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Overview

Warts, or verrucae (singular: verruca), are benign growths on the skin or mucous membranes that cause cosmetic problems as well as pain and discomfort. They are seen on people of all ages but most commonly appear in children and teenagers. The incubation period of a wart is 2 to 9 months following infection with the human papilloma virus (HPV), during which time an excessive proliferation of skin growth slowly develops. Fortunately, more than 50 percent of them disappear on their own within two years.

Causes

More than 80 different types of HPV have been identified, and they have tropism (affinity) for different types of body tissue. Most types of HPV have an affinity for the skin and produce common warts (verruca vulgaris), flat warts (verruca plana), and plantar or foot warts (verruca plantaris). Several other types of HPV have an affinity for mucous membranes and some of these cause ano-genital warts (condyloma acuminata).

HPV is passed from person to person by direct or indirect contact, and from one body location to another on the same person. The virus more easily enters the body through an area of skin that is moist, peeling, or cracked. Some types (e.g., condyloma acuminta) are transmitted sexually. The degree of contact, location of the lesions, the amount of virus present (newer warts tend to contain more viral particles than older warts), and the state of a person's immunity are among the factors that determine HPV infection.

Signs and Symptoms

Common warts appear most often on the tops of the fingers and hands, usually along the cuticles, as rough, thick, cauliflowerlike papules that develop solitarily or in large numbers. Black dots, which are minute blood vessels, can be seen in them, especially after paring down some of the thickened skin. Small satellite warts may surround the original lesion because the virus is usually present in a one-centimeter radius surrounding the wart.

Flat warts are small, slightly elevated, flat-topped, pink or tan papules, are smoother than the common wart, and have minimal scale. They occur primarily on the face, arms, and legs, and a person can have several, even hundreds of them.

Plantar warts occur on the soles of the feet, are often thick and callused, grow inward, and can be quite painful and bothersome. Tiny clusters of warts, called mosaic warts, are particularly stubborn and resistant to treatment.

Ano-genital warts (condyloma acuminata) are flesh to gray in color, grow in mucous membranes, and vary in size from small, shiny papules, to large cauliflowerlike lesions. They can extend internally into the vagina and cervix, the rectal area, and inside the urethra (the tube through which urine is voided from the bladder).

Most of these warts are painless, but there can be itching and burning, and they can progress to more serious disease (e.g., cervical cancer), regress, or remain at their primary growth stage. Anyone who has genital warts should have them examined by a physician.

Diagnosis

The diagnosis is most often made on the basis of clinical appearance. Diagnostic clues include black dots within the warts and/or pinpoint bleeding after paring down the thickened skin. The wart also tends to disturb the natural skin lines and creates a disrupted surface. A biopsy can be used to confirm clinical suspicion, provide proper diagnosis, and help determine if progression to skin cancer, a rare complication, has occurred.

Treatment

There is no single effective treatment for warts; management is based on the age of the individual as well as the size, number, and location of warts. Common warts, especially in children, do not necessarily need to be treated, because they exhibit a high rate of spontaneous remission. Without treatment, however, spread can occur.

Treatment involves the physical or chemical destruction of the lesion. In physical destruction, liquid nitrogen, which is extremely cold, is sprayed onto the wart or applied with a cotton-tipped swab. Because freezing is painful, this form of treatment is not tolerated well by young children. Warts can be anesthetized and then scraped (curetted), burned (desiccated), lasered off, or surgically cut out (excised).

A variety of chemicals are used to eradicate warts. Genital warts respont to a topical resin, podophyllin, applied in strong concentration at regular intervals by the doctor, or a prescription gel (Condylox®) to be used at home. Cantharin, an extract from a blistering beetle, is used alone or in combination with podophyllin to treat warts.

Over-the-counter preparations of salicylic acid are sometimes used. Imiquimod cream (Aldara®) is approved as a prescription for enhancing the immune response to warts, thus helping the body fight the human papilloma virus.

A dilution of bleomycin, a medication used in chemotherapy, can be effective when injected into warts that are resistant to other treatments.

Despite numerous treatment modalities, warts sometimes require repeated treatment because they are difficult to eradicate and commonly recur.

Prevention

Treating warts while they are still small may prevent them from spreading. It seems that imiquimod cream (Aldara®), when applied to the treated areas, can help prevent recurrences by stimulating local immunity to human papilloma virus, but more data is needed to prove this. The most effective way to prevent ano-genital warts (condyloma acuminata) is to use safer sex practices, which may include using a latex condom during sex and avoiding contact with affected individuals.

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