Warts are growths of the skin caused by infection with the Human Papilloma virus.

Infection occurs by direct or indirect contact.

A damaged skin barrier increases the risk of inoculation. Plantar warts are transmitted from swimming pools due to friction of rough surfaces abrading the skin of the feet.

Warts around the nails occur in patients who bite their finger nails.

Shaving spreads warts over the beard area.

New warts may develop along the sites of trauma.

The incubation period ranges from a few weeks to over a year

Common warts

Present as firm papules with a rough surface

Most commonly found on the backs of the hands and fingers but can occur anywhere.

Plantar warts

Most plantar warts are found beneath pressure points. There are two main types:

Sharply defined rounded lesions with a rough thick surface, often painful.

Mosaic warts, which result from a plaque of closely grouped warts and not painful.

Plantar warts can be confused with callosities or corns. Callosities have a smooth surface in which the skin markings are maintained. Warts do not maintain the skin markings and when paired small bleeding points become evident. Warts are more painful when pinched, whereas callosities are more painful on pressure.

Plane (flat) warts

The face and backs of hands are the most common sites, lesions are often numerous.

Lesions are often small (under 5 mm), round, slightly elevated and have a smooth surface.

Filiform warts

These are commonly found on the face and neck in men, but can occur on any part of the body. They have a pointed tip appearance and may have a stalk

Anogenital warts

Are usually multiple:

May cause discomfort during passing stools or bleed. May appear pearly, filiform, fungating, cauliflower or plaque-like.

Can be smooth (particularly on penile shaft), verrucous, or lobulated.

Can be skin-colored, red or pigmented .

They predispose to cervical, penile and vulval cancer. Patients must be checked for other sexually transmitted infections.

Not all anogenital warts are sexually transmitted,

Management

Step 1: prevention

Warts are contagious.

Children with warts should NOT be excluded from physical activities, but should take care to minimize transmission:

Cover the wart with a waterproof plaster when swimming.

Avoid sharing shoes, socks and towels.

Limit personal spread by:

Avoid scratching lesions.

Avoid biting nails or sucking fingers that have warts

Keep feet dry and changing socks daily

Step 2: notes on plantar warts

In general, plantar warts are very difficult to treat. Cryotherapy (freezing by liquid nitrogen) :-many treatments are usually required.

Cryotherapy of the feet is very likely to be painful and can cause blistering.

Injection of local anesthesia is very painful on the palms and soles and is not advised.

Step 3: general management notes (excluding anogenital warts)

Salicylic acid - there are various lotions, paints and special plasters available over the counter. These should be used every night. Topical treatments are avoided on the face due to the risk of irritation and scarring.

Electro- cautery - can be useful for filiform warts, especially on the face. It can also be used for other warts that have failed to respond to other treatments. The main problem is that recurrence rates are up to %30.

Aldara cream for anogenital warts and persistent facial warts. Apply three nights a week (eg Monday, Wednesday, Friday) until the warts resolve. Wash off the following morning

Cryotherapy

Liquid nitrogen is used to treat numerous conditions such as warts, seborrheic keratoses and actinic keratoses. Treatment must only be given if the lesion can confidently be diagnosed as benign, if not a biopsy is required for histological purposes.

Adverse effects

Blistering.

Pain for up to 48 hours afterwards

Post inflammatory hypo / hyperpigmentation, particularly in darker skin