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Wart

warts, wart removal
Warts are typically small, rough, and hard growths that are similar in color to the rest of the skin13 They typically do not result in symptoms except when on the bottom of the feet where they may be painful3 While they usually occur on the hands and feet they can also affect other locations1 One or many warts may appear They are not cancerous3

Warts are caused by infection with a type of human papillomavirus HPV1 Factors that increase the risk include use of public showers, working with meat, eczema, and a low immune system13 The virus is believed to enter the body through skin that has been damaged slightly1 A number of types exist including: common warts, plantar warts, filiform warts, and genital warts3 Genital warts are often sexually transmitted5

Without treatment, most types of warts resolve in months to years A number of treatments may speed resolution including salicylic acid applied to the skin and cryotherapy In those who are otherwise healthy they do not typically result in significant problems1 Treatment of genital warts differ from that of other types3

Warts are very common, with most people being infected at some point in time2 The estimated current rate of non-genital warts among the general population is 1–13% They are more common among young people1 Estimated rates of genital warts in sexually active women is 12%5 Warts have been described at least as far back as 400 BC by Hippocrates4

Contents

  • 1 Types
  • 2 Cause
  • 3 Pathophysiology
  • 4 Prevention
    • 41 Disinfection
  • 5 Treatment
    • 51 Medication
    • 52 Procedures
  • 6 Society and culture
  • 7 Other animals
  • 8 References
  • 9 External links

Typesedit

A filiform wart on the eyelid

A range of types of wart have been identified, varying in shape and site affected, as well as the type of human papillomavirus involved67 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

Causeedit

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 Main article: Human papilloma virus

Warts are caused by the human papilloma virus HPV There are about 130 known types of human papilloma viruses8 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,9 penile, anal10 and some oropharyngeal cancers "Low-risk" types are associated with warts or other conditions1112
  • 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 others13
  • 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

Pathophysiologyedit

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

Preventionedit

Gardasil 6 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,1112 and also cause some vulvar, vaginal,9 penile and anal cancers10 HPV types 6 and 11 are responsible for 90% of documented cases of genital warts14

Gardasil 9, approved in 2014 protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 5815

HPV vaccines do not currently protect against the virus strains responsible for plantar warts verrucas

Disinfectionedit

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 pathogen16

The virus is resistant to drying and heat, but killed by 100 °C 212 °F and ultraviolet radiation16

Treatmentedit

Further information: Plantar wart § Treatment

There are many treatments and procedures associated with wart removal17 A review of clinical trials of various cutaneous wart treatments concluded that topical treatments containing salicylic acid were more effective than placebo18 Cryotherapy appears to be as effective as salicylic acid, but there have been fewer trials18

Medicationedit

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 This image shows throat warts papillomas before treatment and during the treatment process Left to right: warts prior to treatment, warts on day of silver nitrate treatment, warts two days after treatment, warts four days after treatment, warts six days after treatment, and warts remaining nine days after treatment
  • 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 US Food and Drug Administration FDA for genital warts19
  • 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 syndrome2021 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 virus22
  • Cidofovir is an antiviral drug which is injected into HPV lesions within the larynx laryngeal papillomatosis as an experimental treatment23

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 group24 The instructions must be followed to minimize staining of skin and clothing Occasionally pigmented scars may develop

Several randomized, controlled trials have found that zinc sulfate, consumed orally, often reduces or eliminates warts252627 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 25 mg/kg/day may be appropriate as large amounts of zinc may cause a copper deficiency25 Other trials have found that topical zinc sulfate solution28 or zinc oxide29 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, 826% of the women who had high-grade disease had normal cervical conditions, confirmed by smears and biopsies30

Studies of fat-soluble garlic extracts have shown clearing in greater than 90% of cases The extract is applied twice daily and covered with an adhesive bandage Improvements show within 2–4 weeks and total clearing in an average of 6–9 weeks313233

Proceduresedit

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 etc34
  • Electrodesiccation35
  • Cryosurgery or cryotherapy, which involves freezing the wart generally with liquid nitrogen,36 creating a blister between the wart and epidermal layer after which the wart and the surrounding dead skin fall off 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 treatments20
  • 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 hemoglobin 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 insurance plans, 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 important20
  • 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 scarring37
  • Duct tape occlusion therapy involves placing a piece of duct tape over the wart The mechanism of action of this technique still remains unknown Despite several clinical trials, evidence for the efficacy of duct tape therapy is inconclusive38 Despite the mixed evidence for efficacy, the simplicity of the method and its limited side-effects leads some researchers to be reluctant to dismiss it39

Society and cultureedit

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 remedy40 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 wart41 Twain is recognized as an early collector and recorder of genuine American folklore42

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"43 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 warts44

