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Warts
Medical Student Core Curriculum
in Dermatology
Last updated July 29, 2011
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Module Instructions
 The following module contains a number
of blue, underlined terms which are
hyperlinked to the dermatology glossary,
an illustrated interactive guide to clinical
dermatology and dermatopathology.
 We encourage the learner to read all the
hyperlinked information.
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Goals and Objectives
 The purpose of this module is to help medical students
develop a clinical approach to the evaluation and initial
management of patients presenting with warts.
 By completing this module, the learner will be able to:
• Identify and describe the morphology of various types of
warts
• Discuss the pathogenesis of warts
• Develop an initial treatment plan for a patient with warts
• Describe the technique of cryotherapy
• List the side effects of cryotherapy
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Case One
Megan Driskell
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Case One: History
 HPI: Megan is an 8-year-old girl who presents to her
pediatrician’s office with bumps on her fingers and
hands. They have been present for 3 months without
change and are asymptomatic.
 PMH: no chronic illnesses or prior hospitalizations
 Allergies: no known allergies
 Medications: none
 Family history: no affected family members
 Social history: lives at home with parents and attends
school
 ROS: negative
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Case One: Skin Exam
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Case One: Question 1
 How would you describe these lesions?
a. Hyperkeratotic and umbilicated papules and
nodules
b. Hyperkeratotic, endophytic papules and nodules
c. Hyperkeratotic, exophytic papules and nodules
d. Smooth and umbilicated papules and nodules
e. Smooth, exophytic papules and nodules
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Case One: Question 1
Answer: c
 How would you describe these lesions?
a. Hyperkeratotic and umbilicated papules and nodules (these
papules are not umbilicated)
b. Hyperkeratotic, endophytic papules and nodules (these
papules are growing outward, not inward)
c. Hyperkeratotic, exophytic papules and nodules
d. Smooth and umbilicated (marked by a depressed spot)
papules and nodules (more characteristic of molluscum
contagiosum)
e. Smooth, exophytic papules and nodules (these papules are
not smooth)
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Clinical Features of Verruca
Vulgaris
• Hyperkeratotic, exophytic
(growing outward), domeshaped papules or nodules
• Most common on fingers,
dorsal hands, knees or elbows
but may occur anywhere
• Punctate black dots
representing thrombosed
capillaries
• May koebnerize – spread with
skin trauma
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Epidemiology
 One of the top three skin problems in
children
 Cutaneous warts occur in 20% of
school-aged children; also commonly
found in young adults
 Males and females are equally
affected
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Case One: Question 2
 Verruca vulgaris is caused by:
a.
b.
c.
d.
e.
Human immunodeficiency virus
Human papillomavirus
Pox virus
Herpes virus
Varicella-zoster virus
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Case One: Question 2
Answer: b
 Verruca vulgaris is caused by:
a.
b.
c.
d.
e.
Human immunodeficiency virus
Human papillomavirus
Pox virus
Herpes virus
Varicella-zoster virus
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Human Papillomavirus (HPV):
Overview
 Warts are caused by HPV
 HPV infects skin and mucosal epithelia
 HPV causes a variety of wart morphologies
•
•
•
•
Verruca vulgaris: common warts
Verrucae planae: flat warts
Palmoplantar warts
Condylomata acuminata: external genital warts
 The type of HPV determines the wart morphology
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Role of HPV in Cutaneous
Disease
 HPV can be transmitted by skin-to-skin
contact or through contaminated surfaces
or objects
• Patients can also spread virus from lesion to
unaffected skin
 HPV infects the basal keratinocytes of
cutaneous and mucosal epithelium
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Clinical Features of Verrucae
Planae: Flat Warts
• Skin-colored or pink
• Smooth-surfaced,
slightly elevated, flattopped papules
• Dorsal hands, arms,
face (exposed
surfaces)
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Clinical Features of Palmoplantar
Verruca
• Thick, endophytic
papules
• Central depression
• Plantar warts may be
painful when walking
• Mosaic warts: plantar
warts coalescing into
large plaques
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General Treatment Principles
 Majority of all warts will spontaneously
resolve in 1-2 years without scar
 Therefore important to choose a therapy with
low toxicity and low risk of scarring
 No specific antiviral therapy for cure
 Most treatments are destructive or aim at
stimulating the immune response to HPV
 Recurrence rates are high
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Common Wart Treatment
Options
 Watchful waiting – majority of all warts will
spontaneously resolve in 1-2 years without
scarring
 Cryotherapy – liquid nitrogen (see following slide
for more information)
 Salicylic acid – with occlusion and removal of the
dead skin (filing, pumice stone)
 For patients who do not respond to the above
therapies, refer to a dermatologist
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Cryotherapy
 Click here for an instructional video on cryotherapy
 Side effects of cryotherapy include:
• PIPA (post-inflammatory pigment alteration)
– In individuals with darker skin types, more likely to cause
hypopigmentation (see pre and post-cryo photos below)
•
•
•
•
Scar
Pain
Blister
Nail dystrophy
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Side Effects of Cryotherapy
Post inflammatory
hyperpigmentation
Wart ring post cryotherapy
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Flat Wart Treatment Options
 Common 1st line tx:
• Cryotherapy
• Salicylic acid
(caution using on
face)
• Topical tretinoin
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Palmoplantar Wart Treatment
Options
 1st line treatment is the
same as common wart
therapy (often requires
stronger dosing, e.g. 40%
salicylic acid vs. 17%
salicylic acid)
 Referral to a dermatologist
may be made for
chemotherapeutic agents
(e.g. topical 5-Fluorouracil)
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Case Two
Jonathan Cohen
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Case Two: History
 HPI: Mr. Cohen is a 21-year-old man who comes
into the STD clinic because of an increasing
number of bumps on his penis over the last year.
