Verruca (wart) is a benign growth on the skin surface caused by human papillomavirus (HPV) infection. It is contagious. Warts can occur in various parts of the body. Common warts, flat warts, plantar warts, genital warts, etc. are common in clinical practice. Most common warts can disappear on their own. If the warts continue to grow or cause discomfort, they can be treated with topical or oral medications, surgery, and physical therapy such as freezing, laser, electrocautery, microwave, etc.
Clinical classification
1. Classification based on clinical manifestations and site of onset
(1) Common warts: They can occur anywhere on the body, but are more common on the hands. Hand trauma or prolonged immersion in water are common causes. In addition, there are some special types of common warts, such as periungual warts, subungual warts, filiform warts, and finger warts.
(2) Plantar warts: They can occur anywhere on the sole of the foot, but are more common in areas of pressure, especially the middle part of the talus (ankle joint). Trauma, friction, and excessive sweating of the feet are triggering factors.
(3) Flat warts: They are mainly seen in adolescents, so they are also called juvenile flat warts. They often occur on the face, back of the hands, and forearms (elbow to wrist).
(4) Genital warts: Also known as “genital warts”, they mainly occur in sexually active people and are a common sexually transmitted disease. This type has a separate and specific description, so it is only reflected in the type.
2. Classification based on infection status and clinical manifestations
(1) Clinical type: Wart-like growths can be observed with the naked eye.
(2) Subclinical type: No abnormalities in the skin or mucous membranes can be detected by naked eyes, and the acetic acid white test is positive.
(3) Latent infection: The skin appears normal, but HPV or HPV DNA can be detected, which is the main cause of recurrence and spread of warts.
Epidemiology
Infectious
Warts are caused by HPV infection and are contagious.
Source of infection
Patients who already have warts or who are infected with HPV but do not show symptoms can become sources of infection.
Mode of transmission
It is mainly transmitted through direct or indirect contact. Direct skin contact with the affected area of a wart patient can cause the virus to spread. In addition, sexual contact can cause the spread of genital warts. Touching the skin with warts and then touching other parts of the body may cause the warts to spread within the patient. Sharing towels and other personal items with patients can also lead to the spread of warts. However, it should be noted that because each person’s immune system responds differently to the HPV virus, not everyone who has been exposed to the HPV virus will develop warts.
Incidence
Studies have found that the incidence of warts in adolescents is about 500/100,000, and the incidence in the general population is about 300/100,000.
Disease trend
The incidence rate increases with age. In recent years, there has been a clear trend of increasing incidence of perianal and genital warts.
Prone population
Warts can occur at any age, but are rare in infants and young children and more common in young and middle-aged people. The male to female incidence ratio is 1:1.4.
Causes
Overview
The disease is caused by human papillomavirus (HPV). There are more than 100 types of HPV, of which nearly 80 are associated with human diseases [ 1 ] . Different types of warts are caused by different types of HPV. Common warts are mostly caused by HPV-1, HPV-2, HPV-4, HPV-7, and genotypes 26 to 29. Plantar warts are caused by HPV-1 or HPV-4, while flat warts are usually caused by HPV-2, 3, or 10, and occasionally by HPV-5. When the skin and mucous membranes are damaged, HPV can invade through the damaged area, infect the epidermal cells of the skin, and cause the formation of warts.
Basic Cause
Human papillomavirus (HPV) infects the epidermal cells of the skin.
Risk factors
1. People with low immunity, such as AIDS patients, people who have received organ transplants, malignant lymphoma, chronic lymphocytic leukemia, and lupus erythematosus patients are prone to the disease.
2. Children and adolescents are more susceptible to the disease.
3. Sharing personal items such as towels with infected people.
4. People who often bite their nails, have injuries or broken skin.
5. Have you ever had warts?
6. Walking barefoot on the ground, such as in public bathrooms, locker rooms, swimming pools, etc., can easily induce plantar warts.
