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Key Features

Essentials of Diagnosis

  • Verrucous papules anywhere on the skin or mucous membranes, usually < 1 cm in diameter

  • Prolonged incubation period (average 2–18 months); spontaneous "cures" (50% at 2 years for common warts)

  • "Recurrences" (new lesions) are frequent

General Considerations

  • Caused by human papillomaviruses (HPVs)

  • Typing of HPV lesions is not a part of standard medical evaluation except in the case of genital dysplasia

  • Genital HPVs are divided into low-risk and high-risk types depending on the likelihood of their association with cervical and anal cancer

Clinical Findings

Symptoms and Signs

  • There are usually no symptoms

  • Tenderness on pressure occurs with plantar warts; itching occurs with anogenital warts

  • Flat warts are most evident under oblique illumination

  • Periungual warts may be dry, fissured, and hyperkeratotic and may resemble hangnails or other nonspecific changes

  • Plantar warts resemble plantar corns or calluses

Differential Diagnosis

  • Nongenital warts

    • Actinic keratosis

    • Squamous cell carcinoma

    • Molluscum contagiosum

    • Skin tag (acrochordon)

    • Nevus

    • Verrucous zoster (in AIDS)

  • Genital warts (condyloma acuminata)

    • Secondary syphilis (condyloma lata)

    • Psoriasis

    • Seborrheic keratosis

    • Molluscum contagiosum

    • Bowenoid papulosis and squamous cell carcinoma

    • Lichen planus

    • Pearly penile papules

    • Skin tag (acrochordon)

Diagnosis

  • Clinical

  • Biopsy may be necessary for definitive diagnosis

Treatment

Medications

LIQUID NITROGEN

  • Apply to achieve a thaw time of 30–45 s; two freeze-thaw cycles are used every 2–4 weeks for several visits

  • Scarring will occur if used incorrectly

  • May cause permanent depigmentation in darkly pigmented individuals

  • First-line physician applied treatment for genital warts (condyloma acuminata)

KERATOLYTIC AGENTS AND OCCLUSION

  • Salicylic acid products may be used against common warts or plantar warts; they are applied, then occluded

  • Plantar warts may be treated by applying a 40% salicylic acid plaster (Mediplast) after paring; the plaster may be left on for 5–6 days, then removed, the lesion pared down, and another plaster applied; it may take months to eradicate

  • Chronic occlusion alone with water-impermeable tape (duct tape, adhesive tape) is less effective than cryotherapy

PODOPHYLLUM RESIN

  • Paint each anogenital wart carefully (protecting normal skin) every 2–3 weeks with 25% podophyllum resin (podophyllin) in compound tincture of benzoin

  • Contraindicated in pregnancy

  • The purified active component of the resin, podofilox, is available for use at home twice daily 3 consecutive days a week for cycles of 4–6 weeks; it is less irritating and more effective than podophyllum resin

  • May need multiple cycles of treatment

IMIQUIMOD

  • A 5% cream of this local interferon inducer can clear external genital warts, particularly in women

  • Treatment is once daily on 3 alternate days per week; response may take up to 12 weeks; recurrences ...

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