Chapter 34: Warts Revised 8/15/10

1. Chapter 34: WartsRevised 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: 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

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 10-40 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%