Wart

Warts
Warts on the big toe (Plantar warts)
Classification and external resources
Specialty	Dermatology
ICD-10	B07
ICD-9-CM	078.1
DiseasesDB	28410
MedlinePlus	000885
eMedicine	emerg/641
Patient UK	Wart
MeSH	D014860

A filiform wart on the eyelid.

A wart is a small, rough growth resembling a cauliflower or a solid blister. It typically occurs on humans' hands or feet but often in other locations. Warts are caused by a viral infection, specifically by one of the many types of human papillomavirus (HPV). There are as many as 10 varieties of warts, the most common considered to be mostly harmless. It is possible to get warts from others; they are contagious and usually enter the body in an area of broken skin.^[1] Warts are usually asymptomatic except when they occur on weight-bearing areas. ^[2]

Types

A range of types of wart have been identified, varying in shape and site affected, as well as the type of human papillomavirus involved.^[3][4] These include:

• Common wart (Verruca vulgaris), a raised wart with roughened surface, most common on hands, but can grow anywhere on the body. Sometimes known as a Palmer wart or Junior wart.
• Flat wart (Verruca plana), a small, smooth flattened wart, flesh-coloured, which can occur in large numbers; most common on the face, neck, hands, wrists and knees.
• Filiform or digitate wart, a thread- or finger-like wart, most common on the face, especially near the eyelids and lips.
• Genital wart (venereal wart, Condyloma acuminatum, Verruca acuminata), a wart that occurs on the genitalia.
• Mosaic wart, a group of tightly clustered plantar-type warts, commonly on the hands or soles of the feet.
• Periungual wart, a cauliflower-like cluster of warts that occurs around the nails.
• Plantar wart (verruca, Verruca plantaris), a hard sometimes painful lump, often with multiple black specks in the center; usually only found on pressure points on the soles of the feet.

Cause

Micrograph of a common wart (verruca vulgaris) showing the characteristic features (hyperkeratosis, acanthosis, hypergranulosis, rete ridge elongation, and large blood vessels at the dermoepidermal junction, H&E stain)

Warts are caused by the human papilloma virus (HPV). There are about 130 known types of human papilloma viruses.^[5] HPV infects the squamous epithelium, usually of the skin or genitals, but each HPV type is typically only able to infect a few specific areas on the body. Many HPV types can produce a benign growth, often called a "wart" or "papilloma", in the area they infect. Many of the more common HPV and wart types are listed below.

• Common warts – HPV types 2 and 4 (most common); also types 1, 3, 26, 29, and 57 and others.
• Cancers and genital dysplasia – "high-risk" HPV types are associated with cancers, notably cervical cancer, and can also cause some vulvar, vaginal,^[6] penile, anal^[7] and some oropharyngeal cancers. "Low-risk" types are associated with warts or other conditions.^[8][9]

• High-risk: 16, 18 (cause the most cervical cancer); also 31, 33, 35, 39, 45, 52, 58, 59, and others.

• Plantar warts (myrmecia) – HPV type 1 (most common); also types 2, 3, 4, 27, 28, and 58 and others.
• Anogenital warts (condylomata acuminata or venereal warts) – HPV types 6 and 11 (most common); also types 42, 44 and others.^[10]

• Low-risk: 6, 11 (most common); also 13, 44, 40, 43, 42, 54, 61, 72, 81, 89, and others.

• Flat warts – HPV types 3, 10, and 28.
• Butcher's warts – HPV type 7.
• Heck's disease (Focal epithelial hyperplasia) – HPV types 13 and 32.

Pathophysiology

Common warts have a characteristic appearance under the microscope. They have thickening of the stratum corneum (hyperkeratosis), thickening of the stratum spinosum (acanthosis), thickening of the stratum granulosum, rete ridge elongation, and large blood vessels at the dermoepidermal junction.

