Warts
Warts: Excerpt from The 5-Minute Pediatric Consult
Y. Lily Higgins, MD, MS
Warts - BASICS
Warts - description
- Warts (verrucae) are benign epithelial tumors that can occur on any epithelial surface of the body and produce characteristic lesions at various anatomic sites.
- Types of warts:
- Common warts (verruca vulgaris)—rough, minimally scaly papules and nodules on the hands, face, arms, and legs
- Flat warts (verruca plana)—rough, flat-topped, minimally scaly papules on face and legs
- Plantar warts (weight-bearing warts)—painful inward-growing papules and plaques on the bottom of the feet
- Anogenital warts (condyloma acuminata)—subtle skin-colored flat warts or moist, pink to brown, cauliflower-like lesions around the vagina and anal openings. (Please see chapter, Condyloma Acuminata.)
- Laryngeal warts (laryngeal papillomatosis)—transmitted vertically at delivery, and present with stridor and progressive airway obstruction in children
- Humans are the only reservoir for human papillomavirus (HPV).
- HPV can be transmitted by direct skin-to-skin or mucous membrane contact and by fomites.
- Autoinoculation from common warts at another site should be considered as a possible mode of spread.
Warts - general prevention
During contact sports, all lesions should be completely covered prior to participation. If the lesions are too extensive to completely cover, the athlete should not be allowed to participate.
Warts - epidemiology
Warts - prevalence
Affects 5–10% of children ages 5–10 years
Warts - pathophysiology
- The viruses have specific affinity for epidermal cells and cannot replicate in dermal connective tissue cells or other types of nonepithelial tissues.
- After implantation in the epidermis, the viruses enter the nuclei of lower and midepidermal cells. The viruses then take over the machinery of cell production. While replicating themselves, they induce a rapid proliferation of epithelial cells.
- The quantity of the virus, location of the warts, pre-existing skin injury, and cell-mediated immunity all play a role in the transmission of the virus.
Warts - etiology
- Warts are caused by HPV, which is a subgroup of papovaviruses, small double-stranded DNA viruses.
- There are >200 types of HPV.
Warts - DIAGNOSIS
Warts - signs & symptoms
Warts - history
- Obtain exposure history from family members and caretakers.
- Determine the duration of the warts.
- Elicit any history of immunodeficiency.
Warts - physical exam
- Common warts:
- May be solitary or multiple and range in size from millimeters to centimeters
- Linear patterns may be seen from autoinoculation.
- Filiform or threadlike warts may be seen in the skin creases and on mucous membranes.
- Flat warts:
- Small, rough, flat-topped, and slightly scaly papules
- Size ranges from 1–3 mm
- Plantar warts:
- Painful, inward-growing, hyperkeratotic papules and plaques on the plantar surface of the feet
- As a result of trauma from weight bearing, the surface of these lesions may have small black dots from thrombosed blood vessels.
- Anogenital warts (please see chapter, “Condyloma Acuminata”):
- May be skin-colored, flat warts or moist, pink to brown, cauliflowerlike lesions in the skin creases and around the vaginal and anal openings
- In adolescent and adult males, the warts are localized to the penis. The lesions are brown to slate-blue, pigmented macules and papules.
Warts - tests
Tests are rarely needed.
Warts - lab
- Pap smears will show the presence of koilocytic cells in adolescent females with vulvar condyloma.
- The only commercially available screening test is the Hybrid Capture II, which is a DNA probe tests for 13 high-risk HPV types.
Warts - diag proced-surgery
- Biopsy of flat warts shows koilocytic cells with an eccentric, shrunken nucleus surrounded by a perinuclear halo.
- Electron microscopy will show the distinctive viral particles.
- Antigen detection and molecular hybridization techniques have been used in adults to detect HPV in scrapings and biopsies of lesions.
Warts - differencial diagnosis
- Flat warts:
- Moles
- Epidermal nevi
- Tinea versicolor
- Milia
- Molluscum contagiosum
- Granuloma annulare
- Folliculitis
- Lichen nitidus
- Lichen planus
- Plantar warts:
- Corns
- Calluses
- Foreign bodies
- Anogenital warts:
- Irritant contact dermatitis
- Molluscum contagiosum
- Skin tags
- Hemorrhoids
- Underlying immunodeficiency should be considered in any otherwise healthy child with extensive HPV infection. Hereditary severe combined immunodeficiency, acquired immunodeficiency syndrome, and selective T-cell immune defects should be considered.
- Treatment of genital warts in children should be carried out in consultation with a dermatologist.
Warts - TREATMENT
When to expect improvement:
- Spontaneous resolution has been observed in common, flat, genital, and plantar warts. In healthy individuals, 75% of warts regress without treatment within 3 years.
- Any therapy and its side effects must be measured against the high rate of resolution without intervention.
- With the various treatment modalities, a response is generally seen within weeks to several months.
Warts - general measures
Topical irritants and duct tape are inexpensive and easy to use at home:
- Keratolytics—topical irritants such as lactic acid, salicylic acid, other α-hydroxy acids, urea, benzoyl peroxide, and tretinoin cause an inflammatory reaction and are used to remove the excess scale surrounding warts.
