WARTS (VERRUCAE)

- benign intraepidermal tumours of skin

- cause: HPV infection; ds DNA virus
- infects epidermal cells by direct inoculation.
- common
- contagious when in contact with the skin of an infected person
- typically disappear after a few months but can last for years and can recur

Etiology & Pathogenesis

- > 100 types of HPV: cause different warts
- spread by autoinoculation, community baths, contaminated objects and
trauma
- Hyperhidrosis helps their spread
- immune suppressive drugs & immune deficient states (HIV infection,
lymphomas, CLL or Hodgkins disease): prone to develop warts
- most infections: latent/transient (due to intracellular control of viral
replication)
- IP: 1-12 months; average: 2-3 months

Clinical features
- different morphological variants are:
Wart types
Common warts (verruca vulgaris): HPV
2, 4, 27
Plane warts (verruca plana): HPV 3, 10
Filiform or digitate warts
Plantar warts: HPV 1,2, 4, 57
Genital warts (condylomata acuminate):
HPV 6, 11, 16, 18, 31, 33
Description
Firm, single or multiple papules of
diameter 1-fewmm; commonly on hands,
face, feet, eyelids, palm, soles & finges;
usually asymptomatic but painful at
locations like nail folds
Occur over face & chin as asymptomatic
smooth, flat or slightly elevated, usually
skin colored or grayish, round or
polygonal papules measuring 1-2 mm
Occur as single or multiple finger-like
warts on face, neck & scalp as slender,
soft, thin finger like growths ;
autoinoculation by shaving increases
their number
Begins over pressure points like heels,
heads of metatarsals, below toes as
small, shiny, sago-grain papules which
soon become well defined & rounded;
develop rough & hyperkeratotic surface,
more painful on horizontal pressure; skin
markings are discontinuous; on paring
small bleeding points appear
Most commonly STD
Many of HPV causing genital infections
have oncogenic potential
Diagnosis
- primarily by clinical appearance & history
- histologic examination in doubtful cases may be done
Differential diagnosis: The differential diagnosis varies depending on the site of
lesions
Seborrheic keratosis
Acrochordons
Pyogenic granuloma
Squamous cell carcinoma
Sebaceous hyperplasia

Course & prognosis

- natural course: spontaneous resolution; lesions---spontaneous within

6months----1/2 lesions within 1 yr----2/3 within 2 yr
- plantar warts recur despite t/t

Treatment
Various modalities of treatment are
- Occlusive dressing with 40% salicylic acid followed by paring
- 10% glutaraldehyde or 2-3% formaldehyde compresses
- Caustics like trichloroacetic acid (TCA), carbolic acid, phenol and silver nitrate,
which
must not be allowed to spill over to the normal skin lest painful irritant reaction
occurs.
-Podophyllin gives better results in cases of anogenital warts.
- Topical retinoids may need to be applied over plane warts for a period of weeks to
months.
- Genital, plane as well as periungual warts may be most amenable to imiquimod, a
topical immunomodulatory agent
- 5-fluorouracil (5FU) cream, useful in genital warts, has also been used in plane
warts.
- Surgical removal of warts in resistant cases
- Electrocautery is better than surgery but scarring and recurrence may occur.

KEY FEATURES (MUST KNOW)

Warts
Human papilloma viruses are a large group of approx 100 genotypes of DNA
tumor viruses that infect the epithelia of skin or mucosa and most commonly cause
benign papillomas or warts.
Genital HPV infection is highly prevalent STD found predominantly in young
adults.
Condylomata acuminata or benign genital warts are typically caused by HPV 6 or
11 which are considered as low risk types as they are rarely found in high grade
genital dysplasia.
Persistent infection with high risk HPV types 16 and 18 are associated with
neoplasias.
Patients with cellular immunodeficiencies are at higher risk of persistent &
progressive HPV infection.
 No effective antiviral treatment exists and most therapies aim at destruction of
visible
lesions.