7. Frequent friction of the feet and wearing non-breathable shoes can promote the occurrence of plantar warts.
8. People who often soak their hands in water are prone to common warts on their hands.
symptom
Overview
The main clinical feature of warts is the appearance of wart-like growths on the skin, which usually appear after the virus has been incubating for a period of time, usually 6 weeks to 2 years. However, not all people infected with HPV have obvious symptoms, and some can be detected through tests such as acetic acid white. Many people are in a special state of infection after infection, and do not show obvious symptoms, but can act as a source of infection to spread the virus to others.
Typical symptoms
1. Common warts
Commonly known as “thorn warts” or “warts”. Typical manifestations are gray-brown, brown or skin-colored papules (local protrusions above the skin surface) that are the size of soybeans or larger, with a rough surface and hard texture, and can be papilloma-like hyperplasia. Different types have different characteristics:
(1) Periungual warts often occur around the nails and are usually rough, irregular bumps that may cause nail pain and affect their growth.
(2) Subungual warts occur under the nails and, like periungual warts, can affect the growth of the nails and are prone to cracks, pain, and secondary infection.
(3) Filiform warts usually occur on the neck, forehead, eyelids and armpits. The warts are slender with keratin on the tip, like a small nail 1 cm long standing upside down on the skin.
(4) Finger-like warts occur on the scalp and between the toes, and the number is indefinite. They are usually composed of several soft finger-like protrusions, with keratin-like substances on the top and thinner at the bottom. The finger-like protrusions often fuse together like buds about to bloom, or spread out like a blooming lotus.
2. Plantar warts
Initially, it appears as a small, shiny papule on the sole of the foot, which then gradually increases in size. The surface of the pressured area is often covered with a layer of yellowish or brownish yellow calloused rough skin with clear boundaries and a thickened keratin ring around it. There is a loose keratin core under the keratin, and small black spots can be seen around it. Sometimes several warts gather together to form multiple keratin cores, which are called mosaic warts. Patients may feel pain when walking or standing, or they may not have any symptoms.
3. Flat warts
They usually appear suddenly. The lesions are slightly raised, smooth, flat papules. They are usually small (such as rice grains to soybeans), round or oval, and hard. The color is uncertain, usually basically the same as normal skin color, or light brown, and the number is often large and dense. After scratching, the lesions can be arranged in strips or beads, which is called isomorphic reaction or Koebner phenomenon. Patients generally have no subjective symptoms, but sometimes have slight itching.
Associated symptoms
If filiform warts occur on the eyelids, they may be accompanied by conjunctivitis or keratitis.
complication
Warts generally do not have any special complications, but if they are rubbed for a long time, they may rupture and cause pain.
examine
Estimated inspection
For patients who come to see the doctor, the doctor will first conduct a preliminary examination of the patient’s skin to determine the general condition of the skin lesions. Secondly, the patient is recommended to undergo acetic acid white test, pathological histological examination, HPV-DNA test, etc. to further assist in diagnosis.
Physical examination
The doctor will carefully observe the patient’s skin to determine the size, distribution, and color of the lesions. He will also touch them to determine the relationship between the lesions and the surrounding tissues, hardness, etc.
Laboratory tests
HPV-DNA testing: For those with unclear diagnosis, if necessary, part of the diseased tissue can be removed for HPV DNA testing, which will help further confirm the diagnosis.
Imaging tests
Generally, no special imaging tests are required.
Pathological examination
Pathological examination: Cutting off part of the affected skin and observing it under a microscope can help diagnose warts. The typical manifestation is vacuolar degeneration of the granular layer and the subgranular layer of the spinous cells. The degenerated cells contain basophilic inclusions and eosinophilic inclusions, the former being virus particles. It may be accompanied by hyperkeratosis, parakeratosis, acanthosis and papilloma-like hyperplasia.
Other tests
Acetic acid whitening test: The keratin produced by epithelial cells infected with human papillomavirus is different from that produced by normal cells, and can be coagulated and whitened by glacial acetic acid. Apply 5% acetic acid solution to the affected area or wet compress it. After 2 to 5 minutes, if the affected area turns white with clear boundaries, it is positive.
diagnosis
Diagnostic principles
Doctors will ask whether the patient has had close contact with warts and observe the skin lesions. In general, doctors can make a diagnosis based on the appearance of the skin lesions. If necessary, doctors will combine the results of acetic acid white test, pathological examination or HPV DNA test for further diagnosis.