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 it45

Other animalsedit

See also: Papillomavirus and Bovine papillomavirus

Referencesedit

  1. ^ a b c d e f g h i j k l Loo, SK; Tang, WY 12 June 2014 "Warts non-genital" BMJ clinical evidence 2014 PMC 4054795  PMID 24921240 
  2. ^ a b c "Papillomas Warts - National Library of Medicine" PubMed Health Retrieved 2016-11-06 
  3. ^ a b c d e f g h "Warts: Overview" US National Library of Medicine 30 July 2014 
  4. ^ a b Bope, Edward T; Kellerman, Rick D 2012 Conn's Current Therapy 2012 Elsevier Health Sciences p 275 ISBN 1455733059 
  5. ^ a b W Buck, Henry 13 August 2010 "Warts genital" BMJ clinical evidence 2010 PMC 3217761  PMID 21418685 
  6. ^ Anderson, Keith,; Keith, Jeff; Novak, Patricia D; Elliot, Michelle A 2005 Mosby's Medical, Nursing & Allied Health Dictionary 5th ed CV Mosby ISBN 978-0-323-03736-5 CS1 maint: Multiple names: authors list link
  7. ^ "MedlinePlus: Warts" 2010 
  8. ^ de Villiers EM, Fauquet C, Broker TR, Bernard HU, zur Hausen H Jun 2004 "Classification of papillomaviruses" Virology 324 1: 17–27 PMID 15183049 doi:101016/jvirol200403033 
  9. ^ a b "FDA Approves Expanded Uses for Gardasil to Include Preventing Certain Vulvar and Vaginal Cancers" FDA 2008-09-12 
  10. ^ a b Cortez, Michelle Fay; Pettypiece, Shannon 2008-11-13 "Merck Cancer Shot Cuts Genital Warts, Lesions in Men" Bloomberg News Retrieved 2013-05-17 
  11. ^ a b Lowy DR, Schiller JT 2006 "Prophylactic human papillomavirus vaccines" J Clin Invest 116 5: 1167–73 PMC 1451224  PMID 16670757 doi:101172/JCI28607 
  12. ^ a b 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 PMID 15197783 doi:101002/ijc20244 
  13. ^ 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 
  14. ^ Steinbrook, Robert 2006 "The Potential of Human Papillomavirus Vaccines" New England Journal of Medicine 354 11: 1109–12 PMID 16540608 doi:101056/NEJMp058305 
  15. ^ "Prescribing information Gardasil 9" PDF Food and Drug Administration 2015 
  16. ^ a b HUMAN PAPILLOMAVIRUS Public Health Agency of Canada
  17. ^ Lipke MM 2006 "An armamentarium of wart treatments" Clin Med Res 4 4: 273–93 PMC 1764803  PMID 17210977 doi:103121/cmr44273 
  18. ^ a b 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 9: CD001781 PMID 22972052 doi:101002/14651858CD001781pub3 CS1 maint: Multiple names: authors list link
  19. ^ Barclay, Laurie 2011-06-04 "Short-Acting Imiquimod Cream Approved for Genital Warts" Medscape Retrieved 10 August 2011 
  20. ^ a b c Bacelieri R, Johnson SM 2005 "Cutaneous warts: An evidence-based approach to therapy" American family physician 72 4: 647–652 PMID 16127954 
  21. ^ Champion, RH, et al 1998 Rook's Textbook of Dermatology Blackwell Science, p 1044, ISBN 0-632-06429-3
  22. ^ "Treating Warts" British Medical Journal 2002-08-31 Retrieved 2013-05-17 
  23. ^ 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 PMID 18197029 doi:101097/MOO0b013e3282f43408 
  24. ^ Sterling JC, Handfield-Jones S, Hudson PM 2001 "Guidelines for the management of cutaneous warts" PDF British Journal of Dermatology 144 1: 4–11 PMID 11167676 doi:101046/j1365-2133200104066x CS1 maint: Multiple names: authors list link
  25. ^ a b 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 
  26. ^ 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 PMID 19293025 doi:101016/jjaad200809010 
  27. ^ 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 PMID 11952542 doi:101046/j1365-2133200204617x 
  28. ^ 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 
  29. ^ 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 PMID 17442091 doi:101111/j1365-4632200603138x 
  30. ^ HIV drug used to reverse effects of virus that causes cervical cancer University of Manchester, 17 February 2014
  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 7: 612–615 PMID 15985039 doi:101111/j1365-4632200402348x 
  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 5: 272–277 doi:101111/dth12136 
  33. ^ Silverberg N B 2002 "Garlic Cloves for Verruca Vulgaris" Pediatric Dermatology 19 2: 183 doi:101046/j1525-1470200200038x 
  34. ^ Warts at Aboutcom
  35. ^ Stone KM, Becker TM, Hadgu A, Kraus SJ 1990 "Treatment of external genital warts: A randomised clinical trial comparing podophyllin, cryotherapy, and electrodesiccation" Genitourinary medicine 66 1: 16–19 PMC 1194434  PMID 2179111 doi:101136/sti66116 
  36. ^ "Cryotherapy for Warts" WebMD 
  37. ^ Halasz CL 1994 "Treatment of common warts using the infrared coagulator" The Journal of dermatologic surgery and oncology 20 4: 252–256 PMID 8163746 doi:101111/j1524-47251994tb01620x 
  38. ^ Kwok CS; Gibbs S; Bennett C; Holland R; Abbott R 12 Sep 2012 "Topical treatments for cutaneous warts" Cochrane Database Syst Rev 9 9: CD001781 PMID 22972052 doi:101002/14651858CD001781pub3 
  39. ^ 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 PMID 21836182 doi:101136/archdischild-2011-300533 
  40. ^ Greater Celandine For Warts botanical-onlinecom
  41. ^ Mark Twain, The Adventures of Tom Sawyer, ch 6
  42. ^ LeMaster, J R 1993 The Mark Twain Encyclopedia Taylor and Francis, pp 293–294, ISBN 0-8240-7212-X
  43. ^ Webb, Julie Yvonne 1971 "Louisiana Voodoo and Superstitions Relating to Health" HSMHA Health Reports 86 4: 291, 296–297 JSTOR 4594154 PMC 1937133  PMID 4324337 doi:102307/4594154 
  44. ^ Ballard LM 2009 "An approach to traditional cures in Ulster" The Ulster medical journal 78 1: 26–33 PMC 2629017  PMID 19252727 
  45. ^ Clark, Josh "Do toads cause warts" sciencehowstuffworkscom p 2 Retrieved October 20, 2012 

External linksedit

  • Wart photo library, Dermnet
Classification
  • ICD-10: B07
  • ICD-9-CM: 0781
  • DiseasesDB: 28410
External resources
  • MedlinePlus: 000885
  • eMedicine: emerg/641
  • Patient UK: Wart



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