Verruca Warts

Warts are common growths of skin and mucosa caused by the human papillomavirus (HPV). Currently, more than 100 types of HPV have been identified. Specific HPV types often correlate to the lesion location, morphology, or oncogenic potential. Although most are benign, warts can be disfiguring or can cause significant psychological distress, and some cause cancer.

Verruca vulgaris (common warts) are dome-shaped kera-totic papules that usually develop on the dorsal hands, fingers, or other sites on the extremities (Fig. 33-57). Palmo-plantar warts are on the palms or soles and are surrounded by hyperkeratotic calluslike skin. These can be painful when occurring on weight-bearing surfaces. Multiple plantar warts may combine to become a large mosaic wart. Both common

Spreading Verrucas
Figure 33-56 Herpes zoster on face with herpes ophthalmicus. © Richard P. Usatine.)
Very Large Verruca
Figure 33-57 Kissing warts on fingers. © Richard P. Usatine.)

warts and palmoplantar warts have characteristic punctuate black dots, mistakenly leading to the common term "seed warts," whereas these black dots actually represent thrombosed capillaries. Filiform warts have fingerlike projections and often appear on the face. Verruca plana (flat warts) are smooth, small (1-4 mm) flesh-colored papules, often occurring on the face or legs and often spread by scratching or shaving (Fig. 33-58). Although inconspicuous at first, flat warts propagate rapidly, often into the hundreds.

Condylomata acuminata (genital warts) occur on the external genitalia, perineum, perianal, or adjacent intertriginous regions but can also be found on the oral mucosa. These lesions are generally considered sexually transmitted, but it is usually impossible determine when the inoculation

Wart Testis
Figure 33-58 Flat warts on forehead. © Richard P. Usatine.)

occurred. The lesions begin as small papules, which often become whitish with maceration and take on a cauliflowerlike appearance as they grow (Fig. 33-59). Condylomata are associated with cervical carcinoma and penile cancer. Among the many subtypes of HPV, types 6 and 11 are most often associated with condylomata, whereas types 16 and 18 are most often associated with the development of carcinoma.

There is no standard treatment for warts. Most warts spontaneously regress over many months to years. Local treatments include cryotherapy, salicylic acid, imiquimod, podophyllin, 5-fluorouracil (5-FU), cantharidin, and duct tape. For physician-applied treatments such as cryotherapy or podophyllotoxin, patients should be seen every 3 to 4 weeks for repeat treatment as needed. For home treatments with salicylic acid, podofilox (Condylox), or imiquimod (Aldara), most are applied daily, and patients should be advised that treatment can take months of extreme persistence for resolution. Office and home treatment modalities can also be combined to hasten resolution, but studies are lacking.

Women with condylomata should have annual Papanico-laou tests to evaluate for cervical neoplasia. For both men and women, it is advisable to refrain from sexual activity while genital lesions are present, to prevent transmission. In 2006 the FDA approved an HPV vaccine (Gardasil), recommended for females age 11 to 26 regardless of abnormal Pap history, positive HPV status, or genital warts. It is active against HPV types 6, 11, 16, and 18. In clinical trials, Gardasil decreased the incidence of cervical intraepithelial neoplasia (CIN), cervical cancer, and anogenital warts by 90% (Villa et al., 2006).

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