Differential Diagnosis
1. Verrucous skin tuberculosis
Common warts need to be differentiated from verrucous cutaneous tuberculosis, which are irregular, warty plaques surrounded by a red halo.
2. Corns and calluses
Plantar warts need to be differentiated from corns and calluses. Corns are mostly caused by long-term compression and often occur on the edges of the toes and feet. The typical skin lesions are conical keratin plugs with a transparent yellow ring on the outside and a smooth surface. They can be single or scattered, and are painful when pressure is applied. Calluses are caused by long-term friction and compression and often occur on the front of the toes and heels. The typical skin lesions are waxy yellow keratin patches with slight thickening in the center, clear skin lines, and unclear edges. There are usually 1 to 2 patches, and there is usually no or only slight pain.
3. Follicular epithelioma, syringoma
Flat warts sometimes need to be differentiated from follicular epithelioma and syringoma. Although both can occur near the eyelids, their histology is completely different.
4. Lichen planus
Flat warts are sometimes difficult to distinguish from lichen planus. The latter is rare in children and tends to occur on the flexor side of the limbs and rarely on the face. It is obviously itchy and often accompanied by mucosal damage. The lesions are purple with white fine lines.
5. Punctate palmoplantar keratoderma
Plantar warts need to be differentiated from punctate palmoplantar keratoderma, which often develops at an early age, has a family history, and has lesions on the palms and soles that are scattered, with lesions more common in pressure areas.
6. False warts (pseudo-condyloma acuminatum)
Genital warts need to be differentiated from pseudo-warts. Pseudo-warts are also called villous labia minora. They are common on the inner side of the labia minora, around the vagina and urethral opening of young women. They are densely distributed and symmetrical on both sides. They are small white or light red papules with a diameter of 1 to 2 mm. The surface is smooth. Some may be villous or fish roe-like. They do not increase significantly in the short term. There is no discomfort, but occasional itching. The acetic acid white test is negative.
treat
Treatment principles
Not all warts require treatment. Most common warts will disappear on their own without treatment. However, when the pain is obvious, affects the appearance, and spreads over a large area, you need to go to the hospital for treatment. The treatment of warts mainly involves destroying the warts, regulating local skin growth, and stimulating local or systemic immune responses. The doctor will develop a treatment plan based on the type, location, and symptoms of the warts. Physical therapy and topical medications are mainly used. Systemic drug therapy is mostly used for those with a large number of warts or those who have not been cured for a long time. It may take weeks or even months to achieve the ideal treatment effect, but some patients may still relapse or the warts may spread to other parts of the body. At the same time, it should be noted that the treatment should not cause significant scars and other adverse consequences.
Drug treatment
1. Topical medication
Patients who are not suitable for physical therapy can choose topical medications according to different situations. Commonly used medications include the following:
(1) 0.05%~0.1% retinoic acid ointment: For external use 1~2 times a day, suitable for flat warts.
(2) 5% imiquimod ointment: once a day or three times a week, it has a certain effect on flat warts, common warts, etc.
(3) 5-fluorouracil ointment: 1-2 times a day. Use with caution on the face because it may leave pigmentation. Adverse reactions such as local pain, chapped skin, edema, allergic reaction, tearing, suppuration, etc. may occur.
(4) Salicylic acid: Salicylic acid is a keratin exfoliant. External use can heal skin lesions without scars. It has few adverse reactions, is easy to use, and has low treatment costs. However, it takes a long time to take effect and may cause mild skin irritation. Therefore, if redness or swelling occurs during use, it should be discontinued. It should also not be used on the head and face to avoid skin pigmentation and affect appearance.
(5) Cantharidin: It can cause congestion and blistering of the epidermis of the wart. After removing the keratin on the surface of the wart, apply cantharidin externally for 24 hours, and treat once every 1 to 3 weeks, with a total course of about 2 to 3 weeks. Cantharidin treatment of common warts will cause slight pain when blisters form, and no scars will be formed after healing. If erosion occurs during treatment, stop for a few days before continuing treatment.
