Warts: how to recognise and treat them

Warts: history and numbers

Warts were known to the ancient Greeks and Romans, and in writings from 30 BC, Aulus Cornelius Celsus already speaks of leek-like manifestations that could be describing warts. Their identification as infections transmissible by contagion did not occur, however, until the late 1800s. In 1949, the agent causing verrucas was isolated as the papilloma virus (human papillomavirus, or HPV) and, a few years later, characterized as a double-helical DNA virus of the papovavirus family.
Today, it is estimated that nearly 7% of the general population suffers from warts, a sharp increase when compared to the past two or three decades. School-age children and young adults are most likely to have viruses for vulgar warts (58-70% of wart cases) and plantar warts (24-34% of wart cases). The peak range for having warts is between ten and 14 years of age. The transmission of the virus is favored by microtrauma (elbows and knees) and frequenting public environments and swimming pools (plantar warts). Recently, it has been suggested that there is an increased susceptibility to warts in children with atopic dermatitis, however larger scale studies are needed to provide scientific confirmation of this hypothesis.
Certain occupational groups (veterinarians, slaughter workers) are at increased risk. An animal model for HPV has not yet been successfully developed, and the virus cannot be cultivated in vitro. HPV is specifically a host of squamous epithelial cells such as those of the skin, although some types can grow in the epithelial cells of the genital and buccal/laryngeal mucous membranes.
These viruses are extremely small and penetrate cells easily. Once the virus has gained access it uses the resources of the host cell to coordinate its genes and replicate them.

Introduction

Warts were known to the ancient Greeks and Romans, and in some writings from 30 BC. Aulus Cornelius Celsus already mentions leek-like manifestations that could suggest warts. Their identification as infections transmissible by contagion did not occur until the late 1800s, however, while the agent causing them, the Papilloma Virus, (Human Papilloma Virus or HPV) was isolated in 1949 and, a few years later, characterised as a double-helix DNA virus of the Papovavirus family.
Today, it is estimated that almost 7% of the population suffer from warts.
An animal model for HPV has not yet been successfully developed, and the virus cannot be cultivated in vitro. HPV is specifically a host of squamous epithelial cells such as those of the skin, although some types can grow in the epithelial cells of the genital and buccal/laryngeal mucous membranes.
These viruses are extremely small and penetrate cells easily. Once the virus has gained access it uses the resources of the host cell to coordinate its genes and replicate them.
The peak incidence is from 12 to 16 years of age and the vast majority of warts’ location is on the hands and soles of the feet.
Recently, there has been talk of an increased susceptibility to warts in children with Atopic Dermatitis and scientific confirmation of this hypothesis is awaited from large-scale studies.

The HPV

HPV cause many different types of warts in humans, including skin warts, plantar warts, genital condylomas and laryngeal papillomas.
Certain HPV types are implicated in the carcinogenesis of areas such as the cervix, glans, larynx, tongue, etc.

CLASSIFICATION

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Around 7-10% of the population have skin warts at any one time, a figure that has been increasing sharply for the past two to three decades. School-age children and young adults are most likely to have viruses for vulgar warts (58-70% of wart cases) and plantar warts (24-34% of wart cases). The peak age for having warts is between ten and 14 years of age. The transmission of the virus is favored by microtrauma (elbows and knees) and frequenting public environments and swimming pools (plantar warts).
Certain occupational groups such as veterinarians or slaughter workers are also at a higher risk of contracting warts.
However, the hypothesis of transmission by a Papillomavirus of animal origin has never been proven.

Subdivision of warts

• Verruche piane
• Filiform warts
• Hand warts and variants
• Plantar warts and variants

Flat warts

Flat warts usually occur on the face or, in younger patients, they may appear on the back of the hands. They are asymptomatic and can be difficult to recognize, because they appear as small polygonal, isolated or confluent protrusions which are the color of normal or slightly darker skin. They spread rapidly to a certain number then settle without regression. Flat warts are contagious and can last for years without treatment.