 PMH: no chronic illnesses or prior hospitalizations
 Allergies: no known allergies
 Medications: none
 Family history: noncontributory
 Social history: studying economics at a nearby
university
 ROS: negative
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Case Two: Skin Exam
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Case Two: Question 1
 How would you describe these lesions?
a.
b.
c.
d.
Pearly, vesicular papules
Smooth, indurated plaques
Verrucous exophytic papules
Waxy, stuck-on plaques
Case Two: Question 1
Answer: c
 How would you describe these lesions?
a.
b.
c.
d.
Pearly, vesicular papules
Smooth, indurated plaques
Verrucous exophytic papules
Waxy, stuck-on plaques
Clinical Features of
external genital warts
• Sessile, exophytic
papules
• May be broad-based
papules or large confluent
plaques
• External genitalia,
perineum, perianal,
inguinal fold, mons pubis
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Comparison of molluscum and
genital warts
Molluscum Contagiosum
External Genital Warts
(smooth, dome-shaped papules with
central umbilication)
(hyperkeratotic, exophytic
papules and plaques)
Case Two: Question 2
 What further elements in the patient’s
history would you need to complete your
evaluation?
a.
b.
c.
d.
Medications
Sexual history
Surgical history
Allergies
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Case Two: Question 2
Answer: b
 What further elements in the patient’s
history would you need to complete your
evaluation?
a.
b.
c.
d.
Medications
Sexual history
Surgical history
Allergies
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HPV Infection
Clinical Presentation
Frequently Associated
HPV Type
External genital warts
6, 11
High grade intraepithelial
neoplasia
16, 18,31, 33-35, 40, 45
Genital infection with HPV is transmitted by
sexual contact from partners with clinical or
subclinical infection
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External Genital Warts (EGW)
 HPV infection is one of the most common STIs
• Risk factors: sexual intercourse at an early age, numerous partners,
unprotected exposure
• Patients should receive counseling about condom usage, STI
prevention, and potential STI testing for sexual partners
 Effective prophylactic HPV vaccine is available for
prevention of genital warts
 Immunosuppression from HIV infection, organ transplant,
etc. can lead to:
• Increased frequency of HPV infection
• Persistent infection
• More difficulties in treatment
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Back to Case Two
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Case Two: Question 3
 What is the most likely HPV type leading
to this patient’s disease?
a.
b.
c.
d.
e.
2
6
16
31
34
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Case Two: Question 3
Answer: b
 What is the most likely HPV type leading
to this patient’s disease?
a.
b.
c.
d.
e.
2
6
16
31
34
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Case Two: Question 4
 Which of the following treatments could
you use for external genital warts?
a.
b.
c.
d.
Cryotherapy
Imiquimod
Salicylic acid
All of the above
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Case Two: Question 4
Answer: d
 Which of the following treatments could you use for
external genital warts?
a. Cryotherapy (liquid nitrogen is used to freeze the tissue at
the cellular level)
b. Imiquimod (a cream of this interferon inducer can be
applied 3x per week, response takes up to 12 weeks)
c. Salicylic acid (this beta hydroxy acid is applied, occluded
for 5-6 days, the wart is pared down, and then the cycle is
repeated)
d. All of the above
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Treatment (cont.)
 Other destructive methods can be used
as well to treat EGW
• Laser
• Electrocautery and curettage
• Surgical debulking
 Always use protective mask
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Imiquimod: True or False
 Imiquimod therapy is an off label use for
treatment of external genital warts.
• True
• False
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Imiquimod: True or False
False
 Imiquimod is FDA approved for treatment of
EGW
 Interacts with Toll-like receptors 7 and 8 to
increase cytokines from macrophages
 Clearance of 50% EGW compared to placebo
of 11%
 A disadvantage to this treatment is cost
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Prevention Reminder:
HPV Vaccine
 Two HPV vaccines are licensed by the FDA and
recommended by the CDC
• Gardasil™ and Cervarix™
 Both vaccines are effective against HPV types 16
and 18, which cause most cervical cancers
 Gardasil is also effective against HPV types 6
and 11, which cause most genital warts in
females and males
• 100% protection in prevention of genital warts during
5-year follow up period studied
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Take Home Points
 Warts are caused by human papilloma
viruses
 Numerous morphologies exist: common,
flat, palmoplantar, external genital
 Treatment is difficult and there are many
options available
 A vaccine of certain HPV types has proven
effective in reducing external genital warts
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Acknowledgements
 This module was developed by the American
Academy of Dermatology Medical Student Core
Curriculum Workgroup from 2008-2012.
 Primary authors: Kari L. Martin, MD; Susan K. Ailor,
MD, FAAD.
 Peer reviewers: Renee M. Howard, MD, FAAD; Erin
F. D. Mathes, MD, FAAD, FAAP, Timothy G. Berger,
MD, FAAD.
 Revisions and editing: Sarah D. Cipriano, MD, MPH;
Meghan Mullen Dickman. Last revised July 2011.
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References
 Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The WebBased Illustrated Clinical Dermatology Glossary. MedEdPORTAL;
2007. Available from: www.mededportal.org/publication/462.
 Gibbs S, Harvey I. “Topical treatments for cutaneous warts.”
Cochrane Rev. Vol 1. 2009. Online at
eMedicine:http://emedicine.medscape.com/article/1131981-overview.
Updated 12/2009.
 Kirnbauer R, Lenz P, Okun MM. “Chapter 78. Human Papillomavirus”
(chapter). Bolognia JL, Jorizzo JL, Rapini R: Dermatology. 2nd ed.
Mosby Elsevier; 2008. 1183-1198.
 Silverberg NB. “Human papillomavirus infections in children.”
Current Opinion in Pediatrics. 16:402-409. 2004.
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