2. Intralesional injection
(1) Pingyangmycin: Dilute with 1% procaine and inject at the base of the wart once a week. It is suitable for refractory common warts and plantar warts.
(2) Vitamin D 3 : Intralesional injection has a certain therapeutic effect on multiple warts.
3. Systemic drug therapy
There is no definite and effective anti-HPV treatment drug at present, but immunomodulators (such as interferon, levamisole, etc.) can be tried. In addition, therapeutic vaccines are in the clinical trial stage and may have a preventive and therapeutic effect on warts caused by HPV infection.
Related drugs
0.05%~0.1% retinoic acid ointment, 5% imiquimod ointment, 5-fluorouracil ointment, salicylic acid, cantharidin, 0.05%~0.1% retinoic acid ointment, 5% imiquimod ointment, 5-fluorouracil ointment, salicylic acid, cantharidin, bleomycin, vitamin D 3, interferon, levamisole
Surgery
1. Curettage
Warts are removed with a special scraper, but it is generally not suitable for the face.
2. Resection
Common warts and condyloma acuminatum can be removed surgically, but only the warts are removed, and the virus that causes the disease is not eliminated, so they are prone to recurrence after surgery.
Physical therapy
Cryosurgery, electrocautery, and laser therapy are all effective treatments for patients with smaller numbers of warts.
1. Cryotherapy
It is a commonly used treatment method. Liquid nitrogen is usually used to make the warts necrotize and fall off. It may take several repeated treatments to achieve the therapeutic effect. The treatment process is painful, so it is usually not used for younger patients. Side effects such as blisters and skin discoloration may occur after treatment. Blisters usually disappear within a few days. However, it should be noted that cryotherapy can induce the spread or aggravation of warts, because the blister fluid contains viruses, which may cause spread if not handled properly after rupture.
2. Electrocautery
The active electrode emits an electric spark 1 to 2 mm from the skin, which burns the wart. Sometimes this method is used after curettage to stop bleeding or destroy deeper tissue that curettage cannot reach.
3. Laser treatment
Uses high-intensity lasers to remove warts. This method requires repeating treatments every 3 to 4 weeks. May cause pain and scarring.
4. Microwave therapy
The principle is to make the molecules in the tissue move and change at high speed, generate huge oscillation friction, and make the body tissue generate high temperature instantly in a small range, so that it will be necrotic. Compared with laser, it has the advantages of good hemostasis and no pungent smoke and dust. It is forbidden for patients with pacemaker implants. Microwave therapy can completely remove viral tissues and reduce recurrence. It has small damage, fast effect and good effect.
Other treatments
Photodynamic therapy: Photodynamic therapy is a photochemical therapy, which is different from traditional phototherapy or photophysical therapy. This method can be used to treat some flat warts, plantar warts, etc. The method is to use photosensitizers such as aminolevulinic acid (ALA) topically, and then irradiate with light, which can cause the infected cells in the skin lesions to die.
Treatment cycle
The actual treatment period for warts depends on the type and distribution of the patient’s warts, the treatment methods used, daily care, etc. It cannot be generalized and there are obvious individual differences. Generally speaking, for patients who undergo surgery, physical therapy, etc., the wound needs more than a week to recover.
Treatment costs
The specific costs depend on the selected hospital, individual treatment plan, medical insurance policy, etc.
Prognosis
General Prognosis
Different types of warts have different prognoses. Common warts can regress naturally, with about 65% of patients regressing naturally within a year, and about 90% of patients regressing within 5 years. A small number of patients may relapse. At the same time, clinical findings show that the following signs often occur when warts regress: sudden itching, redness and swelling at the base of the warts, sudden enlargement of skin lesions, and an unstable state, or individual warts may regress or small new warts may appear. There are rare reports that common warts may become malignant. Plantar warts have a chronic course and can regress naturally. It is generally believed that children are more likely to regress than adults, and those with sweaty feet or abnormal metatarsals (part of the foot bones) are not likely to regress. Flat warts have a chronic course and can regress suddenly on their own. Their natural remission rate is the highest among all types of clinical HPV infections, and a small number of patients may relapse.