Prevention

Gardasil is an HPV vaccine aimed at preventing cervical cancers and genital warts. Gardasil is designed to prevent infection with HPV types 16, 18, 6, and 11. HPV types 16 and 18 currently cause about 70% of cervical cancer cases,^[8][9] and also cause some vulvar, vaginal,^[6] penile and anal cancers.^[7] HPV types 6 and 11 are responsible for 90% of documented cases of genital warts.^[11] Unfortunately the HPV vaccines do not currently prevent the virus strain responsible for verrucas (plantar warts).

Disinfection

The virus is relatively hardy and immune to many common disinfectants. Exposure to 90% ethanol for at least 1 minute, 2% glutaraldehyde, 30% Savlon, and/or 1% sodium hypochlorite can disinfect the pathogen.^[12]

The virus is resistant to drying and heat, but killed by 100 °C (212 °F) and ultraviolet radiation.^[12]

Treatment

There are many treatments and procedures associated with wart removal. A review of clinical trials of various cutaneous wart treatments concluded that topical treatments containing salicylic acid were more effective than placebo.^[13] Cryotherapy appears to be as effective as salicylic acid, but there have been fewer trials.^[13]

Medication

Two viral warts on a middle finger, being treated with a mixture of acids (like salicylic acid) to remove them. A white precipitate forms on the area where the product was applied.

Throat warts cannot be treated with medication; they require surgery if the immune system does not heal the throat

• Salicylic acid can be prescribed by a dermatologist in a higher concentration than that found in over-the-counter products. Several over-the-counter products are readily available at pharmacies and supermarkets of roughly two types: adhesive pads treated with salicylic acid, and bottled concentrated salicylic acid solution.
• Imiquimod is a topical cream that helps the body's immune system fight the wart virus by encouraging interferon production. It has been approved by the U.S. Food and Drug Administration (FDA) for genital warts.^[14]
• Cantharidin, found naturally in the bodies of many members of the beetle family Meloidae, causes dermal blistering. It is used either by itself or compounded with podophyllin. Not FDA approved, but available through Canada or select US compounding pharmacies.
• Bleomycin is not US FDA approved and can cause necrosis of digits and Raynaud syndrome.^[15][16] The usual treatment is one or two injections.
• Dinitrochlorobenzene (DNCB), like salicylic acid, is applied directly to the wart. Studies show this method is effective with a cure rate of 80%. But DNCB must be used much more cautiously than salicylic acid; the chemical is known to cause genetic mutations, so it must be administered by a physician. This drug induces an allergic immune response resulting in inflammation that wards off the wart-causing virus.^[17]
• Cidofovir is an antiviral drug which is injected into HPV lesions within the larynx (laryngeal papillomatosis) as an experimental treatment.^[18]

Another product available over-the-counter that can aid in wart removal is silver nitrate in the form of a caustic pencil, which is also available at drug stores. In a placebo-controlled study of 70 patients, silver nitrate given over nine days resulted in clearance of all warts in 43% and improvement in warts in 26% one month after treatment compared to 11% and 14%, respectively, in the placebo group.^[19] The instructions must be followed to minimize staining of skin and clothing. Occasionally pigmented scars may develop.

Cryosurgery or cryotherapy devices using a dimethyl ether – propane mixture are inexpensive. A disadvantage is that the sponge applicator is too large for small warts, and the temperature achieved is not nearly as low as with liquid nitrogen. Complications include blistering of normal skin if excess freezing is not controlled.

Several randomized, controlled trials have found that zinc sulfate, consumed orally, often reduces or eliminates warts.^[20][21][22] The zinc sulfate dosage used in medical trials for treatment of warts was between 5 and 10 mg/kg/day. For elemental zinc, a lower dosage of 2.5 mg/kg/day may be appropriate as large amounts of zinc may cause a copper deficiency.^[20] Other trials have found that topical zinc sulfate solution^[23] or zinc oxide^[24] are also effective.

