Warts are tumours or growths of the skin caused by infection with Human
Papillomavirus (HPV). More than 70 HPV subtypes are known.
Warts are particularly common in childhood and are spread by direct contact
or autoinocculation. This means if a wart is scratched, the viral particles may
be spread to another area of skin. It may take as long as twelve months for the
wart to first appear.
What do they look like?
Warts have a hard ‘warty’ or ‘verrucous’ surface. You can often see a tiny
black dot in the middle of each scaly spot, due to a thrombosed capillary blood
vessel. There are various types of viral wart.
- Common warts arise most often on the backs of fingers or toes, and on the knees.
- Plantar warts (verrucas) include one or more tender inwardly growing ‘myrmecia’ on the sole of the foot.
- Mosaic warts on the sole of the foot are in clusters over an area sometimes several centimetres in diameter.
- Plane, or flat, warts can be very numerous and may be inoculated by shaving.
- Periungual warts prefer to grow at the sides or under the nails and can distort nail growth.
- Filiform warts are on a long stalk.
- Oral warts can affect the lips and even inside the cheeks. They include squamous cell papillomas.
- Genital warts are often transmitted sexually and predispose to cervical, penile and vulval cancer.
In children, even without treatment, 50% of warts disappear within 6 months;
90% are gone in 2 years. They are more persistent in adults but they clear up
eventually.
Warts are particularly numerous and troublesome in patients that are
immunosuppressed, most often due to medications such as azathioprine or ciclosporin. In these patients, the
warts almost never disappear despite treatment.
Treatment
Many people don't bother to treat them because treatment can be more
uncomfortable and troublesome than the warts - they are hardly ever a serious
problem. However, warts may be painful and they often look ugly and cause
embarrassment.
To get rid of them, we have to stimulate the body's own immune system to
attack the wart virus. Persistence with the treatment and patience is essential!
Occlusion
Just keeping the wart covered 24 hours of the day may result in clearance.
Duct tape is convenient and inexpensive.
Chemical treatment.
Chemical treatment includes wart paints containing salicylic acid or similar compounds,
which work by removing the dead surface skin cells. Podophyllin is a cytotoxic
agent used in some products, and must not be used in pregnancy or in women
considering pregnancy.
The paint is normally applied once daily. Perseverance is essential -
although 70% of warts will go with wart paints, it may take twelve weeks to
work! Even if the wart doesn't go completely, the wart paint usually makes it
smaller and less uncomfortable.
First, the skin should be softened in a bath or bowl of hot soapy water. The
hard skin should be rubbed away from the wart surface with a piece of pumice
stone or emery board. The wart paint or gel should be applied accurately,
allowing it to dry. It works better if covered with plaster or duct tape
(particularly recommended when the wart is on the foot).
Stronger preparations such as Upton's paste are used for thick verrucas,
applied every few days. It is important to protect the surrounding skin with
adhesive plaster before applying Upton's paste, and to apply a plaster over the
paste to keep it in place.
If the chemical makes the skin sore, stop treatment until the discomfort has
settled, then recommence as above. Take care to keep the chemical off normal
skin.
Cryotherapy
The wart is frozen with liquid
nitrogen repeatedly, at one to three week intervals. This is uncomfortable
for a few minutes and may result in blistering for several days. Success is in
the order of 70% after 3-4 months of regular freezing. Dermatologists debate
whether a light freeze to stimulate immunity is sufficient, or whether a harder
freeze is necessary to destroy all the infected skin. A hard freeze might cause
a permanent white mark or scar.
Electrosurgery
Electrosurgery (curettage & cautery) is used for
particularly large and annoying warts. Under local anaesthetic, the growth is
pared away and the base burned by diathermy or cautery. The wound heals in about
two weeks; even then 20% of warts can be expected to recur within a few months.
Other treatments
There are numerous treatments for warts and none offer a guarantee of cure.
They include:
- topical retinoids such as tretinoin cream or adapalene gel
- fluorouracil cream
- bleomycin injections
- laser vaporisation or pulse dye laser destruction of feeding blood vessels
- Oral retinoids such as acitretin or isotretinoin
- immune modulators such as imiquimod cream
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