Warts are benign (not cancerous) skin growths that appear when a virus infects the top layer of the skin. Viruses that cause warts are called human papillomavirus (HPV). You are more likely to get one of these viruses if you somehow cut or damage your skin. Wart viruses are contagious.
Warts can spread by contact with the wart or something that touches the wart. Warts are often skin-colored and feel rough, but they can be dark (brown or gray-black), flat, and smooth. Warts often go away without treatment. This is especially true when children get warts. In adults, warts may not disappear as easily or as quickly as in children.
Although most warts are harmless, dermatologists do treat them. You should see a dermatologist if you cannot get rid of warts, warts hurt, or you have many warts. Dermatologists have many treatments for warts. The procedure used depends on the patient’s age and health and the type of wart. Vascular lasers or ablative lasers are commonly used.
Types of Warts
HPVs can infect and cause disease at any site in the skin or mucous membranes. Clinical problems encountered with such infections can be broadly divided into skin warts, genital warts, oral warts, and laryngeal warts.
Skin warts occur at any age but are unusual in infancy and early childhood. The incidence in young adults aged 16 to 24 is estimated to be seven hundred per 100 000 overall population. The incidence increases during the school years to reach a peak in adolescence and early adulthood then declines rapidly through the twenties and more gradually after that.
It can seldom ascertain the time of acquisition of the infection for common and plantar warts, but the incubation period has been estimated to range between a few weeks and more than a year.
Person-to-person transmission of genital HPV infection is high as two-thirds of ninety-seven sexual contacts of patients with genital warts themselves developed lesions within nine months; infectivity seemed highest early in the disease. There is no reliable information on the infectivity of common and plantar warts, but experience suggests that it is less.
Modes of transmission
Direct or indirect contact spreads warts. The wart virus particle may need to contact a stem cell in the basal epidermal layer for infection to occur. Impairment of the skin barrier function by trauma (including mild abrasions), maceration, or both significantly predispose to injection of the virus. It is assumed to be required for infection, at least in fully keratinized skin, as in the following examples.
1 Plantar wart is commonly acquired from swimming pools or shower-room floors, whose rough surfaces abrade moistened keratin from infected feet and help to inoculate virus into the softened skin of others.
2 Common hand warts may spread widely around the nails in those who bite their nails or periungual skin, over habitually sucked fingers in young children, and to the lips and surrounding skin.
3 Shaving may spread wart infection over the beard area.
4 Occupational handlers of meat, fish, and poultry have high hand warts attributed to skin injury and prolonged contact with wet flesh and water.
5 Genital warts have high infectivity. The thinner mucosal surface is more susceptible to injection of the virus than thicker keratinized skin. Still, lesions are most typical in sites subject to the most significant coital friction in both sexes.
Anogenital warts in adults.
Acquisition commonly follows sexual contact, but it is agreed that anogenital warts are not always transmitted sexually. Perianal warts may accompany genital warts due to the local infection spread or direct contact during anal coitus. Occasional non-sexual acquisition of anogenital warts in adults is assumed to be possible. HPV-1 and HPV-2 may occur in genital warts [
anogenital warts in children.
Anogenital warts are uncommon in children, but their occurrence frequently stimulates discussion of the possibility of sexual transmission.
It is due to HPV-2 and the closely related types 27, 57, and 1 and 4. commonly situated on the backs of the hands and fingers, and, in children under 12 years of age, on the knees, but may occur anywhere on the skin. Firm bumps with a rough, horny surface range in size from less than 1 mm to over 1 cm in diameter and can form large masses by confluence. A single wart may persist unchanged for months or years, or large numbers may develop rapidly or after an interval. New warts may form at sites of trauma, though this Köbner-like isomorphic phenomenon is usually less marked than plane warts.
It is usually symptomless but may be tender on the palmar aspects of the fingers when fissured or growing beneath the nail plate. It accounts for only 1 or 2% of warts on or around the genitalia in adults; in males, they are always confined to the shaft of the penis. They often retain their typical morphological characteristics with dry nature.
There is a clinical impression that warts in adults, especially older adults, are slower to clear with or without treatment. It is impossible to offer a reliable prognosis for the individual patient. About 65% disappear spontaneously within two years and 95% within four years.
Regression is asymptomatic and occurs gradually over several weeks, usually without blackening. Malignant change in warts is infrequent but has been reported in immunosuppression.
Nail-biting may increase the risk of infection at this site. It occurs around the nails, especially at the nail folds or beneath the nail, and can disturb nail growth. Malignant change is infrequent but reported in immunosuppression and associated with genital HPV disease.
