2.1.4 Warts

Grading & Level of Importance: A

ICD-11

1E80 

Synonyms

Common warts; verruca vulgaris; filiform warts; digitate warts; wart; verruca. 

Epidemiology

Affects 7-10% of the population, most commonly in first three decades of life. 

Definition

Infection caused by human papilloma viruses (HPV), a DNA virus with more than 100 types, karyotropic. Transmission: human to human or animal to human. Incubation period: weeks to months. Predisposing factors: impaired skin barrier, immunosuppression, hyperhidrosis, impaired peripheral circulation, occupation (e.g. butchers).

 

Aetiology & Pathogenesis

Superficial keratinocyte infection by human papilloma virus.

 

Signs & Symptoms

Dome-shaped, firm papules with a papillomatous, hyperkeratotic (verruciform) surface, along with typical dark punctae (capillary thrombi). Plantar warts are flat (mosaic or thorn-like) with pressure-induced inward growth. Warts may be pigmented and painful.

Localisation

Any part of the body, particularly hands and feet. 

Classification

According to HPV subtype. E.g. verruca vulgaris: common wart (HPV 1, 2); v. plantaris: plantar, mosaic warts (HPV 2, 4); v. plana: (HPV 1, 3).

 

Laboratory & other workups

Usually not required. 

Dermatopathology

Usually not required. Acanthotic epidermis with vacuolation of keratinocytes and parakeratotic plug (church-spire feature). 

Course

Usually self-limiting. 

Complications

May persist and become disseminated in immunocompromised individuals. Rarely mMay lead to fingernail destruction. Some HPV subtypes may lead to neoplasia including squamous cell carcinoma. 

Diagnosis

Clinical. 

Differential diagnosis

Corns, macrocomedones, lichen planus, Darier's disease, condylomata lata (Lues II), squamous cell carcinoma.

Prevention & Therapy

Spontaneous resolution in 95% within 2 years. Therefore aggressive therapy should be avoided. Beware scarring from over- treatment (no surgery). Cryosurgery, keratolytics (e.g. salicylic acid), topical retinoids (for facial involvement), 5-fluorouracil (5-FU), diphenylcyclopropenone immunotherapy (DCP), imiquimod.

Special

Consider underlying immunosuppression in extensive or treatment-resistant warts. 

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