Flat warts are difficult to treat.
Due to the fact that they are usually present on the face, thermal energies such as those produced by laser therapy, diathermocoagulation or liquid nitrogen cannot be used to remove them.
Positive results are obtained by using 2S Cream, rich in sulfosalicylic cream to facilitate wart detachment. Topical retinoic acid lotion (Airol Lotion) alternated with the glycolic-salicylic rich Glicosal Lotion may also be used.

Filiform warts

Filiform warts are skin extroversions that have varying degrees of subtlety. As their name suggests, they have a filiform appearance and can appear randomly as single or multiple warts in adults. The face, and particularly the beard area, is most likely to be affected.

To remove filiform warts, a ring curette must be used and coagulated with aluminum chloride. This operation can be performed by a professional without anesthesia.

Warts on the hands

Alongside those on the sole of the foot, hand warts are the most common type of warts. They are contagious and affect children of early school age the most, with hand warts often being present within school communities.

Dorsal and palmar warts

Dorsal and palmar warts appear on the dorsum as embossments with a depressed central crater. When they appear on the palm, warts resemble sunken nodules.

Periungual warts

A variant of palmar warts is the periungual wart, which affects the free margin of the nail.
Periungual warts are difficult to eliminate because they often recur and, due to their anatomically delicate position, they cannot be targeted with thermal energies. Instead, concentrated salicylic acid is the preferred treatment course (see treatments).

TREATMENT METHODS

In short, there is no specific antiviral drug treatment to get rid of warts. Instead, there is a wide variety of methods that are used to treat warts, some of which can do more harm than good.

Surgery

Under local anesthesia, the entire wart is excised with scalpel and sutured. However, this procedure can damage the healthy tissue surrounding the wart, can leave scarring and does not prevent reoccurance.

Curettage

The most traditional method of warts removal, cureattage is performed under local anesthesia and involves penetrating the edge of the wart with the sharp edge of a specialized spoon to dislodge the lesion. This technique does not damage nearby healthy tissue and the post-intervention wound is small, and can be easily treated. It will likely be fully healed within ten days.

Laser therapy, diathermocoagulation and liquid nitrogen

These treatment methods use hot or cold thermal energy to destroy the wart. However, due to the spread of thermal waves, these techniques often end up injuring the surrounding healthy tissue, and can cause scarring, delayed healing and an increased infection risk.
In addition, warts often recur after these treatments. For these reasons, laser therapy, diathermocoagulation and liquid nitrogen are not recommended for the removal of warts.

Chemical agents

Various chemical agents with caustic properties such as trichloroacetic acid, nitric acid and silver nitrate can be used to treat warts. So, too, can agents with keratolytic properties such as salicylic acid and lactic acid. The latter are commercially available both in liquid form and in flexible collodion. Salicylic acid can also be found in wart patches and plasters.

DermaClub suggests: salicylic acid in flexible collodion

The treatment method for the various forms of warts suggested by DermaClub is treatment with salicylic acid concentrated in Collodion Elasticum. This technique was developed mainly to treat warts that cannot be treated with curettes such as periungual warts and plantar mosaic warts but can be extended to hand warts and simple plantar warts. It is not suitable for the treatment of flat warts and filiform warts.
The principle of this treatment lies in the fact that salicylic acid has a high capacity to diffuse through the stratum corneum and remain in place for many days.
In this method, 30% salicylic acid in elastic collodion is used.
The procedure is as follows:
Excess stratum corneum on the wart is removed using a nail file or similar instrument.
A drop of concentrated salicylic acid in collodion is then applied on the prepared wart. After a few seconds, as the collodion dries, a white adherent film forms. The salicylic acid will begin its penetration phase and continue to act for about 48 hours. After 2 days, the excess stratum corneum on the wart is removed again using a nail file or similar instrument. The application of salicylic acid in collodion is then repeated.
These operations must be repeated every two days until the warts disappear. The method has an efficacy comparable to removal with curettes and has the advantage that it can be performed at home by the patient himself or with the help of the podiatrist. It is also completely painless. The formula of Salicylic Acid in Collodion Elastic is as follows:

• Salicylic acid: 3
• Flexible collodion 5%: 5
• Ethyl alcohol: 1
• Ethyl ether: 1

It should be stored in a glass bottle with a pipette lid and should be refrigerated.