School children: 2-20%Children and young adults: 10%General
population: 16%U.S. adults: 75%
Epidemiology of Warts
Immunocompromised: HIV, meds, lymphoma, leukemia, HodgkinsPeak
ages: 12-16 yearsMale: female ratio of 58:72Family members at high
riskHaving warts: 3X greater riskRaw meat workers (butcher, etc.):
trauma and macerationDiabetic
Etiology of Warts
Not from frog urine (based on old Doctrine of Signatures)Human
Papilloma Virus (HPV), a circular DNA virus200 SubtypesStimulate
basal cells to produce skin hyperkeratosis
Wart Transmission
HPV only affects humansMust have an epidermal breakSkin-to-skin
contact with infected person or their shed skin cellsThe 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 facilitiesPerhaps the carpets of hotels leading to the
poolShowers at the poolBathtubs and showers in hotelsSmall foot
skin break + wet environments
Koebnerization of Warts
Intact skin is best barrier to wartsAll people have skin
microabrasionsVirus + microabrasion + maceration allows virion to
contact replicating epidermal layerDamaged skin becomes
wart-prone
Wart Autoinoculation
Having warts makes one 3X more likely to have more
wartsAutoinoculation: trauma to original wart Intentional: biting
or pickingAccidentalViral particles contact uninfected skin and
penetrate skin breaks
Common Warts (Verruca Vulgaris)
70% of warts are common wartsRough papules/nodules; cauliflower
lookDorsum of fingers; handsKnees in childrenFlesh-colored
exophytic (growing outward) or endophytic (growing inward)May
extend to nailbedsSingle or grouped
Common Warts
Common Warts
Flat Warts (Verruca Plana)
Face, hands, legs of childrenCrops of lesions; KoebnerizationSmall,
hard growths, surface resembles a cauliflowerFlesh-colored;
tan/pink, gray, or brownEndophytic, slightly elevated, smallShaving
can spread themPossible fingerlike projections
Flat Warts
Flat Warts
Flat Warts
Plantar Warts (Verruca Plantaris)
24% are plantarSole of foot, where it contacts surfaces;
weight-bearing areasMay see black dots across surface (referred to
as seed warts by lay public)Exquisite pain upon ambulationUsually
endophytic in ambulatory patientsMay coalesce to form mosaic
warts
Plantar Warts
Plantar Warts
Anal, Genital Warts
1% of wartsAny genital surfaceAn STD
Extracutaneous Wart Sites
Usually from finger contact with surfacesHard palate Intranasal
mucosa Inside the conjunctivaLaryngeal area Cervical surfaces
Prognosis of Warts
Usually benign, unsightly81% of patients are embarrassed by
themPainless, except for plantarPlantar can restrict activitiesMay
transform into malignant lesions (squamous cell carcinoma)
Spontaneous Regression
Data from study of institutionalized children66% of warts in
children disappear in 2 yearsFlat warts turn red, itch, and swell
while shrinkingPlantars seldom regressDont rely on spontaneous
regression
Wart-Free Periods
May occur after regressionWart-free periods may last for days or
yearsReasons unknown
Self-Care for Warts
Plantar and common warts onlyNo improvement in 12 weeks? See
Dr.Dont treat warts on mucous membranes, face, genitalsKeep 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
Dont apply to irritated, infected, or reddened skinDiscontinue if
irritation occursKeep away from eyesNot for diabetics or those with
poor circulationRecap bottles tightlyDont use bottles with
crystals
How To Detect Total Cure
Examine skin ridges if on feet or palmsIf ridges are restored, the
area is considered cured
Salicylic Acid
Only safe and effective wart ingredientKeratolytic &
occlusive>water collecting under the collodion/patch macerates
the skin and induces inflammation12-40% plasters5-17%
collodionsPresoak the wart for 5 minutes and dry skin before
application
Salicylic Acid Liquids/Gels
Apply 1-2 times dailyKeep 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 skinBut,
comes out in a blob, cant
see where product
is (opaque tube), so more
likely to get on healthy skin
Salicylic Acid Plaster
Cut to size of wartApply and keep on for 48 hoursReplace with new
patch
Plasters
Plasters
Plasters
Salicylic Acid Karaya Plaster
Also FDA-approvedApply at H.S. after smoothing wart with an emery
fileLeave on for 8 hoursRemove in the morningRepeat each night for
up to 12 weeks
Trans-Ver-Sal
Glycol-Karaya
OTC Freezing Therapies
Marketed in 2003Safety/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 useNot under the age of 4 yearsOnly
treat one side of a finger or toe to avoid freezing
arteries/veinsDo not use on thin skin (breasts, face, axillae,
area) to prevent burns and permanent scarring
Freezing Therapies
Discard applicators after the single useUse will cause stinging,
pain, burning, itching, achingCompanies 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 dermatologistsRelies 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 dermatitisWart is
attacked using the innocent bystander therapy
Duct Tape
2002 Study--Enrolled 61 children with common wartsHalf got liquid
nitrogen--the others had the warts covered with duct tape for 2
monthsMeasured complete resolution of wartsResponse rate with
nitrogen=60%Response rate with duct tape=85%
Prevention of Warts
Avoid skin-to-skin contact with infected individualsTreat existing
warts immediatelyNever bite, scratch, or pick wartsIf warts on
body, use separate towels and wash clothes for affected skinNever
attempt to remove warts with any kind of device; damaged warts may
spread
Prevention of Plantar Warts
Always stand on a personal bath matAlways dry with a clean,
personal towelKeep feet covered at all times when in a public
place
