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| Warts |
Warts are painless, benign skin tumors characterized by an area of well circumscribed epithelial thickening. Most people develop warts on their hands or feet at sometime in their lives. They are most common in childhood, with 4-20% of school children having warts at any one time. The DNA papillomavirus is causative and is passed by direct contact with an infected person or from recently shed virus kept intact in a moist, warm environment. Five types of warts are caused by specific genotypes of HPV:
•Common wart (verruca vulgaris)
•Plantar wart (verruca plantaris)
•Flat wart (verruca plana)
•Venereal wart (condyloma acuminatum)
•Epidermodysplasia verruciformis
SIGNS AND SYMPTOMS:
•Verruca vulgaris: Rough surfaced, raised, skin-colored papules 5-10 mm in diameter. They may coalesce into a mosaic 1-3 cm in diameter. Most frequently seen on hands.
•Verruca plantaris: Rough surfaced (although smoother than the common wart), flat, skin-colored papules not infrequently attaining 2-3 cm in diameter
•Verruca plana: Slightly elevated, flat-topped, skin-colored papules 1-3 mm in diameter sometimes in a linear arrangement often on hands and face
•Condyloma acuminatum: thin, flexible, tall, papules sometimes demonstrating a confluent growth resembling cauliflower. They do not have the visible or palpable keratin of the previous warts. In infants, laryngeal papillomatosis may occur if condyloma is transmitted during vaginal delivery.
•Epidermodysplasia verruciformis: Flat, reddish lesions on the hands and shoulders presenting in childhood with lifelong persistence
CAUSES:
Human papillomavirus (HPV)
RISK FACTORS:
•AIDS and other immunosuppressive diseases (e.g., lymphomas)
•Immunosuppressive drug use
•Atopic dermatitis
•Locker room use
•Skin trauma
DIFFERENTIAL DIAGNOSIS:
•Corns (on paring, a single "eye" of keratin is observed, whereas a wart shows hemorrhagic spots or "roots")
•Scar tissue
•Molluscum contagiosum (central umbilication and, after curettage, the characteristic pearl)
•Condyloma lata (flat warts of syphilis)
•Seborrheic keratoses
LABORATORY:
HPV cannot be cultured
PATHOLOGICAL FINDINGS:
•Papillomavirus found in the nuclei and nucleoli of the stratum granulosum and keratin layers of the epidermis.
•Plantar warts have rete pegs (a downward proliferation of epidermal ridges).
•Thrombosed dermal capillaries
SPECIAL TESTS:
Definitive diagnosis can be achieved with the following, but are not clinically relevant for most presentations:
•Electron microscopy
•Immunohistochemical study
•Nucleic acid hybridization
DIAGNOSTIC PROCEDURES:
Paring or débridement and simple visualization will be diagnostic in most cases.
GENERAL MEASURES:
Spontaneous remissions are common, probably related to a host immune response. Conservative, non-scarring treatments are preferred. Each treatment is associated with a 60-70% cure rate. Cure is achieved when skin lines are restored to a normal pattern.
SURGICAL MEASURES:
•Pretreat with anesthetic cream such as EMLA
•Cryotherapy - often preferred because scar formation is minimized. Freezing periungual warts may result in nail deformation.
•Excision with electrocautery, laser ablation, curettage (the virus may be found in smoke so masks should be worn)
•Disfiguring scars and wart recurrence are problems
ACTIVITY:
If plantar warts are on weight-bearing surface, they may cause significant discomfort and subsequent decrease in activity
PATIENT EDUCATION:
Infectious nature should be discussed; keep warts covered while under treatment to avoid auto-inoculation and transmission to others.
MEDICATIONS:
•Benign neglect - safe cost effective treatment option except when warts are extensive, spreading, symptomatic
•Hyperthermia - safe and inexpensive approach; immerse affected area into 45°C water bath for 30 minutes three times per week
•Chemotherapy - all treatments begin by paring the wart, then soaking the area in warm water to moisten the wart
•Topical retinoids: tretinoin (retinoic acid, Retin-A) for flat warts, less scarring than cryotherapy or surgical approaches; may be best for warts on the face. Apply bid for 4-6 weeks.