Hazards
1. Warts growing in conspicuous places such as the face will affect the patient’s appearance.
2. Warts are contagious to a certain extent and may spread themselves through scratching, etc., and may also be transmitted to others through close contact.
3. If there are symptoms such as itching and pain, it will have a certain impact on the patient’s life.
Self-healing
Warts may disappear on their own, and the time required for disappearance varies depending on individual constitution and the type of wart. For example, most patients with common warts can disappear within a year.
Curative
Warts can be cured by doctors actively taking appropriate medications, surgery and other treatment measures.
Cure rate
There are many types of warts, and there is no exact data on the overall cure rate. Generally speaking, most warts can be cured.
Radical
The treatment effect of warts is good, and it is possible to cure them through active treatment.
Recurrent
Warts may recur, so it is recommended that patients strengthen their self-management in daily life after treatment.
daily
Overview
Some patients can improve their condition through home care. If home treatment is ineffective, they should go to the hospital for regular treatment in time to avoid delaying the disease. Avoiding scratching the affected area and maintaining good personal hygiene habits in daily life can help the recovery of the disease. At the same time, monitor the condition well and seek medical treatment in time if abnormal.
Psychological care
1. Psychological characteristics
Some patients develop an inferiority complex because the warts grow in conspicuous locations and affect their appearance; some patients experience negative emotions such as fear and terror for fear that the warts may become malignant; and some patients believe that warts can disappear on their own, so they do not take good care of them in daily life, resulting in wear and tear and ulceration.
2. Nursing measures
First of all, patients should face up to the occurrence of the disease. They can learn about warts from professional doctors and understand that the prognosis is generally good after active and effective treatment, which can reduce psychological burden and build confidence in overcoming the disease. Secondly, patients should pay attention to their condition, follow the doctor’s advice and do the corresponding care to promote recovery from the disease. Finally, family members should communicate more with patients in daily life, avoid excessive talk about the warts in the conspicuous parts of the patients, and encourage and support the patients to receive treatment.
Medication care
1. Salicylic acid is an over-the-counter wart removal product. For best results, soak the wart in warm water for a few minutes before use, then gently remove the top layer of softened skin with a pumice stone or emery board. After the skin is dry, use the solution or patch. Salicylic acid therapy requires continuous treatment and regular medication to achieve efficacy. Consult a doctor before use, especially for patients with sensitive skin and pregnant women.
2. Some liquid nitrogen products are available in over-the-counter liquid or spray form. Consult a doctor before use and be sure to read the instructions carefully.
3. Patients can use tape to seal the affected area where the ointment has been applied. This treatment needs to be repeated. However, it is recommended that patients use tape to seal the skin, and they must control the strength to avoid excessive squeezing.
Postoperative Care
Patients who undergo surgical excision, laser, freezing and other treatments should pay attention to skin care after the operation and keep the wound clean and dry to avoid secondary infection.
Life Management
1. Avoid scratching or rubbing the warts to prevent them from spreading due to self-inoculation and worsening the condition.
2. Pay attention to the cleanliness of local skin to prevent secondary infection.
3. Adhere to physical exercise to strengthen your physical fitness and improve your body’s resistance.
4. Patients with plantar warts should wear loose and breathable shoes on a daily basis. Those who experience pain can wear soft-soled sports shoes, or put soft insoles under the shoes or make a hole in the insoles that is about the same size as the plantar wart, and avoid wearing high heels.
5. Improve nutrition, eat more vegetables and fruits, drink more water, and avoid spicy and irritating foods.
6. If a male patient has skin lesions on his face, especially on the beard, do not shave with a razor. Instead, carefully trim the beard with scissors.
Disease monitoring
1. After local treatment, you need to pay attention to possible side effects, such as pain, edema, suppuration, allergic reaction and pigmentation. If any abnormality is found, go to the hospital for appropriate treatment in time.
