What is a viral wart?
A viral wart is a very commonbenignlesioncaused byinfectionwith human papillomavirus (HPV). Viral warts can be classified by site as beingcutaneousormucosalas the HPV types are quite distinct [seeAnogenitalwartandSexually acquired human papillomavirusfor further information on mucosal HPV infection]. A cutaneous wart is also called a verruca orpapilloma, andwarty-lookinglesionsof any cause may be described asverrucousorpapillomatous.
Who gets cutaneous viral warts?
Warts are particularly common in:
- School-aged children, however they may occur at any age
- Dermatitis, due to a defective skin barrier
- People withdrug-inducedimmunosuppressionsuch as with long-termazathioprineorciclosporinuse, or havehuman immunodeficiency virus (HIV)infection.
What causes cutaneous viral warts?
Warts are due to infection by the human papillomavirus (HPV), a double-strandedDNAvirus. There are more than 150 known HPV types, only some of which infect the skin, giving rise to a variety of clinical presentations. Infection begins in thebasallayerof theepidermis, causingproliferationof thekeratinocytes(skin cells) andhyperkeratosis, and production of infectious virus particles — the wart. The most common HPV types infecting the skin are types 1, 2, 3, 4, 10, 27, 29, and 57.
HPV is spread by direct skin-to-skin contact orautoinoculation; if a wart is scratched or picked, a wart maydevelopunder the fingernail (subungualwart) or virus may be spread to another area of skin. Autoinoculation of the virus in a scratch can result in a line of warts (pseudo-koebnerisation) Theincubationperiod can be as long as twelve months, depending on the amount of virusinoculated.
Autoinoculation of warts
What are the clinical features of viral warts?
Cutaneous viral warts have a hard, keratinous surface. Tiny red or black dots visible in the wart are papillarycapillaries.
Common warts (verruca vulgaris) present as cauliflower-likepapuleswith a rough, papillomatous andhyperkeratoticsurface ranging in size from 1 mm to 1 cm or more. They may be solitary or multiple. Common warts are found most often on the knees, backs of fingers or toes, and around thenails(periungual).
Common warts (verruca vulgaris)
Plantar warts (verruca plantaris) include tender inwardly growing myrmecia on the sole caused by HPV 1, and clusters of superficial less painful mosaic warts due to HPV 2. Myrmecial warts are typically tender withlateraland direct pressure, are surrounded by yellow hyperkeratotic callus-like skin showingaccentuatedskin markings, but with discontinuation of the skin lines through the actual wart.
Plantar epidermoidcystsare associated with HPV 60 infection of theeccrineducts.
Plantar warts, myrmecial type (verruca plantaris)
Plantar warts, mosaic type
Plane warts are typically multiple small flat-topped skin-coloured papules located most commonly on the face, hands, and shins. On the shins and beard-area of the face the virus is often spread byshavingresulting in numerous warts. Plane warts are mostly caused by HPV types 3 and 10.
Plane warts (verruca plana)
A filiform wart is a cluster of fine fronds emerging from a narrow pedicle base usually found on the face. They are also described as digitate (finger-like).
Filiform and digitate warts
Butcher's warts are specifically caused by HPV 7 infecting the hands of butchers and others whose occupation involveschronicexposure to a cold moist environment. They clinically resemble common warts and tend to be numerous.
What are the complications of cutaneous viral warts?
- 病毒疣are infectious to the patient and others.
- Cutaneous warts can have significantpsychosocialeffects such as teasing at school, embarrassment, permission refused for swimming lessons.
- Periungual warts can causenaildystrophyand destruction.
- Pain due to plantar warts (myrmecia type) interferes with walking and sporting activities, causing knee or hip pain.
- In epidermodysplasia verruciformis the specific HPV types involved can cause cutaneoussquamous cellcarcinomas.
Periungual warts causing nail dystrophy
How is a cutaneous viral wart diagnosed?
Cutaneous viral warts are usually diagnosed clinically. Clinical clues to diagnosis can include:
- Pinpoint red or black dots (papillary capillaries) are revealed when the wart is pared down. Patent capillaries cause pinpoint bleeding. Plantar corns lack the papillary capillaries.
- Location of a plantar wart is not restricted to pressure sites whereas a plantar callus or corn is always at a pressure site.
- 温柔是maximalwith lateral pressure for a plantar wart whereas a corn or callus is more tender with direct pressure.
Diagnosis of viral warts
Skinbiopsyis sometimes required when squamous cell carcinoma cannot be excluded clinically such as in an organtransplantrecipient susceptible to both. [seeVerruca vulgarispathology,Verruca plana pathology]
What is thedifferential diagnosisof a cutaneous viral wart?
Differential diagnoses for a cutaneous viral wart can include:
- Seborrhoeic keratosis
- Squamous cell carcinoma
- Plantarcorn and callus.
What is the treatment for viral warts?
Treatment may not be required in all cases as most warts resolve spontaneously especially in children. Indications for active treatment include:
- Presence of complications
- Patient preference.
Treatments do not kill the virus, but work by removing virus-containing skin.Persistencewith the treatment and patience is essential! Remember HPV infects the basal cell layer of the epidermis so wartsrecurrapidly if the virus has not been eradicated.
Topical treatment is applied once daily to the wart. Treatment with wart paint usually makes the wart smaller and less uncomfortable; 70% of warts resolve within twelve weeks of daily applications.
- Soften the wart by soaking in a bath or bowl of hot soapy water.
- Rub the wart surface with a piece of pumice stone or emery board.
- Apply wart paint orpasteaccurately and include a rim of normal skin.
- Allow the paint to dry before covering with plaster or duct tape.
- Next day remove the old paint and dead surface skin layer with a pumice stone and reapply the paint or paste.
If the wart paint makes the skin sore, stop treatment until the discomfort has settled, then recommence as above.
Cryotherapywith liquid nitrogen is repeated at one to two–week intervals to cause peeling of the surface layer. It is uncomfortable and results in blistering for several days or weeks. Treatment is required frequently to prevent the wart regrowing between appointments. Success is in the order of 70% after 3–4 months of regular freezing.
A hard freeze using liquid nitrogen might leave a permanent white mark. It can also cause temporary numbness if performed over a superficialnervesuch as on the side of a finger.
Treatment of warts
Electrosurgery(curettage andcautery) has been used for large and resistant warts. Under localanaesthetic, the growth is pared away and the base burned. The wound heals in two weeks or longer (depending on the site); even then 20% of warts can be expected to recur within a few months. This treatment leaves a permanentscarwhich can be painful to walk on if located on a pressure site.Recurrentwart in a scar is very hard to treat.
Other treatments for recurrent, resistant or extensive warts include:
- The immune modulator,imiquimodcream- is approved for treating anogenital warts but is usually ineffective for cutaneous warts
- Bleomycin injections
- Pulsed dyelaserdestruction of feedingblood vessels
- Diphencyprone, dinitrochlorobenzene, or squaric acid to causelocalised所有ergic contact dermatitis over the wart.
How can viral warts be prevented?
Vaccines against human papillomavirusare available to preventanogenital warts. Anecdotally, these have been reported to result in the clearance of non-genitalwarts in some people without definite evidence that the vaccine is the cause ofremission.
What is the outcome for cutaneous viral warts?
No treatment is universally effective at eradicating viral warts.
In children, even without treatment, 50% of warts disappear within six months, and 90% are gone in 2 years.
病毒疣are morepersistentin adults, but they clear up eventually. They are likely to recur in patients that areimmunosuppressed, for example, organ transplant recipients.Recurrenceis more frequent in tobaccosmokers.
Immunity to HPV is likely to be type-specific.