A 2014 study indicates that lopinavir is effective against the human papilloma virus (HPV). The study used the equivalent of one tablet twice a day applied topically to the cervices of women with high-grade and low-grade precancerous conditions. After three months of treatment, 82.6% of the women who had high-grade disease had normal cervical conditions, confirmed by smears and biopsies.^[25]

Procedures

Liquid nitrogen spray tank

• Keratolysis, of dead surface skin cells usually using salicylic acid, blistering agents, immune system modifiers ("immunomodulators"), or formaldehyde, often with mechanical paring of the wart with a pumice stone, blade etc.^[26]
• Electrodesiccation^[27]
• Cryosurgery, which involves freezing the wart (generally with liquid nitrogen), creating a blister between the wart and epidermal layer after which the wart and the surrounding dead skin supposedly fall off by themselves, although this was tested by the NHS to be ineffective. An average of 3 to 4 treatments are required for warts on thin skin. Warts on calloused skin like plantar warts might take dozens or more treatments.^[15]
• Surgical curettage of the wart;
• Laser treatment – often with a pulse dye laser or carbon dioxide (CO₂) laser. Pulse dye lasers (wavelength 582 nm) work by selective absorption by blood cells (specifically haemoglobin). CO₂ lasers work by selective absorption by water molecules. Pulse dye lasers are less destructive and more likely to heal without scarring. CO₂ laser works by vaporizing and destroying tissue and skin. Laser treatments can be painful, expensive (though covered by many insurances), and not extensively scarring when used appropriately. CO₂ lasers will require local anaesthetic. Pulse dye laser treatment does not need conscious sedation or local anesthetic. It takes 2 to 4 treatments but can be many more for extreme cases. Typically, 10–14 days are required between treatments. Preventative measures are important.^[15]
• Infrared coagulator – an intense source of infrared light in a small beam like a laser. This works essentially on the same principle as laser treatment. It is less expensive. Like the laser, it can cause blistering pain and scarring.^[28]
• Duct tape occlusion therapy involves placing a piece of duct tape over the wart. The mechanism of action of this technique still remains unknown, and despite several clinical trials the evidence for the efficacy of duct tape therapy is inconclusive.^[29] Despite the mixed evidence for efficacy, the simplicity of the method and its limited side-effects leads some researchers to be reluctant to dismiss it.^[30]
• Garlic extract therapy- fat soluble garlic extracts have been shown to clear greater than 90% of cases. The extract is applied twice daily and covered with a bandaid. Improvements show within 2–4 weeks and total clearing in an average of 6–9 weeks.^[31][32][33]

Society and culture

Despite their appearance, toads do not cause warts.

A variety of traditional folk remedies and rituals claim to be able to remove warts.

The acrid yellow sap of Greater Celandine is used as a traditional wart remedy.^[34] The sap can be applied directly to the wart in a similar manner to concentrated salicylic acid solution, but in more modest quantities.

In The Adventures of Tom Sawyer, Mark Twain has his characters discuss a variety of such remedies. Tom Sawyer proposes "spunk-water" (or "stump-water", the water collecting in the hollow of a tree stump) as a remedy for warts on the hand. You put your hand into the water at midnight and say:

Barley-corn, barley-corn, injun-meal shorts,
Spunk-water, spunk-water, swaller these warts

You then "walk away quick, eleven steps, with your eyes shut, and then turn around three times and walk home without speaking to anybody. Because if you speak the charm's busted." This is held to be superior to Huckleberry Finn's preferred remedy which involved throwing a dead cat into a graveyard. Another remedy involved splitting a bean, drawing blood from the wart and putting it on one of the halves, and burying that half at a crossroads at midnight. The theory of operation is that the blood on the buried bean will draw away the wart.^[35] Twain is recognized as an early collector and recorder of genuine American folklore.^[36]

Similar practices are recorded elsewhere. In Louisiana, one remedy for warts involves rubbing the wart with a potato, which is then buried; when the "buried potato dries up, the wart will be cured".^[37] Another remedy similar to Twain's is reported from Northern Ireland, where water from a specific well on Rathlin Island is credited with the power to cure warts.^[38]

A longstanding tradition holds that touching toads will cause warts. The most common Northern Hemisphere toads have glands that protrude from their skin that superficially resemble warts. Warts are caused by a virus, and toads do not harbor it.^[39]

