High Yield Topics

Warts

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Ovid: 5-Minute Sports Medicine Consult, The


Warts
Kathleen Weber
Basics
Description
Warts are caused by a human papillomavirus (HPV) infection, resulting in a variety of lesions on the skin and mucous membranes.
Epidemiology
  • More than 130 different genotypes of HPV have been identified (1).
  • Cutaneous HPV infections, 3 types:
    • Common warts (verruca vulgaris): 70%
    • Plantar warts (verruca plantaris): 25–30%
    • Flat warts (verruca plana): 3–4%
  • 10–20% of children will develop cutaneous warts, with the peak incidence occurring between 12 and 16 yrs.
  • Mucosal HPV infections:
    • Most common are genital warts (condyloma acuminatum)
    • Estimated prevalence rate of HPV genital infection in the U.S. adult population is 10–20% (2).
Risk Factors
  • Cutaneous HPV infections:
    • Transmission: Direct or indirect contact; minor superficial abrasions of the skin promote infection
    • Autoinoculation occurs especially in younger children.
    • Risk factors: Immunocompromised
  • Mucosal HPV infections:
    • Transmission: Sexual contact; contact with contaminated objects; autoinoculation; vertical transmission during vaginal delivery (2)
    • Risk factors: Unprotected sexual relations; multiple sex partners
General Prevention
  • Cutaneous lesions: No restrictions for participation; coverage recommended (3)
  • Mucosal lesions: Condoms recommended, but not completely effective
  • Anogenital warts: The importance of Pap smears should be stressed; screen for other sexually transmitted diseases (1)
  • HPV vaccination is indicated for use in women who are between 9 and 26 yrs of age; not recommended for pregnant women (1)[A]
  • Ideally, young women should be vaccinated before they have sexual intercourse for the 1st time (1).
Etiology
  • HPV infects epithelial tissues and mucous membranes.
  • The virus infects the mucosa or the basal layer of the skin, causing cellular proliferation and vascular growth, resulting in a mucosal or skin lesion.
  • Incubation period, once exposed, varies from weeks to more than a year.
Commonly Associated Conditions
  • Cutaneous HPV infection: Warts may regress spontaneously; immunocompromised individuals may be refractory to all treatment.
  • Condylomata recurs commonly despite therapy.
  • Condylomata is associated with cervical dysplasia and cervical squamous cell carcinoma, invasive carcinoma of genitalia, and anal squamous cell carcinoma.
Diagnosis
Warts are usually diagnosed based on their appearance (4).
History
  • Cutaneous and anogenital warts are usually asymptomatic, but plantar warts can cause discomfort during activities.
  • Without treatment, the wart can remain for months to years.
  • Diagnosis is usually made by characteristic appearance of lesions.
Physical Exam
  • Verruca vulgaris (common warts):
    • Skin-colored papule, hyperkeratotic with horny surface
    • Normal skin markings are disrupted.
    • Pathognomonic for warts are red-black dots seen on the surface
    • Can be 1 or multiple lesions
    • Typically asymptomatic, but may be painful, especially if located over areas of pressure
    • Distribution: Fingers, hands (most common), knees, may occur anywhere
  • Verruca plantaris (plantar warts):
    • Skin-colored papule with coarse, keratotic surface; has characteristic red-black dots
    • Normal skin markings are disrupted.
    • Painful, especially if located over areas of pressure
    • Distribution: Plantar surface of foot

    • P.625


  • Verruca plana (flat warts):
    • Skin-colored or lightly pigmented; well-defined, smooth, flat, or slightly elevated papules
    • Variety of shapes: Round, oval, linear
    • Sizes vary from pinhead to a few millimeters.
    • Numbers range from a few to hundreds.
    • Distribution: Face; dorsum of the hands; extremities, especially shins
    • Most commonly seen in children and less common in adolescents and adults
  • Condylomata acuminata (anogenital warts):
    • Skin-colored, slightly pigmented, or pink
    • Range from soft, tiny isolated papules, filiform and often pedunculated sessile papules to cauliflower masses (2)
    • Distribution: Glans penis, prepuce, shaft, labia, vagina, cervix, perianal area, urethra, bladder, rectum, and oral cavity (2)
    • Most asymptomatic or subclinical; may go unrecognized
    • Subclinical lesions on the genital skin can be visualized as white patches by applying 5% acetic acid to the suspected area.
    • Confirmed by biopsy if diagnosis unclear by exam
Differential Diagnosis
  • Verruca vulgaris: Callus, guttate psoriasis, molluscum contagiosum, seborrheic keratosis
  • Verruca plantaris: Callus, corn
  • Verruca plana: Lichen planus, molluscum contagiosum, seborrheic keratosis, moles, skin tags
  • Condylomata acuminata: Lichen planus, pearly penile papules, skin tags, squamous cell carcinoma, condyloma lata due to secondary syphilis
Treatment
  • Salicylic acid preparations (10–70%) (5)[A]
  • Cryosurgery (liquid nitrogen): Apply to wart and surrounding normal tissue (1 mm) for ∼10–15 sec; repeat every 4 wks (may be painful) (5)[B]
  • Alternative therapies: Excision, electrocautery, CO2 laser surgery (6)[A], or pulsed dye laser (PDL) (6)[A]
  • Duct tape (4)[C]
  • For mucosal lesions: Cryosurgery as described above; repeat weekly
  • Podophyllotoxin (7)[A], podophyllin (2)[B] contrai-ndicated during pregnancy
  • Trichloroacetic acid 80–90% (2)[B]
  • Imiquimod 5% (7)[A]
  • CO2 laser, PDL (6)[A]
  • Alternative therapies: Electrocautery or excision (2)[A]
Additional Treatment
Referral
Referral to a dermatologist should be considered in recalcitrant warts or immunocompromised patients.
Ongoing Care
Follow-Up Recommendations
  • Papanicolaou tests screening for cervical cancer at age 18 or at the onset of sexual activity
  • In cases of extensive or recalcitrant anogenital warts, consider immune deficiency, especially HIV.
References
1. Kahn JA. HPV vaccination for the prevention of cervical intraepithelial neoplasia. N Engl J Med. 2009;361:271–278.
2. Scheinfeld N, Lehman DS. An evidence-based review of medical and surgical treatments of genital warts. Dermatol Online J. 2006;12:5
3. Cordoro KM, Ganz JE. Training room management of medical conditions: sports dermatology. Clin Sports Med. 2005;24:565–598, viii–ix.
4. Herman BE, Corneli HM. A practical approach to warts in the emergency department. Pediatr Emerg Care. 2008;24:246–251; quiz 252–254
5. Gibbs S, Harvey I. Topical treatments for cutaneous warts. Cochrane Database Syst Rev. 2006;3:CD001781.
6. Ockenfels HM, Hammes S. [Laser treatment of warts.] Hautarzt. 2008.
7. Yan J, Chen SL, Wang HN, et al. Meta-analysis of 5% imiquimod and 0.5% podophyllotoxin in the treatment of condylomata acuminata. Dermatology. 2006;213:218–223.
Codes
ICD9
  • 078.10 Viral warts, unspecified
  • 078.12 Plantar wart
  • 078.19 Other specified viral warts


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