Foot warts (plantar warts)
The deep ‘Myrmecia’ form is due to HPV-1. Other are caused by HPV-1, 2, 4, 27, or 57. Smaller lesions may contain HPV-2, 4, 27, or 57, while HPV-2 commonly causes mosaic types.
Dermoscopy can also help to distinguish a plantar wart from corn or a callosity. At first, it appears as a small shining ‘sago-grain’ papule. Still, it soon assumes the typical appearance of a sharply defined, rounded lesion, with a rough, keratotic surface surrounded by a smooth collar of the thickened horn.
If the surface is gently pared with a scalpel, the abrupt separation between the wart tissue and the protective horny ring becomes more apparent on the wart surface. If the paring is continued, minor bleeding points, the tips of the elongated dermal papillae, are evident.
They occur beneath pressure points, the heel, or the metatarsal heads. Individuals may be affected by single or numerous lesions. Sometimes, a cluster of small satellite warts, the smallest of pinhead size, having at first an almost vesicular appearance, may develop around a large mass.
Mosaic warts are described from the appearance presented by a plaque of closely grouped small warts. The angular outlines of the tightly compressed are seen when the surface is pared. It is often painless. Pain is a common but variable symptom. It may be severe and disabling but absent, and many warts are discovered only on routine inspection.
The duration of the lesion is very variable. Spontaneous regression occurs sooner in children than in adults and is delayed if hyperhidrosis or orthopedic defects are present.
In children before puberty, the average duration is less than a year. Still, a longer duration is expected in older children and adults, and persistence for several years is not exceptional.
The number of lesions present does not influence the prognosis, but mosaic types tend to be incredibly persistent. Regression is occasionally clinically inflammatory and often culminates in blackening from thrombosed blood before the lesion separates, but in many cases takes the form of apparent drying and gradual separation.
Flat Warts or Plane Warts
Due to HPV-3 and 10, plane warts are smooth, flat, or slightly elevated and are usually skin-colored or greyish-yellow but may be pigmented. They are round or polygonal in shape and vary in size from 1 to 5 mm or more in diameter.
The face and the back of the hands are common sites. Their number ranges from two or three to many hundreds. Contiguous lesions may coalesce, and a characteristic of a linear arrangement in scratch marks.
Regression of lesions is usually heralded by inflammation in the lesions, causing itch, erythema, and swelling. Depigmented haloes may appear around the lesions. Resolution is usually complete within a month and appears to be HPV-type specific. In differential diagnosis, lichen planus is the most difficult.
Filiform and digitate warts commonly occur on the face and neck in males. Digitate warts, often in small groups, also occur on the scalp in both sexes, where they are occasionally confused with epidermal naevi. Isolated warts on the limbs often assume a filiform shape.
Anogenital warts are common and are caused by 75% by HPV-6. The remainder is caused by HPV-11 or more unusual, low-risk HPVs.
The typical lesion is soft, pink, elongated, and sometimes filiform or pedunculated. The lesions are usually multiple. They are often asymptomatic but occasionally may cause discomfort, discharge, or bleeding. On the other hand, a sizeable malodorous tumor is present. It grows faster during pregnancy.
The most typical sites, the area of the frenulum, corona, and glans in men and the posterior fourchette in women, correspond to the sites of most significant coital friction.
Most other lesions are flat, though more conspicuous than plane warts elsewhere. Some may be sufficiently dark on non-mucosal surfaces such as the penile shaft, pubic skin, perianal skin, and groins. Both acuminate and flat types may coexist.
Occasionally, only lesions resembling common warts are seen in men, usually on the penile shaft. These may result from contact with common warts elsewhere in the patient or the sexual partner.
In children, lesions in the anogenital area are often more hyperkeratotic than in adults and may be caused by HPV types associated with a skin disease and HPV types 6 and 11.
The duration of infection varies from a few weeks to many years. Recurrences can be expected in about 25% of cases, varying from 2 months to 23 years.
Flat anogenital lesions can appear remarkably similar to lesions of anogenital intraepithelial neoplasia containing high-risk HPVs. Any lesion should raise the possibility that the patient may also be infected with high-risk HPVs and prompt screening for anogenital intraepithelial neoplasia. Vulval papillomatosis, with a diffuse velvety or granular appearance in the vaginal introitus, and pearly penile papules, may confuse with the possibility of warts.
Very florid lesions should warrant consideration of an underlying immune deficiency. The development of large protuberant masses, induration, pain, or serosanguinous discharge should arouse suspicion of malignancy.