Other animals

References

1. "Warts Types, Causes, Symptoms, Treatments, Prevention". Webmd.com. 2010-09-02. Retrieved 2013-05-17.
2. Tamparo, Carol. Diseases of the Human Body (Fifth Edition ed.). Philadelphia,PA. p. 195. ISBN 978-0-8036-2505-1.
3. Anderson, Keith,; Keith, Jeff; Novak, Patricia D.; Elliot, Michelle A. (2005). Mosby's Medical, Nursing & Allied Health Dictionary (5th ed.). C.V. Mosby. ISBN 978-0-323-03736-5.
4. "MedlinePlus: Warts". 2010.
5. de Villiers EM, Fauquet C, Broker TR, Bernard HU, zur Hausen H (Jun 2004). "Classification of papillomaviruses". Virology 324 (1): 17–27. doi:10.1016/j.virol.2004.03.033. PMID 15183049.
6. "FDA Approves Expanded Uses for Gardasil to Include Preventing Certain Vulvar and Vaginal Cancers". 2008-09-12. Retrieved 2009-08-04.
7. Cortez, Michelle Fay and Pettypiece, Shannon (2008-11-13). "Merck Cancer Shot Cuts Genital Warts, Lesions in Men". Bloomberg News. Retrieved 2013-05-17.
8. Lowy DR, Schiller JT (2006). "Prophylactic human papillomavirus vaccines". J. Clin. Invest. 116 (5): 1167–73. doi:10.1172/JCI28607. PMC 1451224. PMID 16670757.
9. Muñoz N, Bosch FX, Castellsagué X, Díaz M, de Sanjose S, Hammouda D, Shah KV, Meijer CJ (2004-08-20). "Against which human papillomavirus types shall we vaccinate and screen? The international perspective". Int J Cancer 111 (2): 278–85. doi:10.1002/ijc.20244. PMID 15197783.
10. Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Mitchell, Richard (2007). "Chapter 19 The Female Genital System and Breast". Robbins Basic Pathology (8 ed.). Philadelphia: Saunders. ISBN 1-4160-2973-7.
11. Steinbrook, Robert (March 16, 2006). "Perspective – The Potential of Human Papillomavirus Vaccines".
12. http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/papillome-eng.php
13. Kwok CS, Gibbs S, Bennett C, Holland R, Abbott R (Sep 12, 2012). Gibbs, Sam, ed. "Topical treatments for cutaneous warts". The Cochrane database of systematic reviews 9: CD001781. doi:10.1002/14651858.CD001781.pub3. PMID 22972052.
14. Barclay, Laurie (2011-06-04). "Short-Acting Imiquimod Cream Approved for Genital Warts". Medscape. Retrieved 10 August 2011.
15. Bacelieri R, Johnson SM (2005). "Cutaneous warts: An evidence-based approach to therapy". American family physician 72 (4): 647–652. PMID 16127954.
16. Champion, R.H., et al. (1998) Rook's Textbook of Dermatology. Blackwell Science, p. 1044, ISBN 0-632-06429-3
17. "Treating Warts". British Medical Journal. 2002-08-31. Retrieved 2013-05-17.
18. Soma, Marlene A; Albert, David M (2008). "Cidofovir: to use or not to use?". Current Opinion in Otolaryngology & Head and Neck Surgery 16 (1): 86–90. doi:10.1097/MOO.0b013e3282f43408. ISSN 1068-9508. PMID 18197029.
19. Sterling JC, Handfield-Jones S, Hudson PM (2001). "Guidelines for the management of cutaneous warts" (PDF). British Journal of Dermatology 144 (1): 4–11. doi:10.1046/j.1365-2133.2001.04066.x. PMID 11167676.
20. Stefani M, Bottino G, Fontenelle E, Azulay DR (2009). "Efficacy comparison between cimetidine and zinc sulphate in the treatment of multiple and recalcitrant warts". An Bras Dermatol 84 (1): 23–9. PMID 19377755.