•Lactic-salicylic acid (Duofilm): daily treatment for about 3 months
•Salicylic acid (Trans-Ver-Sal) in a transdermal delivery system : daily treatment for about 6 weeks
•Keralyt (salicylic acid in propylene glycol); rub into warts each night
•Combination cantharidin; 30% salicylic acid, 2% podophyllin, and 19% cantharidin in flexible collodion: apply thin coat, occlude 4-6 hours (or less if painful), then wash off; blisters when form require roof to be removed, debridement of base, and antibiotic cream applied: multiple applications at 2-4 week intervals
•Imiquimod; for external genital and perianal warts; apply 5% cream (250 mg single use packets) three times/week at bedtime. Wash off after 6-10 hours. May be used for up to 16 weeks. May weaken condoms and diaphragms.
•Induction of delayed type hypersensitivity with dinitrochlorobenzene or diphencyclopropene, or squaric acid dibutylester: apply 2% solution to light shielded area every 2-3 weeks until sensitivity reaction occurs; then apply lower concentration to affected areas
•Occlusion - the easiest and least expensive; cover the wart with a waterproof tape and leave on for a week. Remove and leave open for 12 hours then re-tape if wart is still present. The environment under the tape does not foster viral growth. May be the best for periungual warts.
Contraindications: See specific treatments. Vascular insufficiency is a relative contraindication to some treatments.
Precautions: Avoid normal skin when using the topical chemicals
Significant possible interactions: N/A
ALTERNATIVE DRUGS:
•Chemotherapy
•Benzoyl peroxide: apply bid for 4-6 weeks
•Bleomycin - intradermal injection, is expensive and causes severe pain, but has a 75% cure rate
•Cimetidine - 30-40 mg/kg divided tid for 3 months. 86% of patients will have partial or complete regression.
•24% podophyllin applied weekly to anogenital warts, or 5% podofilox (Condylox) self-applied twice daily for 3 days each week for 1 month
•Others - dichloroacetic acid, trichloroacetic acid, podophyllin, 5-fluorouracil, silver nitrate, idoxuridine (Herplex Liquifilm), formaldehyde, glutaraldehyde
•Immunotherapy
•Dinitrochlorobenzene (DNCB) - should be considered a last resort because of side effects and possible mutagenicity
•Interferon - intralesional for urogenital warts
•Interferon alpha - systemic for genital warts
•Interferon beta or gamma - systemic for disseminated verruca vulgaris
•Imiquimod (Aldara) applied daily
PREVENTION/AVOIDANCE:
•Cover warts under treatment. Avoid the wound fluid after cryotherapy.
•Use personal footwear in locker room settings
POSSIBLE COMPLICATIONS:
•Auto-inoculation
•Scar formation
•Chronic pain after plantar wart removal and scar formation
•Nail deformity after injury to nail matrix
REFERENCES
•Bolton RA: Warts. Am Fam Phys 1991;43(6):2049-2056
•Lynch PJ: Dermatology for the House Officer. 3rd Ed. Baltimore, Williams & Wilkins, 1994
•Sams W, et al: Principles and Practices of Dermatology. 2nd Ed. New York, Churchill Livingston, 1996
•Ordoukhanian E: Warts and molluscum contagiosum; beware of treatments worse than the disease. Postgrad Med 1997;2:223-235
•Siegfried EC: Warts on children: an approach to therapy. Ped Annuals 1996;2:79-90
•Gaspari AA, et al: Successful treatment of a generalized human papillomavirus infection with granulocyte-macrophage colony-stimulating factor and interferon gamma immunotherapy in a patient with a primary immunodeficiency and cyclic neutropenia. Arch of Dermatol 1997;133(4):491-96
•Anonymous. Tackling warts on the hands and feet. Drug Ther Bull 1998;36(3):22-4Labels: papilloma virus |
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| 5 Comments: |
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Can you tell me more about this emla cream? Is it something i can purchase or do i get it from my doctor??
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You can purchase emla at your phamacy. It is non-prescription in the UK. You can go to www.ihateneedles.co.uk for more information.
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This blog always create some informational and amazing things, which add in my knowledge and experience.But I am a bit confuse. Thanks for sharing.Waiting for next post.
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Can you tell me more about this emla cream? Is it something i can purchase or do i get it from my doctor??