Benign (non-cancerous) lesions that occur in the mucosa and skin.
Aetiology
Agent:
Human papillomavirus (HPV) (DNA virus)
Enter via breaks in skin/mucosa
M/C strains:
Common warts: Type 2, 4
Plantar warts: Type 1
Genital warts: Type 6, 11
Flat warts: Type 3, 10, 28
Butcher’s warts: Type 7
Risk factors:
Use of public showers
Butcher’s warts (working with meat) (8.5-23.8% prevalence)
Eczema
Weakened/compromised immune system
Clinical features
Warts have a finely “verrucous” surface
Primary manifestations:
Common wart
Flat wart
Genital wart
Filiform wart
Periungual wart
Plantar wart
Common wart “Verruca vulgaris” or Palmer wart or Junior wart
Raised wart with roughened surface, most common on hands, but can grow anywhere on the body
A large number of warts on the big toe | Raimar – Public Domain, https://commons.wikimedia.org/w/index.php?curid=179705
Common warts can grow on hands or fingers. They’re small, grainy bumps that are rough to the touch. They’re usually flesh-colored, white, pink or tan. | A Virus And. (2019) Common warts – Symptoms and causes – Mayo Clinic. Retrieved January 09, 2019, from https://www.mayoclinic.org/diseases-conditions/common-warts/symptoms-causes/syc-20371125
Common Warts are found in areas which are exposed and frequently rubbed, such as on the hands and knees. They are raised and rough. | University of Indiana Department of Pathology
Flat wart “Verruca plana”
Small, smooth flattened wart, flesh-coloured, which can occur in large numbers M/C on face, neck, hands, wrists and knees.
Verruca plana is a condition that results in flat warts typically seen or the face of the back of the hands. The warts are pink, brown, or skin-colored papules. Pictured are verruca plana on the back of a child’s hand. | Color Atlas & Synopsis of Pediatric Dermatology Kay Shou-Mei Kane, Jen Bissonette Ryder, Richard Allen Johnson, Howard P. Baden, Alexander Stratigos Copyright 2002 by The McGraw-Hill Companies. All rights reserved.
Genital/venereal wart “Verruca acuminata” or Condyloma acuminatum:
Wart occurring on genitalia
Type of STD
A woman afflicted with genital warts (aka condylomata acuminata), around the anus. These warts are caused by human papillomavirus (HPV). | SOA-AIDS Amsterdam, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=45743
Severe case of genital warts on a male | SOA-AIDS Amsterdam, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=45727
Small condylomata on scrotum | Bikepunk2 – CC0, https://commons.wikimedia.org/w/index.php?curid=53538959
Filiform/digitate wart:
Thread- or finger-like wart, M/C on face, especially near eyelids and lips.
Filiform wart on the eyelid | Schweintechnik – Public Domain, https://commons.wikimedia.org/w/index.php?curid=3383897
Periungual wart:
Cauliflower-like cluster of warts that occurs around the nails.
Often cause:
Loss of the cuticle and paronychia.
Damage to the nail (either by lifting the nail from the skin or causing the nail to partially detach)
Pain (if extends under the nail)
Nail biting increases susceptibility to these warts
Periungual wart of 2 years duration over right ring finger and left middle finger nails. Patient was a habitual nail biter. | Wang, J., Zhu, X., Li, R., & al, et. (2005). Paraneoplastic pemphigus associated with castleman tumor: A commonly reported subtype of paraneoplastic pemphigus in china. Archives of Dermatology, 141(10), 1285–1293. Retrieved from http://dx.doi.org/10.1001/archderm.141.10.1285
Multiple periungual and subungual warts | Wang, J., Zhu, X., Li, R., & al, et. (2005). Paraneoplastic pemphigus associated with castleman tumor: A commonly reported subtype of paraneoplastic pemphigus in china. Archives of Dermatology, 141(10), 1285–1293. Retrieved from http://dx.doi.org/10.1001/archderm.141.10.1285
Plantar wart “Verruca plantaris” or verruca:
Hard, sometimes painful lump, often with multiple black specks in the center, usually only found on pressure points on the soles of the feet.
Colour is typically similar to that of skin.
May result in pain with pressure such that walking is difficult.
Commonly mistaken for corns and calluses
Close up image of a large plantar wart | James Heilman, MD – CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=37013880
Showing a veruca just behind the toes on the right foot of a 49 year old female. Note that the skin striæ can be observed as going around the lesion, at least on one side. | CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=740282
Plantar Wart. | DermNetNZ
Mosaic wart (group of tightly clustered plantar-type warts, commonly on the hands or soles of the feet.)
Mosaic cluster of Plantar warts – with salicylic acid recently applied | Lynes225 – Public Domain, https://commons.wikimedia.org/w/index.php?curid=6757190
Other manifestations:
Deep palmoplantar warts (Myrmecia)
Focal epithelial hyperplasia (Heck disease)
Epidermodysplasia verruciformis
Abul Bajandar suffered warts weighing 5kg on his hands | AFP/Getty Images
Focal epithelial hyperplasia affects only the lining of the mouth, most often: inside the lips inside the cheeks sides of the tongue However, the gums and tonsils can also to be involved. It is most often in the form of a smooth, slightly elevated and slightly elevated aspect. It is usually the same color as the rest of the mouth, but sometimes paler. There are often several lesions less than 1 cm in diameter. | Mohammad2018 – CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=71454727
Diagnosis
Histopathology
Hyperkeratosis (thickening of the stratum corneum)
Acanthosis (thickening of the stratum spinosum)
Thickening of the stratum granulosum
Rete ridge elongation
Large blood vessels at dermoepidermal junction
Micrograph of a common wart (verruca vulgaris) showing the characteristic features pf hyperkeratosis, acanthosis, hypergranulosis, rete ridge elongation, and large blood vessels at the dermoepidermal junction. H&E stain | Nephron – CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=16247974
Micrograph of a genital wart with the characteristic changes (parakeratosis, koilocytes, papillomatosis). H&E stain. | CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=535993
Differential diagnosis
Molluscum contagiosum
Seborrheic keratosis
Lichen planus
Squamous cell carcinoma
Keratoacanthoma
Management
Prevention
Gardasil 6 vaccine
Approved in 2014 protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58.
Do not currently protect against plantar warts (verrucas) strains
Treatment
Salicylic acid solution
Put on hardened skin of wart several times a day over the course of a few weeks to gradually dissolve it
Salicylic acid may cause skin irritation, but it is usually well tolerated.
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. | Steven Fruitsmaak – CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=1167096
Cryotherapy
Freezing the wart by applying liquid nitrogen which is extremely cold, and destroys cells in the skin’s outer layer.
Treatment is repeated several times with a break of at least 1 week between each session.
Liquid nitrogen is very cold so it may cause brief stabbing pain, and the skin may turn red or swell afterwards. Blisters sometimes develop too.
Liquid nitrogen spray tank | Effi B – CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=1825118
Cryotherapy being applied to a plantar wart with a cotton swab | Tonicthebrown – Public Domain, https://commons.wikimedia.org/w/index.php?curid=47599599
Podophyllum resin, aka podophyllin:
Resin made from the roots of the American mandrake, used as a medication to treat genital warts and plantar warts, including in people with HIV/AIDS.
Not recommended in HPV infections without external warts.