1. Chapter 34: Warts Revised 8/15/10

2. Wart Prevalence School children: 2-20% Children and young adults: 10%
General population: 16%
U.S. adults: 75%

3. Epidemiology of Warts
Immunocompromised: HIV, meds, lymphoma, leukemia, Hodgkin’s
Peak ages: 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Common Warts

12. Common Warts

13. 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

14. Flat Warts

15. Flat Warts

16. Flat Warts

17. 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

18. Plantar Warts

19. Plantar Warts

20. Anal, Genital Warts
1% of warts
Any genital surface
An STD

21. Extracutaneous Wart Sites
Usually from finger contact with surfaces
Hard palate
Intranasal mucosa
Inside the conjunctiva
Laryngeal area
Cervical surfaces

22. 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)

23. 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

24. Wart-Free Periods May occur after regression
Wart-free periods may last for days or years
Reasons unknown

25. 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

26. 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

27. How To Detect Total Cure
Examine skin ridges if on feet or palms
If ridges are restored, the area is considered cured

28. 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

29. 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

30. Liquids

31. 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

32. Salicylic Acid Plaster
Cut to size of wart
Apply and keep on for 48 hours
Replace with new patch

33. Plasters

34. Plasters

35. Plasters

36. 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

37. Trans-Ver-Sal
Glycol-Karaya

38. 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

39. 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

40. 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 seconds of use at home?

41. 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

42. 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

43. Wartner was the first
OTC freezing therapy

44. Dual action also has a bottle of salicylic acid

46. Cimetidine?
Anecdotal evidence that oral cimetidine may help

47. Suggestion Therapy? Engaged in by some dermatologists
Relies on making the patient become engaged in the process in some way

48. Wart Charmers?
Same category as suggestion therapy

49. 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

50. 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%

51. 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

52. 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