Candida allergen) have been used to treat warts. Oral treatments include cimetidine Some Trade Names
TAGAMET
Click for Drug Monograph
, isotretinoin Some Trade Names
ACCUTANE
Click for Drug Monograph
, and oral zinc. In most instances, modalities should be combined to increase the likelihood of success.
BLENOXANE
Click for Drug Monograph
and interferon-α2b, but these treatments are reserved for the most recalcitrant warts. Topical imiquimod Some Trade Names
ALDARA
Click for Drug Monograph
5% cream induces skin cells to locally produce antiviral cytokines. Topical cidofovir Some Trade Names
VISTIDE
Click for Drug Monograph
, HPV vaccines, and contact immunotherapy (eg, squaric acid dibutyl ester and Candida allergen) have been used to treat warts. Oral treatments include cimetidine Some Trade Names
TAGAMET
Click for Drug Monograph
, isotretinoin Some Trade Names
ACCUTANE
Click for Drug Monograph
, and oral zinc. In most instances, modalities should be combined to increase the likelihood of success.
Common
warts: In immunocompetent hosts, common warts
usually spontaneously regress within 2 yr, but some linger for many years.
Numerous treatments are available. Destructive methods include electrocautery,
cryosurgery with liquid nitrogen, and SCA preparations. Application of these
methods varies depending upon the location and severity of involvement. For
example, 17% liquid SCA can be used on the fingers, and 40% plaster SCA can be
used on the soles.
The most
common topical agent to be used is SCA. SCA is available in a liquid, plaster,
or impregnated within tape. Patients apply SCA to their warts at night and
leave on for 8 to 48 h depending on the site.
Cantharidin
can be used alone or in combination (1%) with SCA (3%) podophyllum (2%) in a
collodion base. Cantharidin alone is removed with soap and water after 6 h;
cantharidin with SCA or podophyllum is removed in 2 h. The longer these agents
are left in contact with the skin, the more brisk the blistering response.
Cryosurgery
is painful but extremely effective. Electrodesiccation with curettage and/or
laser surgery is effective and indicated for isolated lesions but may cause
scarring. Recurrent or new warts occur in about 35% of patients within 1 yr, so
methods that scar should be avoided as much as possible.
Filiform
warts: Treatment is removal with scalpel,
scissors, curettage, or liquid nitrogen. Liquid nitrogen should be applied so
that up to 2 mm of skin surrounding the wart turns white. Damage to the skin
occurs when the skin thaws, which usually takes 10 to 20 sec. Blisters can
occur 24 to 48 h after treatment with liquid nitrogen. Care must be taken when
treating cosmetically sensitive sites, such as the face and neck, since
hypopigmentation frequently occurs after treatment with liquid nitrogen.
Patients with darkly pigmented skin can develop permanent depigmentation.
Flat
warts: Treatment is daily tretinoin Some Trade Names
RETIN-A
Click for Drug Monograph
(retinoic acid 0.05% cream). If peeling is not sufficient for wart removal, another irritant (eg, 5% benzoyl peroxide Some Trade Names
BENZAC AC
BENZAGEL
NEUTROGENA ACNE MASK
Click for Drug Monograph
) or 5% SCA cream can be applied sequentially with tretinoin Some Trade Names
RETIN-A
Click for Drug Monograph
. Imiquimod Some Trade Names
ALDARA
Click for Drug Monograph
5% cream can be used alone or in combination with topical drugs or destructive measures. Topical 5- fluorouracil Some Trade Names
ADRUCIL
Click for Drug Monograph
(1% or 5% cream) can also be used. Spontaneous resolution may follow unprovoked inflammation of the lesions; however, flat warts are frequently recalcitrant to treatment.
RETIN-A
Click for Drug Monograph
(retinoic acid 0.05% cream). If peeling is not sufficient for wart removal, another irritant (eg, 5% benzoyl peroxide Some Trade Names
BENZAC AC
BENZAGEL
NEUTROGENA ACNE MASK
Click for Drug Monograph
) or 5% SCA cream can be applied sequentially with tretinoin Some Trade Names
RETIN-A
Click for Drug Monograph
. Imiquimod Some Trade Names
ALDARA
Click for Drug Monograph
5% cream can be used alone or in combination with topical drugs or destructive measures. Topical 5- fluorouracil Some Trade Names
ADRUCIL
Click for Drug Monograph
(1% or 5% cream) can also be used. Spontaneous resolution may follow unprovoked inflammation of the lesions; however, flat warts are frequently recalcitrant to treatment.
Plantar
warts: Treatment is vigorous maceration with 40%
SCA plaster kept in place for several days. The wart is debrided while damp and
soft, then destroyed by freezing or using caustics (eg, 30 to 70%
trichloroacetic acid). Other destructive treatments (eg, CO2 laser,
pulsed-dye laser, various acids) are often effective. Duct tape is effective
when applied for 6-day intervals, followed by debridement of macerated tissue.
Periungual:
Combination therapy with liquid nitrogen and imiquimod Some Trade Names
ALDARA
Click for Drug Monograph
5% cream, tretinoin Some Trade Names
RETIN-A
Click for Drug Monograph
, or SCA is effective.
ALDARA
Click for Drug Monograph
5% cream, tretinoin Some Trade Names
RETIN-A
Click for Drug Monograph
, or SCA is effective.
