Warts: Clinical tl,pe and treaffnent

CPD
Warts: Clinical tl,pe and treaffnent
./aclk ll'K, Ml)
Head of the Deparlrnent, Department of Dermakrkrg',
Universiryof Pretoria, Pretoria Academic Hospiurl
(-rtL-t'.sJx.urletxr;(012) 354 2000
Make a clinical diagnosisof warts
o
Understand the nature and causesof wartsat different
sites.
. The principles and methods of fighting the
papillomatousbatde.
o
INTRODUCTION
Warts(vemrcae)arecausedbyinfection
with human papillomaviruses (HPV).
Human papillomaviruses are widespread in nature and a great part ofthe
population has warts at one time or
another.
Warts are benign, often spontaneously resolving, epidermal proliferations.
The clinical lesionsresulting from HPV
infection can be divided into two broad
categories, cutaneous and extracutaneous. The cutaneouslesions include
common warts (verruca vulgaris),
filiform warts, plane warts (verruca
juvenilis), plantar warts (myrmecia and
mosaic warts), epidermodyplasia
vemrciformis and anogenitalwarts.
All the cutaneouswarts listed above
and of the extracutaneous ones, oral
common warts and focal epithelial
hyperplasiawill be discussedin this
article.
There are many types of HPV.
Identification ofthe strain, not routinely
performed in daily clinical practice, is
important as, while most strains are
benign, certain may initiate malignant
changes. Different types of warts are
associatedwith certain HPV strains.
Common W'ans (most often
IIPV-2 and I{PV-4)
They are rough, keratotic papules that
may appear singly or grouped on any
. Mairk'n kliniese diagnosevan vratte.
. Verstaandie aard en oorsake van watte op verskillende plekke.
. Die beginselsen metodes om die papillomateuse
aanslaghok te slaan.
SA Fan Pract 200,7;45(7):36-39
cutaneous site. They are most often
located on the dorsal aspects of the
handsand fingers. (Fig. 1), (Fig.2)
Periungual common warts (Fig. 3) are
often painful, may involve the nail bed
and causea nail dystrophy.
Figure 1: A single common wart after
ear piercing
Filiform wats
These warts are slender with filiform
projections and are mainly located on
the neck and on the eyelids.
Plane watts
Planewarts fiuvenile) (most often HPV3 and HPV-10) (Fig. 4) are generally
multiple, slightly elevated, smooth
papules occurring most often on the
face,hands,neck and legs ofchildren.
They may group and a linear arrangement implying a role of trauma
(Koebner phenomenon)is common.
Figure 4: Plane warts
f
I
Figure3: Periungualcommonwarts
Plantat watts
There are two main types of plantar
warts. Deep and painful, usually single
warts (HPV-l) are called myrmecia
(ant-hill) due to their dome-shaped
appearance. (Fig.s)
SA Fam Pract 2003;45(7)
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Figure 5: Deep plantar wart
disorder characterizedby persistent
refractoryHPV infection manifestingas
widely disseminate, flat, wart-like
lesions and erythematous,hyperpigmented or hypopigmentedmacules.
(Fig.7)
Figure 7: Epidermodysplasiaverruciformis
cally soft, fragile, pink to flesh-coloured
lesions found on moist areaslike the
glanspenis,inner surfaceofthe prepuce,
urethral meatus, anal mucosa,perianal
region and labia. (Fig. 8) Theselesions
canbecomelarge,grosslyexophyticand
cauliflower-like.
Figure 8: Condylomata acuminata
More superficial (HPV-2 and HPV-4)
numerous plantar warts are usually
nonpainful.They oftencoalesceinto large
plaques. (Fig. 6) Plantar warts most
points
oftenoccurbeneaththepressure
suchas the heel or metatarsalheads.
Figure 6: Multiple mosaic plantar warts
Approximately one third of lighfskinned individuals w ith epidermodysplasia
verruciformis develop non-melanoma
skin cancerson sun-exposedareas.This
malignanttransformationis much less
common in African patientsthough the
sameHPV strainswith high oncogenic
potential have been detected in their
lesions.' Epidermodysplasia verruciformis is a multifactorial diseasein
which viral, genetic,immunologicaland
environmental factors play a role.
The diagnosis of common and plane
warts is easy - most patients make the
correctdiagnosisthemselvesbut plantar
warts are often mistaken for corns.
Paring down aplantar callus will reveal Anogenital warts
the characteristicspeckled appearance Anogenital warts can be divided into
h y p e r p l a s t i cl e s i o n s ( c o n d y l o m a t a
of the plantar wart.
acuminata), sessile papules and
Epi d erm odyspl asi a vetr u ciformi s
commonwart - like lesions.
HPV-9)
(most orten IIPV-3,IIPV-\
Condylomataacuminata (HPV-6,
This is a rare, lifelong, cutaneous H P V - 1 1 ,H P V - 1 6 ,H P V - 1 8 ) a r e t y p i -
The sessilepapules (HPV-2, HPV-4)
and common warts are seen on the
penile shaft.