Human papillomavirus and warts in special situations
Butchers’ warts. Occupational handlers of meat, poultry, or fish have a high incidence of hand lesions where the skin is in prolonged contact with moist animal flesh. These lesions affect the hands, are often larger than typical lesions, and have a considerable risk of recurrence even after successful treatment
Epidermoid plantar cysts. Epidermoid cysts of weight-bearing areas of the sole have been found to contain papillomavirus.
Oral warts. Oral warts, including some that appear to have been sexually transmitted, usually contain HPV-6 or 11  and, more rarely, HPV-2, 57, or 16 . They are common in association with HIV disease when a greater variety of HPV types may be found, including HPV-7, more usually associated with butchers’ warts. Antiretroviral treatment may lead to worsening of warts rather than improvement.
Respiratory papillomatosis]. This condition is due most commonly to HPV-11 but is also associated with other common genital types such as HPV-6 and very rarely with high-risk type 16. Childhood cases are believed to result from maternal infection at birth during vaginal delivery.
Malignant transformation occurs very rarely and is most associated with HPV type 11. It might explain adult-onset cases, although some may be due to sexual transmission Treatment usually involves recurrent debulking of lesions. Latent or subclinical infection in the laryngeal mucosa explains recurrences after successful treatment.
Conjunctival papilloma. HPV of the low-risk mucosal type is frequently detected in conjunctival papilloma.
Nasal inverting papilloma. HPV-11 and -57 have been detected in nasal papilloma and papilloma of the maxillary sinus.
How do Dermatologists Diagnose Skin Warts (Verrucae)?
A dermatologist can tell whether you have a wart by looking at it. In rare cases, a dermatologist may need to perform a skin biopsy to be sure. If a dermatologist needs to perform a biopsy, the doctor will remove the wart and send it to a lab. It will look at a small piece of the wart in the lab under a microscope. A biopsy is a safe and quick procedure for a dermatologist to perform. It should not cause any anxiety.
How do Dermatologists Treat Skin Warts (Verrucae)?
Not all warts need treatment as many give minor inconvenience and will resolve spontaneously. In addition, patients may need encouragement to persevere with long-term daily use of more straightforward preparations, and more aggressive therapies, such as cryotherapy or surgery, have potential disadvantages.
Whatever method is used, there will be failures and recurrences. The best clinical guide to curing is restoring normal epidermal texture, including the epidermal ridge pattern where appropriate.
Advice on simple measures to limit the spread of the infection will be appreciated. Plantar lesions should be covered with suitable plaster strapping, the foot with close-fitting rubber ‘verruca socks,’ pool-side sandals worn at swimming pools, communal baths, or showers.
The spread of periungual and perioral lesions is often due to biting nails or periungual skin. This practice must be discouraged if attempted treatment is worthwhile; the use of adhesive strapping after applying a ‘wart paint’ helps break the habit. In addition, simple domestic hygiene, such as cleaning baths after use and avoiding shared towels, may be advised.
The most used treatments for warts involve the destruction of the epidermis area infected with the virus. Such treatments may involve the application of topical preparations or surgical approaches. Other therapies aimed at modifying the growth of the epidermis or stimulating an immune response require either a topical or a systemic approach.
Continuous duct tape occlusion of common warts for up to 2 months compared favorably with cryotherapy every 2–3 weeks in children.
The keratolytic effect of salicylic acid helps to reduce the thickness of lesions. Further, it may stimulate an inflammatory response. A preparation containing 12–26% salicylic acid, with another lactic acid, in a quick-drying collodion or acrylate base is the treatment of the first choice for standard.
Daily use in a comparative study for three months achieved cure rates of 67% for hand lesions, 84% for simple plantar lesion starts, and 45% for mosaic plantar lesion starts, comparing favorably with other methods, including liquid nitrogen. Removing surface keratin and the remnants of the previous application by gentle use of a pumice stone, emery board, or foot file is a helpful preliminary in all lesions and essential in very thick plantar lesions.
However, over-enthusiastic abrasion is an expected, if understandable, mistake, which may enhance the spread of the virus by injection into the adjacent skin. It is conceivable that a lesion’s abrasion may help stimulate an immune response.
Accurate application of a salicylic acid preparation, avoiding normal skin, may require a fine applicator such as a sharpened matchstick or a cocktail stick and minimize subsequent local discomfort. After drying, a whitish deposit remains. Penetration into thick keratin, as on the sole, is enhanced by adhesive plaster occlusion, promoting maceration of the keratin layer and reducing barrier function. Occlusion can improve the response rate for treatment with salicylic acid.
These preparations are not suitable for anogenital lesions. They can be particularly irritant on facial skin, though applications or weaker formulations, such as 4% salicylic acid in flexible collodion, may be successful.