Refractory:
Several methods whose long-term value and risks
are not fully known are available for recalcitrant warts. Intralesional
injection of small amounts of a 0.1% solution of bleomycin
Some Trade Names
BLENOXANE
Click for Drug Monograph
in saline often cures stubborn plantar and periungual warts. However, injected digits may develop Raynaud's phenomenon or vascular damage (especially when injected at the base of the digit), warranting caution. Interferon, especially interferon-α, administered intralesionally (3 times/wk for 3 to 5 wk) or IM, has also cleared recalcitrant skin and genital warts. Extensive warts sometimes improve or clear with oral isotretinoin Some Trade Names
ACCUTANE
Click for Drug Monograph
or acitretin Some Trade Names
SORIATANE
Click for Drug Monograph
. Cimetidine Some Trade Names
TAGAMET
Click for Drug Monograph
at doses up to 800 mg po tid has been used with success but is more effective when combined with another therapy.
BLENOXANE
Click for Drug Monograph
in saline often cures stubborn plantar and periungual warts. However, injected digits may develop Raynaud's phenomenon or vascular damage (especially when injected at the base of the digit), warranting caution. Interferon, especially interferon-α, administered intralesionally (3 times/wk for 3 to 5 wk) or IM, has also cleared recalcitrant skin and genital warts. Extensive warts sometimes improve or clear with oral isotretinoin Some Trade Names
ACCUTANE
Click for Drug Monograph
or acitretin Some Trade Names
SORIATANE
Click for Drug Monograph
. Cimetidine Some Trade Names
TAGAMET
Click for Drug Monograph
at doses up to 800 mg po tid has been used with success but is more effective when combined with another therapy.

Treatments and drugs
Plantar warts usually go away on their own,
but most people would rather treat them than wait for them to disappear. Unless
you have an impaired immune system or diabetes or are pregnant, there's no
reason you can't treat warts with over-the-counter remedies. But you may wish
to consult your doctor for help. He or she may suggest a combination of
over-the-counter and office treatments for plantar warts.
No wart treatment works 100 percent of the
time. In general, your doctor will recommend the least painful — and least
destructive — methods first, especially for children.
Common treatments for simple
plantar warts
Your doctor may suggest trying these common treatments one at a time or in combination:
Your doctor may suggest trying these common treatments one at a time or in combination:
§ Salicylic
acid. Wart medications and patches are available at drugstores. To
treat plantar warts, you'll need a 40 percent salicylic acid solution or patch
(Curad Mediplast, Dr. Scholl's Clear Away Plantar, others), which peels off the
infected skin a little bit at a time. Apply the solution once or twice each
day, being careful to avoid healthy skin, which can become irritated from the
acid. In between applications, pare away the dead skin and wart tissue using a
pumice stone or emery board. You may need to repeat this process for up to
three or four weeks to completely eliminate warts.
§ Duct
tape. In a well-publicized 2002 study, duct tape wiped out more warts
than freezing (cryotherapy) did. Study participants who used "duct tape
therapy" covered their warts in duct tape for six days, then soaked their
warts in water, and gently rubbed warts with an emery board or pumice stone.
They repeated this process for up to two months or until their warts went away.
Researchers hypothesize that this unconventional therapy may work by irritating
warts and the surrounding skin, prompting the body's immune system to attack.
Today, duct tape is commonly used to treat warts, especially for children who
may find freezing painful or scary. It's often combined with salicylic acid.
§ Freezing
(cryotherapy). Freezing is one of the most
common treatments for plantar warts and is usually effective, but may require
multiple trips to your doctor every two to four weeks. Your doctor can apply
liquid nitrogen with a spray canister or cotton-tipped applicator. The chemical
causes a blister to form around your wart, and the dead tissue sloughs off
within a week or so. Freezing isn't commonly used in young children because it
can be painful.
§ Cantharidin.
Doctors and healers have used cantharidin — a substance extracted from the blister
beetle — to treat warts for centuries. Today, this therapy is sometimes
paired with salicylic acid. Your doctor paints this beetle juice onto your wart
and covers it with clear tape. The application is painless, but it causes the
skin under the wart to blister, lifting the wart off the skin. Your doctor can
then clip away the dead part of the wart in about a week. However, some doctors
are hesitant to use cantharidin because it's not approved by the Food and Drug
Administration for the treatment of warts.
Aggressive treatments for
persistent plantar warts
If your warts don't respond to common treatments, your doctor may suggest one or more of these other options:
If your warts don't respond to common treatments, your doctor may suggest one or more of these other options:
§ Minor
surgery. This involves cutting away the wart or
destroying the wart by using an electric needle in a process called
electrodesiccation and curettage. This treatment is effective, but may leave a
scar if not done carefully. Your doctor will anesthetize your skin before this
procedure.
§ Laser
surgery. Doctors can use several types of lasers to
eliminate stubborn warts. But laser surgery is expensive and painful and may
take longer to heal than do other treatments.
§ Immunotherapy.
This therapy attempts to harness your body's natural rejection system to remove
tough-to-treat warts. This can be accomplished in a couple of ways. Your doctor
may inject your warts with interferon, a medication that boosts your immune
system's instinct to reject warts. Or your doctor may inject your warts with a
foreign substance (antigen) that stimulates your immune system. Doctors often
use mump antigens, because many people are immunized against mumps. As a
result, the antigen sets off an immune reaction that may fight off warts.
§ Imiquimod
(Aldara). This prescription cream is an
immunotherapy medication that encourages your body to release immune system
proteins (cytokines) to help ward off warts. You can apply this cream directly
to your warts. Imiquimod is approved by the Food and Drug Administration for
the treatment of genital and perianal warts, but it's also successful in
treating common warts and plantar warts.
§ Other
medications. In severe cases that haven't cleared with
other therapies, your doctor may inject each wart with a medication called
bleomycin, which kills the virus. This medication is given systemically in
higher doses to treat some kinds of cancer. The injections for wart treatment
can be painful and can cause rashes or itching. They're not used if you're
pregnant or breast-feeding or if you have circulation problems.
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