- Duct tape (or any durable, occlusive tacky tape)—causes local irritation and stimulates an immune response. Distant warts also resolve, which suggests a systemic immune response. Duct tape has been proven to be more effective than cryotherapy in some studies.
Warts - special therapy
- Destructive techniques:
- Cryotherapy:
- Involves using liquid nitrogen and deep-freezing the warts
- Causes necrosis and blister formation
- Is inexpensive, produces a rapid response, and does not require anesthesia; however, the treatment is painful and may lead to infection, scarring, and damage of normal skin
- Caustic agents—such as topical acids, podophyllum, and podophyllotoxin:
- Applied to pared-down warts
- Treatment takes several weeks to months.
- May be painful and produce scarring
- Cantharidin:
- A topical applicant that triggers painless intraepidermal blisters
- There is a high incidence of wart recurrence and postinflammatory pigment changes.
- Electrocautery and CORequire local or general anesthesia
- Both treatments can leave scars, and healing of the open wounds may take several months.
- Bleomycin:
- Diluted and injected into the warts under local anesthesia
- Edema, crusting, and hemorrhage may occur.
- Healing may take several days.
- Yellow, pulsed, dye laser:
- Generates 585 nm light, which is absorbed by oxyhemoglobin in the skin. The light energy is converted to heat energy.
- The warts have to be pared down and require repetitive pulsing.
- There is a small chance of scarring.
- Treatment may be painful for young children.
Immunotherapy and other treatment modalities:- Contact sensitization:
- Uses an allergen, such as dinitrochlorobenzene or diphenylcyclopropenone
- The patient is sensitized to the allergen, and then low concentrations of the same allergen are applied to the warts. This will create a type IV delayed hypersensitivity reaction.
- Applications are repeated for several months.
- The treatment can cause severe blistering and systemic reactions.
- Cimetidine:
- An H2-blocker that causes nonspecific stimulation of T lymphocytes
- This therapy has not been proven to be effective.
- Intralesional interferon:
- Requires multiple injections given daily for weeks
- Approved for anogenital warts
- Often used in combination with laser therapy
- Imiquimod:
- The 1st member of a new class of immune response modifiers
- The 1st FDA-approved imidazoquinoline
- A 5% cream is applied to the warts and results in an increase in the production of cytokines, especially interferon-α.
- The cream is approved for treatment of adults with external anogenital warts for home use.
- Data have supported efficacy in children with anogenital warts.
Warts - FOLLOW UP
Warts - prognosis
In healthy individuals, 75% of warts will spontaneously resolve without treatment within 3 years.
Warts - complications
- Irritation and secondary infection of common warts may result in itching and pain.
- HPVs have also been associated with melanoma, keratoacanthoma, squamous cell carcinoma, leukoplakia, and oral carcinoma.
- Laryngeal warts can cause stridor and airway obstruction.
Warts - patient monitoring
Patients receiving treatment should be followed up at 3–4-week intervals to check the results and assess for any side effects.
Warts - bibliography
- Cohen B. Warts and children: Can they be separated? Contemp Pediatr. 1997;14:128–149.
- Darville T. Genital warts. Pediatr Rev. 1999;20:271–272.
- Focht DR, Spicer C, Fairchok MP. The efficacy of duct tape vs cryotherapy in the treatment of verruca vulgaris. Arch Pediatr Adolesc Med. 2002;156:971–974.
- Gibbs S. Local treatments for cutaneous warts: Systemic review. BMJ. 2002;325:461.
- Lynch TJ. Duct tape removes warts. J Fam Pract. 2003;52:111–112.
- Tyring S, Conant M, Marini M, et al. Imiquimod: An international update on therapeutic uses in dermatology. Int J Dermatol. 2002;41:810–816.
Warts - CODES
Warts - icd9
- 078.10 Verruca vulgaris
- 078.19 Verruca plana
- 078.19 Verruca plantaris
- 078.11 Anogenital warts
Warts - FAQ
- Q: How can one differentiate corns and/or calluses from warts?
- A: Using a no. 15 blade, pare down the surface of the wart. If the surface is smooth with normal markings without small black dots (thrombosed blood vessels) at the base, then they are not warts.
- Q: A child is seen for anogenital warts. What is the role of the physician?
- A: The child needs a complete medical examination. The anogenital area should be examined for any signs of sexual abuse. All skin lesions should be documented and possibly photographed. Serologic studies for syphilis and cultures for gonorrhea should be considered. Family members and caretakers should be asked about anogenital and common warts. Parents should be informed that anogenital warts could be caused by sexual abuse, particularly in children over 3 years of age. Consultation with a child abuse expert should be considered. See “Condyloma Acuminata” chapter.
- Q: I am not sure if the lesions are warts. What else can I do in the office to confirm the diagnosis?
- A: Apply 3–5% acetic acid solution, and the lesions will turn white if they are warts. This, however, is not a specific test.
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Medical Books Excerpts
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- "Professional Guide to Diseases (Eighth Edition)" (2005)
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- "The 5-Minute Pediatric Consult" (2008)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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