Updated: 12/21/2021

Cutaneous Warts (Verrucae)

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  • Snapshot
    • A 6-year-old girl presents to the pediatric dermatologist’s office for multiple warts on her hands and feet. She reports that they are not physically painful or itchy, but they are embarrassing. Her friends avoid touching her because of the warts. Her past medical history includes atopic dermatitis. On physical exam, she has multiple 4-5 mm flesh-colored papules. Because of the associated stigma at school, the pediatrician suggests using topical salicylic acid to treat these lesions.
  • Introduction
    • Clinical definition
      • cutaneous warts, or verrucae, are skin lesions caused by infection with human papillomaviruses (HPVs)
        • common forms
          • common warts (verruca vulgaris)
          • flat warts (verruca plana)
            • HPV type 3 and 10
          • plantar warts (verruca plantaris)
            • HPV type 1
          • anogenital warts
            • also known as condylomata acuminata
            • HPV type 6 and 11
  • Epidemiology
    • Demographics
      • children and young adults
    • Risk factors
      • atopic dermatitis
      • immunosuppression
      • walking barefoot in communal swimming areas
      • occupations
        • handlers of meat and fish
  • Etiology
    • Pathogenesis
      • transmitted through contact with infected skin of mucous membranes
        • warts contain high viral load
        • virus invades epidermal basal layer through microabrasions and are confined to epidermis
      • incubation period is 2-6 months
    • HPVs
      • over 150 subtypes
  • Presentation
    • Symptoms
      • asymptomatic
      • commonly appear at sites of trauma
    • Physical exam
      • commonwarts
        • flesh-colored papules
        • can be cauliflower-shaped or smooth
        • black dots, which are thrombosed capillaries, appear when pared with a surgical blade
        • hands are most commonly involved
      • flat warts
        • pink, light brown, or light yellow flat-topped papules
        • most commonly on mouth and forehead
      • plantar warts
        • on plantar surface of feet, often at points of maximum pressure
        • accompanied with thick callus
      • single or grouped lesions
      • warts on adjacent toes
        • “kissing lesions”
  • Studies
    • Biopsy
      • indications
        • if diagnosis is unclear
    • Histology
      • epidermal hyperplasia
      • hyperkeratosis
      • koilocytosis
    • Diagnostic criteria
      • a clinical diagnosis
  • Differential
    • Seborrheic keratosis
      • “stuck on” appearance
    • Acrochordon (skin tags)
      • pedunculated
  • Treatment
    • Medical
      • destruction of warts
        • indications
          • cosmetic reasons
          • associated pain or irritation
          • immunosuppression
        • modalities
          • topical salicylic acid
            • first-line
          • cryotherapy
            • because of pain, it usually used in older children or adults
          • topical cantharidin
          • laser
      • topical immunotherapy
        • indications
          • refractory to first-line treatment
        • modalities
          • squaric acid dibutylester
          • dinitrochlorobenzene (DNCB)
          • diphenylcyclopropenone (DPCP)
  • Complications
    • No significant complications
  • Prognosis
    • Often spontaneously resolves in children
    • Often require several sessions of treatment in adults
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