Common warts similar to their
cutaneous counterparts, though less
keratotic, can occur in the oral cavity.
(Fig. e)
Figure 9: Common warts inside the
mouth
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SA Farn Pract 2003:45(7)
First Option
Second Option
Third Option
Fourth Option
Common warts
Leave untreated.
Many resolve
Keratolytics
Cryotherapy
Curettage
Periungualcommon warts
Combinationcryotherapy
followed by
Imiquimod cream
under occlusion
Imiquimod cream
under occlusion
Repeatedsuperficial cryotherapy
Solitary common wart on the face
Leave unkeated.
Often resolves
Curettage
Cryotherapy
Planewarts
Leave untreated
Topical retinoic
acid
Cryotherapy
Genital warts
Imiouimod cream
Podophyllin
Podophyllotoxin
Cryotherapy
Plantar wart Mosaic
Keratolytics
Formaldehyde
soaks
Cryotherapy
Plantarwarts Deep
Keratolytics
Cryotherapy
Curettage
Curettage
Treatmentshould causeminimal oain
and inconvenience.
Cryotherapy
Freezingwith liquid nitrogenapparently
does not kill human papillomaviruses.
Several factors influence the
It destroysthe tissuein which the virus
rcsponse of warts to tteatment
lives and possiblyenhancesthe host's
L Warts in children respond more immune response.
readily than in adults.
Cryotherapyis effective for warts on
2. Deep plantar warts (myrmecia) are the face,hands,annsandlegs. Thewart
easierto treatthanmosaicwarts.
and a small rim of apparentlynormal
3 . S i n g l e w a r t s a n d t h o s e o f s h o r t tissuehaveto be frozen.The freezetime
durationdisappearmore readily than rangesform 10to 30 seconds.Repeated
multiple and long lastingones.
TREATMENT
liquid nitrogen treatmentsare usually
4. Treatmentsaregenerallynot entirely needed,since one freezeseldom leads
The nature of warts is unpredictable.
successfulin immunocompromised to resolutionof the wart. The interval
T h e y o f t e n f a i l t o d i s a p p e a rw i t h
p a t i e n t s , t h o s e o n l o n g t e r m betweenfreezingsshouldnot be longer
treatment or they recur after apparent
i m m u n o s u p p r e s s i oonr.g a n l r a n s - than 3 weeks,in anogenitalwarts even
cure. Somewarts resolvespontaneously
plant recipients and HlV-infected
shorter as they proliferaterapidly.
andthusthe evaluationof treatmentmay
patients.
Repeatedfreezing avoids the need to
be difficult. Thereis no way to prevent
freezedeeplythusminimisingscarring.
warts and both patientsand physicians It is very important to make patients
Combining
liquid nitrogentherapywith
often becomefrustratedby an apparent understandthat warts are unpredictable
(salicylic acid/ lactic
local
keratolytics
and that they should have a realistic
endlessappearance
ofnew warts.
a
c
i
d
)
o
n
d
a
y
s
between freezing
S y s t e m i c m e d i c a t i o n s a r e n o t v i e w o f t h e s p e e do f c u r e . T w e l v e
increases
the
cure
rate.
s u c c e s s f u la n d l o c a l l y d e s t r u c t i v e weeks,not shorter,is a realisticperiod
Cryotherapy
is
effective in plantar
of time in which to expect warts to
methodsare the mainstayof therapy.
warts. Paring of the keratotic surface
disappearwith treatment.
The aim is to destroythe wart and to
Sometimesa wart persists,regardless before freeztng and a freeze-thawspare the normal skin. Treatment
shouldn'tcausedistressto the patient. how much it is treated. A biopsy may secondfreeze cycle is more effective
than a single freeze.
T h i s e x c l u d e s r a d i o t h e r a p y a n d be neededto confirm the diagnosisofa
w a r t ( s q u a m o u sc e l l c a r c i n o m am a y
Liquid nitrogentherapyofthe lesions
systemic immunotherapy. Local
on the feet can, however,produceproimmunotherapywith Imiquimod cream look like a wart).
blems,painful blistersand evenperrnawill be discussedlater.
Treatment options:
nent, painful scars. Similar efficacy is
Scarring should be avoided, thus
'I'ablc
I s u m m a r i s e st h e t r e a t m e n t achievedwith the sprayandcottonwool
there is no place for excisions and
overenthusiasticelectrodessication. optionsof differenttypes of warts.
methodwhen treatinscommonwarts.
Focal epithehal hlperplasia
(IIeck's disease) (HPV-13, PV32)
Focal epithelialhyperplasiaaffectsthe
oral mucosa.It occursin cerlainethnic
groups (also in Cape Colouredsz)and
thereforea geneticcofactoris probable.
Most often labial and buccal mucusae
are affectedwith multiple pinpoint to
peasizedsoft ovoid papules.
