Warts Diagnosis and Treatment

1. Warts Diagnosis and Treatment Rick Lin, DO MPH First Year Dermatology Resident Texas Division of KCOM Dermatology Residency Program

2. Background Information • Warts are small harmless lesions of the skin • caused by a virus: the human papilloma virus. • The appearance of warts can differ based on the type of wart and where it is located on the body. • Warts are common in children. Most cases occur between ages 12-16 years. • Up to 30% of warts disappear by themselves within 6 months. Most will disappear without any treatment within 3 years.

3. Background Information • Warts are caused by the DNA-containing human papillomavirus (HPV). There are at least 63 genetically different types of HPVs. • The virus enters the skin after direct contact with recently shed viruses kept alive in warm, moist environments such as a locker room, or by direct contact with an infected person. • The entry site is often an area of recent injury. The incubation time—from when the virus is contracted until a wart appears—can be 1-8 months.

4. Background Information • Contrary to popular mythology, touching a frog will not give you warts.

5. Types of warts • Common warts (verrucae vulgaris): These common warts typically develop on the hand, especially around the nail. They are gray to flesh colored, raised from the skin surface, and covered with rough, hornlike projections.

15. Types of warts • Plantar warts (verrucae plantaris): Plantar warts, by definition, occur on the plantar surface, or bottom, of the foot. • They usually occur in high pressure areas such as the heel and the metatarsal heads (just behind the toes). • They usually grow into the skin, not outward like common warts. • This growing into the skin makes them more difficult to treat.

19. Flat warts (verrucae plana): Flat warts are most commonly seen on the face, the back of the hands, and lower legs. They usually appear as small individual bumps about 1/4 inch across. Flat warts may spread rapidly on the face and lower legs from the activities involved in shaving. Types of warts

23. Histopathology • Verruca vulgaris (common wart) is caused  by varous strains of human papilloma virus (HPV 1, 2, 4, 7, 26-29). • Macroscopically  verruca vulgaris may present as hard, rough surfaced papule 2 – 20 mm (solitary or multiple). • Microscopically, this  is an exophytic, symmetric, papillomatous lesion with large keratohyaline granules and characteristic inturning of the rete ridges.

24. Histopathology • Parakeratotic columnar tiers of stratum corneum overlie the papillomatous surface. • Small amounts of hemorrhage may be present within the columns of parakeratosis. • Other characteristic features include koilocytosis,  hypergranulosis and presence of  multinucleated cells.

27. Treatment • Home care is effective in making the wart or warts go away. No matter what technique you use, warts will disappear 60-70% of the time. • Techniques may be done with and without medication.

28. Treatment • The ultimate goal of the medical therapies (not the surgical treatments) is to get your body to recognize the wart as something foreign and to destroy it, much like the body destroys a cold virus.

29. Adhesive tape therapy • Place several layers of waterproof adhesive tape over the wart region (even duct tape). • Do not remove the tape for 6-1/2 days. Then take off the tape and open the area to the air for 12 hours. • Reapply tape for another 6-1/2 days.

30. Adhesive tape therapy • The tape works best in the region around the fingernail. • Tape works because the air-tight, moist environment under the tape does not allow the virus to grow and reproduce

31. Salicylic acid therapy • Salicylic acid is available by many different trade names at the drug store. • Dual Film • Wart-Off • Dr. Scholl’s Wart Medication • Medi-Plast • It comes either as a liquid to paint on the wart or as a plaster to be cut out and placed on the wart tissue.

32. Salicylic acid therapy • The area with the wart should be soaked in warm water for 5-10 minutes. • The wart should then be pared down with a razor. A simple razor works fine for this, then throw it away. • Do not shave far enough to make the wart bleed.

33. Salicylic acid therapy • Apply the salicylic acid preparation to the wart tissue. • Do not apply it to other skin because of salicylic acid's potential to injure normal tissue. • Follow directions on the package for how long to apply the acid.

34. Cryosurgery • Liquid nitrogen or cryotherapy is used to deep freeze the wart tissue. • With liquid nitrogen applied to the wart, the water in the cells expands, thus exploding the infected tissue. • The exploded cells can no longer hide the human papillomavirus from the body's immune system. • The immune system then works to destroy the virus particles.

35. Cryosurgery • Periungual area may scar if cryotherapy with liquid nitrogen is used improperly. • Scarring could lead to permanent nail disfiguration.

39. Laser Therapy • Laser therapy: Lasers are simply very intense light sources. • This light has an enormous amount of energy that heats the tissue enough that it vaporizes.

40. Shave Removal • Shave removal and electrodessication of the base may be necessary when other treatment methods fail. • This would involve numbing the region around the wart and shaving the wart flat with the surface and light electrodessication of the base.

45. Prognosis: • Most warts will disappear without treatment anywhere from 6 months to 3 years. • Warts may recur after treatment and require additional treatments.

46. Prevention: • Avoid touching warts on others or touching them on yourself (refrain from rubbing a warty finger across your face). • Children needs to avoid biting or chewing warts. • Wear shower shoes in the gym locker room to lower your risk of picking up the virus that causes plantar warts from the moist environment.

47. When to Refer • If you feel uncomfortable treating warts. • Warts that are resistant to your treatment • Unsure of diagnosis

48. Questions and Answers