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Wart

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Wart
SpecialtyDermatology Edit this on Wikidata
A filiform wart on the eyelid.

A wart (also known as verruca) is generally a small, rough tumor, typically on hands and feet but often other locations, that can resemble a cauliflower or a solid blister. Warts are common, and are caused by a viral infection, specifically by the human papillomavirus (HPV) and are contagious when in contact with the skin of an infected person. It is also possible to get warts from using towels or other objects used by an infected person. They typically disappear after a few months but can last for years and can recur.

Cause

A virus called human papilloma virus or HPV. There are approximately 100 strains of human papilloma viruses.[1][2] Type 1, 2, and 3 causes most of the common warts. Type 1 is associated with deep plantar (sole of the feet) and palmar warts (palm of the hand). Type 2 causes common warts, filiform warts, plantar warts, mosaic plantar warts. Type 3 causes "plane" warts, or commonly known as flat warts..[3] Anogenital warts are caused by types 6, 11, 16, 18, 30, 31, 33, 34, 35, 39, 40 and others. HPV types 6 and 11 cause about 90% of genital warts cases. HPV types 16 and 18 currently cause about 70% of cervical cancer cases[4][5], and also cause some vulvar, vaginal[6], penile and anal cancers[7]. Gardasil, a vaccine for HPV is designed to prevent infection with HPV types 16, 18, 6, and 11; it is claimed to prevent infections to other strains of anogenital warts through cross protection against other types of HPV's. HPV is associated with oral cancer, laryngeal cancers, and tracheal cancers. [8]

Types of wart

A range of different types of wart has been identified, varying in shape and site affected, as well as the type of human papillomavirus involved.[9] These include

  • common wart (Verruca vulgaris), a raised wart with roughened surface, most common on hands and knees;
  • flat wart (Verruca plana), a small, smooth flattened wart, tan or flesh coloured, which can occur in large numbers; most common on the face, neck, hands, wrists and knees;
  • filiform or digitate wart, a thread- or finger-like wart, most common on the face, especially near the eyelids and lips;
  • plantar wart (verruca, Verruca pedis), a hard sometimes painful lump, often with multiple black specks in the center; usually only found on pressure points on the soles of the feet;
  • mosaic wart, a group of tightly clustered plantar-type warts, commonly on the hands or soles of the feet;
  • genital wart (venereal wart, Condyloma acuminatum, Verruca acuminata), a wart that occurs on the genitalia.

Treatment

Prescription

Two viral warts on a middle finger, being treated with a mixture of acids (like salicylic acid) to remove them. A white precipitate forms on the area where the product was applied.

Treatments that may be prescribed by a medical professional include

  • Application of podophyllum resin paint [podophyllum resin I.P.'66 (20% w/v), benzoin I.P. (10% w/v), aloes I.P. (2% w/v), isopropyl alcohol I.P. to make (100% v/v)]
  • Keratolysis, removal of dead surface skin cells usually using salicylic acid, blistering agents, immune system modifiers ("immunomodulators"), or formaldehyde, often with mechanical paring of the wart with a pumice stone, blade etc.[10];
  • Cryosurgery, which involves freezing the wart (generally with liquid nitrogen), creating a blister between the wart and epidermal layer, after which the wart and surrounding dead skin falls off by itself; Average of 3 to 4 treatment is required for warts of thin skin. Wart on calloused skin like plantar warts might take dozens or more treatments. [11]
  • Surgical curettage of the wart;
  • Laser treatment - often with a pulse dye laser or carbon dioxide (CO2) laser. Pulse dye laser (wavelenght 582) work by selective absorption by blood cells (specifically hemoglobin). CO2 laser work by selective absorption by water molecules. Pulse dye lasers are less destructive and more likely to heal without scarring. CO2 laser work by vaporizing and destroying tissue and skin. Both laser treatment can be painful, expensive, and can cause scarring. CO2 laser will require local anesthetic, while pulse dye laser might need conscious sedation. Takes 1 to 4 treatments.[12]
  • Infrared coagulator - an intense source of infrared light in a small beam like a laser. Works essentially in the same principle as laser treatment. It is less expensive. Like the laser, can cause blistering pain and scarring.[13]
  • Imiquimod, a topical cream that helps the body's immune system fight the wart virus by encouraging interferon production. Not FDA approve for common wart. Drug is expensive, and response is very poor as compared to genital warts.
  • Injection of Candida, mumps, or Trichophyton antigens at the site of the wart, which stimulate the body's immune system[14];
  • Cantharidin, a chemical found naturally in many members of the beetle family Meloidae which causes dermal blistering. Either used by itself or compounded with podophyllin. Not FDA approved but available through Canada or select US compounding pharmacy.
  • Bleomycin, not FDA approved, one to two injections, can cause necrosis of digits and Raynaud syndrome[15][16] Drug is expensive = $200-300 per vial USD.
  • Dinitrochlorobenzene (DNCB), like salicylic acid, is applied directly to the wart. Studies showed this method was effective with a cure rate of 80% compared to 38% for placebo. But DNCB must be used much more cautiously than salicylic acid; the chemical is a known mutagen, able to cause genetic mutations. So a physician must administer DNCB. This drug induces an allergic immune response resulting in inflammation that wards off the wart-causing virus.[17]