21. Yaghoobi R, Sadighha A, Baktash D (April 2009). "Evaluation of oral zinc sulfate effect on recalcitrant multiple viral warts: a randomized placebo-controlled clinical trial". J. Am. Acad. Dermatol. 60 (4): 706–8. doi:10.1016/j.jaad.2008.09.010. PMID 19293025.
22. Al-Gurairi FT, Al-Waiz M, Sharquie KE (March 2002). "Oral zinc sulphate in the treatment of recalcitrant viral warts: randomized placebo-controlled clinical trial". Br. J. Dermatol. 146 (3): 423–31. doi:10.1046/j.1365-2133.2002.04617.x. PMID 11952542.
23. Sharquie KE, Khorsheed AA, Al-Nuaimy AA (September 2007). "Topical zinc sulphate solution for treatment of viral warts". Saudi Med J 28 (9): 1418–21. PMID 17768472.
24. Khattar JA, Musharrafieh UM, Tamim H, Hamadeh GN (April 2007). "Topical zinc oxide vs. salicylic acid-lactic acid combination in the treatment of warts". Int. J. Dermatol. 46 (4): 427–30. doi:10.1111/j.1365-4632.2006.03138.x. PMID 17442091.
25. HIV drug used to reverse effects of virus that causes cervical cancer University of Manchester, 17 February 2014.
26. Warts at About.com
27. Stone KM, Becker TM, Hadgu A, Kraus SJ (1990). "Treatment of external genital warts: A randomised clinical trial comparing podophyllin, cryotherapy, and electrodesiccation" (PDF). Genitourinary medicine 66 (1): 16–19. doi:10.1136/sti.66.1.16. PMC 1194434. PMID 2179111.
28. Halasz CL (1994). "Treatment of common warts using the infrared coagulator". The Journal of dermatologic surgery and oncology 20 (4): 252–256. doi:10.1111/j.1524-4725.1994.tb01620.x. PMID 8163746.
29. Kwok CS; Gibbs S; Bennett C; Holland R; Abbott R (12 Sep 2012). "Topical treatments for cutaneous warts.". Cochrane Database Syst Rev 9: CD001781. doi:10.1002/14651858.CD001781.pub3. PMID 22972052.
30. Stubbings A, Wacogne I (September 2011). "Question 3. What is the efficacy of duct tape as a treatment for verruca vulgaris?". Archives of Disease in Childhood 96 (9): 897–9. doi:10.1136/archdischild-2011-300533. PMID 21836182.
31. Dehghani F., Merat A., Panjehshahin M. R., Handjani F. (2005). "Healing effect of garlic extract on warts and corns". International Journal of Dermatology 44: 612–615. doi:10.1111/j.1365-4632.2004.02348.x.
32. Kenawy S., Mohammed G. F., Younes S., Elakhras A. I. (2014). "Evaluation of TNF-α serum level in patients with recalcitrant multiple common warts, treated by lipid garlic extract". Dermatologic Therapy 27: 272–277. doi:10.1111/dth.12136.
33. Silverberg N. B. (2002). "Garlic Cloves for Verruca Vulgaris". Pediatric Dermatology 19: 183. doi:10.1046/j.1525-1470.2002.00038.x.
34. http://www.botanical-online.com/english/celandine_for_warts.htm
35. Mark Twain, The Adventures of Tom Sawyer, ch. 6
36. LeMaster, J. R. (1993) The Mark Twain Encyclopedia (Taylor and Francis, pp. 293–294, ISBN 0-8240-7212-X.
37. Webb, Julie Yvonne (1971). "Louisiana Voodoo and Superstitions Relating to Health". HSMHA Health Reports 86 (4): 291, 296–297. doi:10.2307/4594154. PMC 1937133. PMID 4324337.
38. Ballard LM (2009). "An approach to traditional cures in Ulster". The Ulster medical journal 78 (1): 26–33. PMC 2629017. PMID 19252727.
39. Clark, Josh. "Do toads cause warts?". science.howstuffworks.com. p. 2. Retrieved October 20, 2012.

External links

• Wart photo library, Dermnet