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An 11-year-old girl presents with warts on her fingers that have not responded to nonprescription wart medications (Figure 131-1). It causes her and her mother some social embarrassment and they would like to be rid of them. Her mother is also worried that it is affecting her daughter's nails. The girl was able to tolerate the discomfort of liquid nitrogen treatment and wanted all her warts treated. The mother was instructed to purchase 40% salicylic acid to continue treatment of any residual warts at home.

Figure 131-1

Common warts on the hands of an 11-year-old girl. These periungual warts are particularly difficult to eradicate. (Courtesy of Richard P. Usatine, MD.)

Human papillomaviruses (HPVs) are DNA viruses that infect skin and mucous membranes. Infection is usually confined to the epidermis and does not result in disseminated systemic infection. The most common clinical manifestation of these viruses is warts (verrucae). There are more than 100 distinct HPV subtypes based on DNA testing. Some tend to infect specific body sites or types of epithelium. Some HPV types have a potential to cause malignant change but transformation is rare on keratinized skin.

Verrucae, verruca vulgaris, common warts.

  • Nongenital cutaneous warts are widespread worldwide and are more common in children, with a peak incidence in the teenage years and a sharp decline thereafter.1
  • They are most commonly caused by HPV types 1 to 5, 7, 27, 29.1
  • Common warts account for approximately 70% of nongenital cutaneous warts.2
  • Common warts occur most commonly in children and young adults (Figures 131-1 and 131-2).3

Figure 131-2

Many common warts on the hand of an human immunodeficiency virus-negative young adult. (Courtesy of Richard P. Usatine, MD.)

  • Infection with HPV occurs by skin-to-skin contact. It starts with a break in the integrity of the epithelium caused by maceration or trauma that allows the virus to infect the basal layers.
  • Warts may infect the skin on opposing digits causing “kissing warts” (Figure 131-3).
  • Individuals with subclinical infection may serve as a reservoir for HPVs.
  • An incubation period following inoculation lasts for approximately 2 to 6 months.

Figure 131-3

Warts may infect the skin on opposing digits causing “kissing warts.” (Courtesy of Richard P. Usatine, MD.)

See reference 1.

  • Young age.
  • Disruption to the normal epithelial barrier.
  • More common among meat handlers.
  • Atopic dermatitis.
  • Nail biters more commonly have multiple periungual warts.
  • Conditions that decrease cell-mediated immunity such as HIV (Figure 131-4) and immunosuppressant drugs (Figure 131-5).

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