The wart often regrows after the skin has healed.

One review of 52 clinical trials of various cutaneous wart treatments concluded that topical treatments containing salicylic acid were the best supported, with an average cure rate of 75% observed with salicylic acid compared with 48% for placebo in six placebo-controlled trials including a total of 376 participants.[18] The reviewers also concluded that there was little evidence of a significant benefit of Cryotherapy over placebo or no treatment.[18]

Over-the-counter

There are several over-the-counter options. The most common ones involve salicylic acid. These products are readily available at drugstores and supermarkets. There are typically two types of products: adhesive pads treated with salicylic acid or a bottle of concentrated salicylic acid solution. Removing a wart with salicylic acid requires a strict regimen of cleaning the area, applying the acid, and removing the dead skin with a pumice stone or emery board. It may take up to 12 weeks to remove a wart.

Another over-the-counter product that can aid in wart removal is silver nitrate in the form of a caustic pencil, which is also available at drug stores. This method generally takes three to six daily treatments to be effective. The instructions must be followed to minimize staining of skin and clothing.

Cryosurgery device using freon refrigerants are inexpensive. Disadvantage is that the sponge applicator is too large for small warts, and the temperature achieved is much lower than liquid nitrogen. Complications include blistering of normal skin if excess freezing is not controlled. [19]

Duct tape occlusion therapy

Main article: Duct tape occlusion therapy

Duct tape occlusion therapy (DTOT) involves placing a piece of duct tape over the wart(s) for six days, followed by soaking the area in water and scraping it with a pumice stone or emery board. There is conflicting evidence as to whether or not DTOT is an effective wart therapy.

The study cited above[20] had 9 patients lost to the follow-up from the original 61 patients entered. In contrast to the flaws (15% of subjects lost to the follow-up) and favorable results of the above study, a more stringent study of 103 children found no benefits from duct tape[21] . The evaluators were blinded during treatment for the most part, a placebo (corn pad) was used and there were no patients lost to the follow-up. After six weeks, rates of wart resolution were similar in the duct tape and corn pad groups and much lower than the rates seen in the earlier trial.

A similar trial comparing duct tape with a control treatment with a moleskin pad in 90 adults also found no difference in the rate of wart resolution at the end of two months (21 versus 22 percent).[22] However, the median age in this study was 54 years, and transparent duct tape was used, which contains no rubber found in the standard gray variety.[23]

Prevention

Gardasil is a vaccine aimed at preventing cervical cancers and anogenital warts. Gardasil is designed to prevent infection with HPV types 16, 18, 6, and 11. HPV types 16 and 18 currently cause about 70% of cervical cancer cases[4][5], and also cause some vulvar, vaginal[6], penile and anal cancers[7]. HPV types 6 and 11 cause about 90% of genital warts cases.


See also

Look up wart in Wiktionary, the free dictionary.