SA l';un Plact 2003;4.5(7)
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Curettage
Curettage should only be used when
other methods fail. It is painful and
thereis a risk ofscarring. Curettageis
effectively usedfor solitary facial warts
in adults.
every evening. The warts should be
paredevery few days. Treatmentshould
be stoppedif the warts becomepainful.
Originally imiquimod was indicatedfor
the treatment of external genital and
perianalwarts. Subsequently
it hasalso
been found effective in other types of
warts including plantar and periungual
and also warts in immunocomoromised
patients.5
A limiting factor in the treatmentwith
imiquimod is its high cost.
However,its non-invasiveactionand
the freedom from pain and scarring
experiencedwith other therapiesmay
balancethe high cost.Thereis no effective treatmentfor the multitude of warts
itt epidermodysplasiaverruciformis.
Strict sun protection may reduce the
number of developing tumours and the
malignantgrowthsshouldbe timeously
removed.0
Podophyllin
Podophyllincompoundpaint (15-20%)
is commonly used for friable genital
warts. Podophyllin is very toxic and
Keratolytics
Keratolytic agents act by increasing should be applied by trained staff and
sheddingof the infectedkeratinocytes. not by the patient.
Apply small amounts with a cotton
In SouthAfrica DUOFILM preparation
containing salicylic actd 16.7%oand wool bud. Dust with talcum powder
immediately after application. The
lactic acid 15.03%in colodion baseis
p
atient is advisedto wash off the
most often used.
The crucial thing is for the patient to
solution 2-3 hours after application.
understandthe principles of treatment. Later, on subsequentvisits, leave the
The agent is applied most conve- solution for an increasinglength of time
niently at bedtime. If the wart surface - up to 8 hours. Apply at weekly or
is coveredwith hard keratotictissueor
fortnightly intervals.
Applicationof podophyllinis contradeaddebris,removeit using a pumice
metal
Later
indicated
in childrenand in pregnancy. Pleaserefer to the CPD
stoneor the tip of a
nail file.
Podophyllotoxin(Wartec),availableas Questionnaire on page 71
apply a few drops of the solution using
products a solution,is lesstoxic andmay be used
the applicator.Colodion-based
Refetences:
at home. It should be applied twice
dry on the wart and do not require
l. Jacyk WK, de Villiers EM. Epidermodysplasia verruciformis in Africans. Int J
dressings.Continuethe sameprocedure daily for 3 days and the application can
D e r m a t o l I 9 9 3 ; 3 2 : 8 0 6 - 18 0 .
be repeatedfor residuallesionsafter one
on the following days. Do not treat if
2. Van Wyk, CW. Focal epithelialhyperplasia
the wart is painful - stop the treatment week.
of the mouth recently discovered in South
Africa. Brit J Dermatol 197'7;96:381-388.
for one or two days.
3. Sparling JD, CheckettsSR, ChapmanMS.
Imiquimod
Imiquimod for plantar and periungual warts.
Imiquimod (5o/o Aldara cream) is a
Cutis 2002; 68:391-399.
Formaldehyde soaks
4. Grussendorf-Conen
EI, JacobsS, RubbenA.
When there are multiple plantar warts topical immune responsemodifier. It
et al.Topical 5% Imiquimod long-term
(mosaic),applicationof keratolyticsis
hasno directantiviralellect. lt induces
t r e a t m e n to f c u t a n e o u sw a r t s r e s i s t a n t o
standard therapy modalities. Dermatologt
not practical. Diluted formaldehyde the releaseof cytokines,principally
2002:205:139-145.
nucrosis 5. Cutler K. Kagen MH, Don PC et al. Treatbut alsotr-rmour
soaks (2-15%) are useful. The sur- Interleron-alfa,
ment of facial verrucae with topical
rounding normal skin must be protected factor-alfa and several interleukins.
Imiquimod cream in a patient with Human
Thus,
its
from
antiviral action stems
enby applying vaseline. The soaks are
Immunodeficiency virus. Acta Dermatol
applied to the skin for 10-15 minutes hancementof cell-mediatedimmunity.
Venereol2000;80:I 34- I 35.
P BITfTTNTREY
K i n d l yj o i n o u r g u e s ts p e a k e r- a l l t h e w a y f r o m t h e
Netherlands- Henk van der Eng (Psychotherapist,
Acupuncturist, Physiotherapist with 30 years of
therapeuticexperience)for workshopson Bio-Energy
Diagnostics and Therapy.
o
o
o
o
(-!
He will demonstrate
the measuringof bio-energylevels
in the body to detectorgan-related
energydeficiencies,
disharmonies
or blockages,as well as threetreatment
- with the
modules- sound,lightand electro-magnetic
o b j e c t i v eo f e n e r g i s i ncge l l u l a rm e t a b o l i s mi n o r d e rt o
healand preventillness.Therapychecksare done after
treatmentto measure effectiveness.
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