2. During the treatment, patients should closely monitor the condition of the warts, including their size, color, hardness, range, etc. If they gradually increase in size, change in appearance and color, or change from one to a large area, go to the hospital for a follow-up examination in time and adjust the treatment plan.
3. Monitor for other discomfort symptoms. If they affect your daily life, seek medical attention in a timely manner.
Follow-up consultation instructions
Patients should follow the doctor’s instructions for follow-up visits and seek medical attention in a timely manner if they feel unwell.
diet
Diet
In addition to actively cooperating with treatment, patients with skin warts also need to pay attention to their eating habits. Good eating habits not only have a positive effect on alleviating the condition, but also play a positive role in human health.
Dietary advice
1. Patients with warts should have a balanced diet, mainly focusing on staple foods, and eat less fatty, sweet and greasy foods.
2. Eat more vegetables and fruits, and supplement with foods that clear heat and detoxify, such as mung beans, loofah, rice, cucumber, bitter melon, green tea, etc.
Dietary taboos
Traditional Chinese medicine believes that seafood products such as fish, shrimp, and crab, as well as irritating foods such as spicy food, tobacco, and alcohol, are “irritating foods”. These foods are not good for the condition of wart patients and should be avoided during the onset of the disease or for a period of time after the disease is cured.
prevention
Precautions
The main measure to prevent warts is to avoid contact with the pathogenic virus. Those who are already infected should prevent the spread of warts on themselves.
1. Avoid contact with human papillomavirus
(1) People who do physical labor or are prone to injury should take care to protect themselves during work to prevent trauma and skin damage.
(2) Avoid direct contact with other people’s warts.
(3) Maintain good living habits and avoid sharing personal items such as towels, bath towels, razors, slippers, etc. with others.
(4) Keep your feet clean and dry, and change your shoes and socks every day. Try to choose socks that absorb sweat better and avoid wearing non-breathable shoes.
(5) Avoid walking barefoot on wet surfaces, such as around swimming pools and in public bathrooms.
2. Prevent the spread of warts
(1) After touching the skin with warts, wash it thoroughly with your hands and avoid touching other parts of the body directly.
(2) Do not bite your nails or the skin around your nails to avoid damage that could lead to the spread of the disease.
Medical Guide
Outpatient Indications
1. Single or multiple wart-like growths appear on the skin, and self-treatment with over-the-counter medications is ineffective.
2. If growths appear on the skin surface and you are over 60 years old and have never had warts, you should consult a hospital in time to rule out the possibility of skin cancer.
3. Wart-like growths appear on the soles of the feet, affecting walking.
4. Wart-like growths recur on the genitals.
5. Warts grow or spread rapidly.
6. The color or appearance of the wart changes.
7. Other abnormal situations occur.
The above suggestions require prompt medical consultation.
Department
When you find abnormal wart-like growths on the skin surface, you should first consult a dermatologist.
Medical preparation
1. Make an appointment in advance and bring your ID card, medical insurance card, medical card, etc.
2. The doctor will carefully examine the condition of the skin and recommends that the patient wear loose clothing to facilitate examination.
3. If you have taken any medicine recently, you can record the name, usage and dosage of the medicine to facilitate communication with the doctor.
4. If you have had medical treatment recently, please bring relevant medical records, examination reports, test results, etc.
5. Family members may accompany you to the clinic and they should prepare questions they want to ask.
Questions your doctor may ask
1. When did you first notice any unusual new growths on your skin?
2. Have you had similar symptoms before?
3. Are there any family members who are sick? Do they share towels or other items?
4. Have you been injured or had any skin damage recently?
5. Any history of other diseases?
6. Has the size and appearance of the lesions changed?
7. Have you tried treatment? How long did the treatment last and what was the effect?
Questions Patients Can Ask
1. Is there a clear diagnosis now? Do I have warts?
2. What are the causes of my disease?
3. Is my condition serious? Will it turn into cancer?
4. What tests do I need to do?
5. What medicines do I need to take? Are there any side effects?
6. How long will the treatment take? Can it be cured? Will it recur in the future?
7. What should I pay attention to in my daily life?