References

  1. ^ http://health.rutgers.edu/hpv/
  2. ^ Champion, R.H., et al. Rook's Textbook of Dermatology. Blackwell Science. 1998. pp. 1029-1051.
  3. ^ Champion, R.H., et al. Rook's Textbook of Dermatology. Blackwell Science. 1998. pp. 1029-1051.
  4. ^ a b Lowy DR, Schiller JT (2006). "Prophylactic human papillomavirus vaccines". J. Clin. Invest. 116 (5): 1167–73. doi:10.1172/JCI28607. PMID 16670757. Retrieved 2007-12-01.
  5. ^ a b Muñoz N, Bosch FX, Castellsagué X, Díaz M, de Sanjose S, Hammouda D, Shah KV, Meijer CJ (2004-08-20). "Against which human papillomavirus types shall we vaccinate and screen? The international perspective". Int J Cancer. 111 (2): 278-85.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  6. ^ a b "FDA Approves Expanded Uses for Gardasil to Include Preventing Certain Vulvar and Vaginal Cancers". 2008-09-12. Retrieved 2008-10-12.
  7. ^ a b Cortez, Michelle Fay and Pettypiece, Shannon. "Merck Cancer Shot Cuts Genital Warts, Lesions in Men". Bloomberg News. (Bloomberg.com) 13 Nov 2008.
  8. ^ Gypsyamber, D, et al. Case–Control Study of Human Papillomavirus and Oropharyngeal Cancer NEJM. 356;19. May 10, 2007.
  9. ^ Mosby's Medical, Nursing, & Allied Health Dictionary (5th edn), Anderson KN, Anderson LE, Glanze WD, eds, Mosby
  10. ^ Warts at About.com
  11. ^ http://www.aafp.org/afp/20050815/647.html
  12. ^ http://www.aafp.org/afp/20050815/647.html
  13. ^ HALASZ C. L. G., Treatment of common warts using the infrared coagulator. The Journal of dermatologic surgery and oncology ISSN 0148-0812. 1994, vol. 20, no4, pp. 252-256 (21 ref.)
  14. ^ Horn TD, Johnson SM, Helm RM, Roberson PK (2005). "Intralesional immunotherapy of warts with mumps, Candida, and Trichophyton skin test antigens: a single-blinded, randomized, and controlled trial". Arch Dermatol. 141 (5): 589–94. doi:10.1001/archderm.141.5.589. PMID 15897380.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  15. ^ Champion, R.H., et al. Rook's Textbook of Dermatology. Blackwell Science. 1998. p. 1044
  16. ^ http://www.aafp.org/afp/20050815/647.html
  17. ^ http://www.health.harvard.edu/fhg/updates/update0303d.shtml
  18. ^ a b Gibbs S, Harvey I, Sterling JC, Stark R (2003). "Local treatments for cutaneous warts". Cochrane Database Syst Rev (3): CD001781. doi:10.1002/14651858.CD001781. PMID 12917913.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ http://www.wartner-us.com/
  20. ^ Focht DR, Spicer C, Fairchok MP (2002). "The efficacy of duct tape vs cryotherapy in the treatment of verruca vulgaris (the common wart)". Arch Pediatr Adolesc Med. 156 (10): 971–4. PMID 12361440. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link) lay-summary
  21. ^ de Haen M, Spigt MG, van Uden CJ, van Neer P, Feron FJ, Knottnerus A (2006). "Efficacy of duct tape vs placebo in the treatment of verruca vulgaris (warts) in primary school children". Arch Pediatr Adolesc Med. 160 (11): 1121–5. doi:10.1001/archpedi.160.11.1121. PMID 17088514.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  22. ^ Wenner R, Askari SK, Cham PM, Kedrowski DA, Liu A, Warshaw EM (2007). "Duct tape for the treatment of common warts in adults: a double-blind randomized controlled trial". Arch Dermatol. 143 (3): 309–13. doi:10.1001/archderm.143.3.309. PMID 17372095.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  23. ^ "Study: Duct tape wart cure overstated".
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