Adhesive plaster containing 40% salicylic acid is helpful for plantar lesions. It is applied daily, cut to the shape of the wart or group of warts, and held in place by plain adhesive plaster. The regular use of salicylic acid preparations on warts may need to be continued for at least three months and often longer.
I can use the virucidal properties of glutaraldehyde in wart treatment. Treated skin hardens and is colored brown, limiting acceptability on the hands. Still, the glutaraldehyde dries into the skin without a surface deposit that could be rubbed off, making it a useful application for warts on the feet. Proprietary preparations contain 10% glutaraldehyde in aqueous ethanol or gel formulations. A preparation of 20% glutaraldehyde in an aqueous solution produced a 72% cure rate for various skin lesions in twenty-five individuals.
Podophyllin and podophyllotoxin
Podophyllin is a plant-derived resin containing several cytotoxic compounds in unpredictable ratios. The most active of these is podophyllotoxin. Crude resin and purified podophyllotoxin are used to treat anogenital warts, as they are more effective on mucosal than on keratinized surfaces.
Podophyllin resin is not used so commonly now, but treatment should be under professional supervision. A solution of 10–25% in a compound tincture of benzoin is applied accurately to the area and then allowed to dry for a few minutes. The resin should be thoroughly washed off after 4 hours, though the time can be cautiously increased if the treatment is well tolerated. Applications are repeated weekly or more often.
Podophyllin is contraindicated in pregnancy. Due to presumed systemic absorption, its application has been followed by intrauterine death, vomiting, diarrhea, liver damage, renal damage, coma, peripheral neuropathy, bone marrow suppression, and death. It should not use on exceptionally large or bleeding areas.
Podophyllin and podophyllotoxin are ineffective if applied to lesions of other types due to the lack of penetration of the keratin layer. However, I can use them cautiously under occlusion or salicylic acid. Although clearance rates may be as high as 80–95%, acute pain can occur with intense local inflammation.
The soaking or compressing of 2–3% formalin in water (formalin is about 37% formaldehyde in water) may be effective for plantar lesions but is time-consuming and difficult to limit to affected skin. The formalin is virucidal and dries and hardens the skin, facilitating paring. The affected area must be soaked in the solution for 15–20 min daily, using soft paraffin as a barrier application to protect more sensitive skin.
A 5% solution of 5-fluorouracil (5-FU) carefully applied daily under occlusion for a month is more effective than a placebo. A combination of 5% 5-FU and 10% salicylic acid tested in several studies cleared 63% of warts. Intralesional injection of 40 mg/ml 5-FU weekly for up to 4 weeks produced clearance in over 60% of skin lesions .
Monochloroacetic acid, trichloroacetic acid, silver nitrate, cantharidin], phenol, and others can be used with the same effect. In treating genital lesions, cryotherapy is slightly more effective than trichloroacetic acid alone.
This treatment topically may be tried on plane lesions, but the best results are claimed for higher than usual concentrations, and irritation is common.
Systemic or topical aminolaevulinic acid can be taken up by dividing cells, metabolized to protoporphyrin, and then photoactivated to produce a damaging effect on the cell. The treatment may need to be repeated two or three times but can be limited by pain.
Curettage can; also be effective as a treatment for filiform lesions. Excision is usually avoided since scarring is inevitable, and recurrences of the wart in the scar are frequent. However, good results have been obtained by snipping out perianal lesions after sub-skin injection of adrenaline 1: 300000 in physiological saline under general or local anesthesia].
Curettage and cautery/electrocoagulation, usually in combination, may be used for painful or resistant lesions but carry a risk of scarring. Topical application of local anesthetic cream to the vulva for 10 min numbed the area in over 90% of cases, but otherwise, and for keratinized skin, It would require a local anesthetic injection or even general anesthesia.
Carbon dioxide, snow, and liquid nitrogen can produce cold thermal damage to the skin. Liquid nitrogen is commonly used in hospital practice, applied either by a cotton wool bud or from a cryospray. The rate of application of the freezer is affected by the size of the hole in the spray nozzle or by the size, shape, and density of the cotton wool at the tip of the bud.
Any thick keratin should be pared off, especially in plantar lesions, and the surface is dry before freezing begins. In a standard treatment, the application is continued until a rim of iced tissue (easily seen as a white discoloration) about 1 mm in width develops in the normal skin surrounding the lesion. This may stimulate the development of an immune response. After thawing, a second freeze cycle will improve the cure rate in plantar lesions, although the benefit is less marked in hand skin lesions.
The response to treatment with cryotherapy is comparable to that achieved with salicylic acid. After three months, repeated treatment every three weeks gives a 30–70% cure rate for hand warts. More frequent treatments may improve responses, although they induce more pain, and longer intervals are less effective.
