ESSENTIALS OF DIAGNOSIS
Verrucous papules anywhere on the skin or mucous membranes, usually not > 1 cm in diameter.
Prolonged incubation period (average 2–18 months).
Spontaneous “cures” of common warts in 50% at 2 years.
“Recurrences” (new lesions) are frequent.
Warts (common, plantar, and genital [condylomata acuminata]) are caused by HPVs. Typing of HPV lesions is not a part of standard medical evaluation except in the case of anogenital dysplasia.
There are usually no symptoms. Tenderness on pressure occurs with plantar warts; itching occurs with anogenital warts (Figure 6–14) (eFigure 6–46). Flat warts are most evident under oblique illumination. Periungual warts may be dry, fissured, and hyperkeratotic and may resemble hangnails. Plantar warts resemble plantar corns or calluses.
Perianal condylomata acuminata. (Reproduced, with permission, from Orkin M, Maibach HI, Dahl MV [editors]. Dermatology. Originally published by Appleton & Lange. Copyright © 1991 by The McGraw-Hill Companies, Inc.)
Condylomata acuminata around the clitoris, labia minor, and opening of the vagina. (Reproduced with permission from Richard P. Usatine, MD, in Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley H. The Color Atlas of Family Medicine, 2nd ed. McGraw-Hill, 2013.)
Some warty-looking lesions are actually seborrheic keratosis, hypertrophic actinic keratoses or squamous cell carcinomas. Some genital warty lesions are condylomata lata of secondary syphilis. Molluscum contagiosum lesions are pearly with a central dell. In AIDS, wart-like lesions may be caused by varicella zoster virus.
Administration of a vaccine against certain anogenital HPV types (including 6, 11, 16, 18, 31, 33, 45, 52, and 58) can prevent infection with these wart types and reduce anogenital, oropharyngeal, and cervical cancer. It is recommended for teenagers and young adults, men who have sex with men, and immunocompromised patients (see Chapters 1 and 18). There may be a role for adjuvant vaccination in HPV-infected patients.
Treatment is aimed at inducing “wart-free” intervals for as long as possible without scarring, since no treatment can guarantee a remission or prevent recurrences. In immunocompromised patients, the goal is to control the size and number of lesions present. Certain types (HPV 1) are more responsive to treatment than others (eg, HPV 2, HPV 27).
A. Treatment of Nongenital Warts
For common warts of the hands, patients are usually offered liquid nitrogen or keratolytic agents. The former may work in fewer treatments but requires office visits and is painful.