Chapter 34: WartsRevised 8/15/10

Wart Prevalence• School children: 2-20%

• Children and young adults: 10%

• General population: 16%

• U.S. adults: 75%

Epidemiology of Warts• Immunocompromised: HIV, meds, lymphoma,

leukemia, Hodgkin’s• Peak ages: 12-16 years• Male: female ratio of 58:72• Family members at high risk• Having warts: 3X greater risk• Raw meat workers (butcher, etc.): trauma and

maceration• Diabetic

Etiology of Warts• Not from frog urine (based on old

“Doctrine of Signatures”)

• Human Papilloma Virus (HPV), a circular DNA virus

• 200 Subtypes

• Stimulate basal cells to produce skin hyperkeratosis

Wart Transmission• HPV only affects humans• Must have an epidermal break• Skin-to-skin contact with infected person

or their shed skin cells• The long incubation period (1-8 months)

makes it difficult to identify the geographic location where the wart was contacted

Wart Transmission• Virus is stable in environment for long

periods, resistant to desiccation, heat, detergents, and prolonged storage: allows fomite spread via towels, clothing, tanning beds, finger-puncture devices

Plantar Wart Transmission• Swimming facilities• Perhaps the carpets of hotels leading to

the pool• Showers at the pool• Bathtubs and showers in hotels• Small foot skin break + wet environments

Koebnerization of Warts• Intact skin is best barrier to warts

• All people have skin microabrasions

• Virus + microabrasion + maceration allows virion to contact replicating epidermal layer

• Damaged skin becomes wart-prone

Wart Autoinoculation• Having warts makes one 3X more likely to

have more warts

• Autoinoculation: trauma to original wart

• Intentional: biting or picking

• Accidental

• Viral particles contact uninfected skin and penetrate skin breaks

Common Warts (Verruca Vulgaris)

• 70% of warts are common warts

• Rough papules/nodules; cauliflower look

• Dorsum of fingers; hands

• Knees in children

• Flesh-colored exophytic (growing outward) or endophytic (growing inward)

• May extend to nailbeds

• Single or grouped

Common Warts

Common Warts

Flat Warts (Verruca Plana)• Face, hands, legs of children• Crops of lesions; Koebnerization• Small, hard growths, surface resembles a

cauliflower• Flesh-colored; tan/pink, gray, or brown• Endophytic, slightly elevated, small• Shaving can spread them• Possible fingerlike projections

Flat Warts

Flat Warts

Flat Warts

Plantar Warts (Verruca Plantaris)• 24% are plantar

• Sole of foot, where it contacts surfaces; weight-bearing areas

• May see black dots across surface (referred to as “seed warts” by lay public)

• Exquisite pain upon ambulation

• Usually endophytic in ambulatory patients

• May coalesce to form mosaic warts

Plantar Warts

Plantar Warts

Anal, Genital Warts• 1% of warts

• Any genital surface

• An STD

Extracutaneous Wart Sites• Usually from finger contact with surfaces

• Hard palate

• Intranasal mucosa

• Inside the conjunctiva

• Laryngeal area

• Cervical surfaces

Prognosis of Warts• Usually benign, unsightly

• 81% of patients are embarrassed by them

• Painless, except for plantar

• Plantar can restrict activities

• May transform into malignant lesions (squamous cell carcinoma)

Spontaneous Regression• Data from study of institutionalized

children

• 66% of warts in children disappear in 2 years

• Flat warts turn red, itch, and swell while shrinking

• Plantars seldom regress

• Don’t rely on spontaneous regression

Wart-Free Periods• May occur after regression

• Wart-free periods may last for days or years

• Reasons unknown

Self-Care for Warts• Plantar and common warts only

• No improvement in 12 weeks? See Dr.

• Don’t treat warts on mucous membranes, face, genitals

• Keep hands & feet as dry as possible during treatment (except for presoak)

• Stay away from moles, birthmarks, hairy warts--all may be premalignant

Self-Care for Warts• Don’t apply to irritated, infected, or

reddened skin

• Discontinue if irritation occurs

• Keep away from eyes

• Not for diabetics or those with poor circulation

• Recap bottles tightly

• Don’t use bottles with crystals

How To Detect Total Cure• Examine skin ridges if on feet or palms

• If ridges are restored, the area is considered cured

Salicylic Acid• Only safe and effective wart ingredient

• Keratolytic & occlusive>water collecting under the collodion/patch macerates the skin and induces inflammation

• 12-40% plasters

• 5-17% collodions

• Presoak the wart for 5 minutes and dry skin before application

Salicylic Acid Liquids/Gels• Apply 1-2 times daily

• Keep away from surrounding healthy skin by circling it with a ring of petrolatum (Vaseline)

• If dropper, apply one drop at a time until wart covered, then allow to dry

Liquids

Compound W Fast-Acting Gel

• Initially, thought to prevent running down to healthy skin

• But, comes out in a blob, can’t

see where product

is (opaque tube), so more

likely to get on healthy skin

Salicylic Acid Plaster• Cut to size of wart

• Apply and keep on for 48 hours

• Replace with new patch

Plasters

Plasters

Plasters

Salicylic Acid Karaya Plaster

• Also FDA-approved

• Apply at H.S. after smoothing wart with an emery file

• Leave on for 8 hours

• Remove in the morning

• Repeat each night for up to 12 weeks

Trans-Ver-Sal• Glycol-Karaya

OTC Freezing Therapies• Marketed in 2003

• Safety/Efficacy questionable due to marketing method as a device similar to another device already marketed rather than as a true OTC medication; not proven safe or effective

OTC Freezing Therapies• Physician freezing requires several painful

applications of liquid nitrogen-the patient may need reappointments

• For small children with multiple warts, the pain limits its use

• Several companies have marketed OTC freezing therapies

OTC Freezing Therapies• OTC products are only butane/dimethyl

ether/propane--can they possibly achieve the same level of tissue penetration and viral death with 10-40 seconds of use at home?

Freezing Therapies• Numerous directions for safe use

• Not under the age of 4 years

• Only treat one side of a finger or toe to avoid freezing arteries/veins

• Do not use on thin skin (breasts, face, axillae, area) to prevent burns and permanent scarring

Freezing Therapies• Discard applicators after the single use

• Use will cause stinging, pain, burning, itching, aching

• Companies promise most common/plantar warts will disappear after 2 weeks

Wartner was the first OTC freezing therapy

Dual action also has a bottle of salicylic acid

Cimetidine?• Anecdotal evidence that oral cimetidine

may help

Suggestion Therapy?• Engaged in by some dermatologists

• Relies on making the patient become engaged in the process in some way

Wart Charmers?• Same category as suggestion therapy

Immune System Manipulation?

• Apply dinitrochlorobenzene, squaric acid dibutylester, or Toxicodendron to the wart to cause an allergic dermatitis

• Wart is attacked using the “innocent bystander” therapy

Duct Tape• 2002 Study--Enrolled 61 children with common

warts• Half got liquid nitrogen--the others had the warts

covered with duct tape for 2 months• Measured complete resolution of warts• Response rate with nitrogen=60%• Response rate with duct tape=85%

Prevention of Warts• Avoid skin-to-skin contact with infected

individuals• Treat existing warts immediately• Never bite, scratch, or pick warts• If warts on body, use separate towels and wash

clothes for affected skin• Never attempt to remove warts with any kind of

device; damaged warts may spread

Prevention of Plantar Warts• Always stand on a personal bath mat

• Always dry with a clean, personal towel

• Keep feet covered at all times when in a public place