If this fails, or when a wart is particularly painful or deep, or both, as may occur over a bony prominence on foot, more prolonged application, typically up to 30 s, repeated after thawing, may be used to achieve a more significant destructive effect at the cost of significantly greater blistering and pain. Local or even general anesthesia may be considered for such treatment.
The common practice of dipping cotton buds for different patients into an ordinary flask containing liquid nitrogen may risk cross-infection. The main disadvantage of freezing is pain. This is unpredictable and surprisingly variable between patients. Still, in some cases, especially with longer freezing times, it may be severe and persist for many hours or even a few days.
The carbon dioxide laser has been used to treat various wart forms, skin, and mucosal. It can effectively eradicate some difficult warts, such as periungual and subungual warts, which have been unresponsive to other treatments.
Carbon dioxide laser therapy is well-tolerated but, as with cryotherapy, surgery, or other destructive methods, can cause significant postoperative pain, scarring, and temporary loss of function]. Hypertrophic scarring may be exacerbated by concomitant ciclosporin treatment. Infectious viruses can be detected in the plume during carbon dioxide laser us, so an operator mask and air extraction system are advised.
Laser treatment for other indications has been associated with the spread of facial warts. The pulsed dye laser produces less scarring and has been used to treat warts with 50–70% cure rates, using a minimum of two treatments [56–58]. It appears comparable to other treatments such as cryotherapy. Other lasers, such as the Er: YAG and the Nd: YAG, can also be used.
As another destructive method, the infrared coagulator can be used to treat warts.
Dinitrochlorobenzene has elicited a repeated contact sensitivity reaction at the wart site and induces clearance. Still, this chemical is no longer used due to the potential risk of carcinogenesis.
Different routes have administered different interferons (IFNs) to patients with refractory warts. These studies are seldom directly comparable, and the use of interferons in warts is still experimental.
Topical immunomodulation with imiquimod 5%the cream is licensed to treat genital warts. Skin warts have also responded to imiquimod treatment. However, poor penetration through the keratinized surface may necessitate twice daily application for up to 24 weeks, combined with occlusion or salicylic acid to achieve valuable results. Butchers’ warts, filiform facial, and plane warts may all respond, and immunosuppression does not block the therapeutic effect.
The treatment can cause irritation, discomfort, and occasionally erosion at the point of application with a small risk of causing vitiligo-like depigmentation].
Results from oral cimetidine in wart treatment in adults have been conflicting.
Oral retinoids can help debulk warts by reducing epidermal proliferation, although the infection may persist, making relapse likely.
Doses of this cytotoxic agent are given in units of milligrams; 1 mg contains 1500 to 2000 U. Typically, bleomycin sulfate 0.25–1 mg/mL is injected up to three times to a maximum total dose of 4 mg. A lower concentration of 500 U/mL seemed as effective.
Injections are into the wart itself, confirmed by observing blanching in the lesion, the volume per injected lesion ranging between 0.2 and 1.0 mL. Injections are excruciating, and preceding, or concurrent local anesthesia should be considered, especially for sensitive sites such as fingers and soles.
A hemorrhagic eschar develops; 2–3 weeks later, it is pared down if it has not detached spontaneously. Cure rates for previously refractory warts are reported to be between 30 and 100%, with some superiority over cryotherapy. There has been no evidence of systemic toxicity. Local complications include nail loss.
Repeated raising of the temperature of wart-affected skin to a maximally tolerated level of about 50°C is reported to induce wart clearance. The Nd: YAG laser can be used to produce a similar effect .
Many myths and studies claiming that warts can be effectively treated by suggestion or ‘magic’ have been inadequately controlled for spontaneous regression . Formal hypnosis, however, was reported to be precise.
The antiviral cidofovir can be used systemically by infusion (5 mg/kg once weekly) or locally as a 1% gel or cream or by intralesional injection. It can be highly effective in plantar, anogenital, oral, and laryngeal.
Prophylactic vaccination to prevent primary infection with HPV types 6, 11, 16, and 18 has recently become available and is hoped, over the years, to lead to a gradual reduction in the number of cases of anogenital malignancies and genital warts. The effects are type-specific and could speed wart resolution in recalcitrant cases.
The Outcome of Warts (Verrucae) Treatment
There is no cure for the wart virus. This means that warts can return to the same site or appear in a new spot. Sometimes, new warts appear as fast as old ones go away. This happens when old warts shed virus cells into the skin before the warts are treated. This allows new warts to grow around first warts. The best way to prevent this is to have your dermatologist treat new warts as soon as they appear.