Skin warts are benign tumours caused by infection of keratinocytes with HPV, visible as well‐defined hyperkeratotic protrusions. We will explore the detailed types, presentation, and treatment modalities of most common warts.

1. WARTS
Presented by: Dr. Aryan

2. Skin warts are benign tumours caused by infection of keratinocytes
with HPV, visible as well‐defined hyperkeratotic protrusions

3. AETIOLOGY
Human Papilloma Virus
Over 200 distinct subtypes of HPV
Association exists between HPV type and clinical disease caused

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5. PREDISPOSITION
Predisposing conditions for extensive or recalcitrant involvement include:
atopic dermatitis and
conditions associated with decreased cell-mediated immunity (e.g. acquired
immune deficiency syndrome [AIDS], organ transplantation)
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6. TRANSMISSION
Non genital warts
 transmitted through direct skin to skin contact and autoinoculation (pseudo
Koebner’s phenomenon)
 If scratched or picked, viral particles may spread to another area of skin.
The incubation period can be as long as twelve months (2-6 months usually)
 Frequent in children and young adults
Anogenital warts
 Sexual transmission – both heterosexual and homosexual
 More common in adolescents and adults
 Vertical transmission – during vaginal delivery, mother with anogenital warts
can transmit infection to new born
 Manifests as laryngeal papilloma in infants

7. CLINICAL CLASSIFIATION
Verruca vulgaris
Palmoplantar warts
Verruca plana
Filiform warts
Epidermodysplasia verruciformis
Anogenital warts

8. VERRUCA VULGARIS (COMMON WARTS)
Usually asymptomatic
Morphology
Single/multiple, circumscribed, firm , dome shaped papules with verrucous
(hyperkeratotic) dry surface, stippled with black dots (d/t thrombosed
capillaries).
May be arranged linearly due to auto inoculation
60% resolve spontaneously
Sites of Prediliction
Anywhere in the body
Frequently in trauma prone sites i.e dorsae of hands, fingers including
peri/subungal areas, knees and feet

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11. PALMOPLANTAR WARTS
I. Superficial palmoplantar warts
C/f – Usually painless
Hyperkeratotic papules and plaques consisting of multiple,
small warts which are tightly packed
Several contiguous warts fuse and appear as one, plaque
known as mosaic wart
Sites of predilection – Soles and less often palms

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Multiple hyperkeratotic papules are present on the sole of the foot. Note the presence of
thrombosed capillaries and the interruption of dermatoglyphics (skin lines).

14. II. Deep palmoplantar warts (Myrmecia)
 C/f – Painful
 Hyperkeratotic, deep seated papules (barely visible above the
skin surface), surrounded by a horny collar and wart actually
becomes apparent as a soft, granular brown papule only when
collar is pared
 Further paring may reveal punctate black dots (thrombosed
capillaries)
 Almost always discrete
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16. VERRUCA PLANA (PLANE WARTS)
Multiple
Slightly elevated, flat, smooth papules
Lesions may be arranged linearly (pseudo Koebners
phenomenon), secondary to autoinoculation
Site of predilection – face and dorsae of hands

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18. FILIFORM WARTS
Asymptomatic
Thin elongated, firm projections arising from a horny base
Site of predilection – frequently on face (inoculation by
shaving), neck and scalp

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21. EPIDERMODYSPLASIA VERRUCIFORMIS
Rare autosomal recessive disorder
Characterized by defective cell mediated immunity to certain types of HPV (3, 5, 8, 9)
leading to wide spread lesions
2 types
A. Plane wart like lesions – many become confluent on face and acral
parts
B. Pityriasis versicolor like lesions – irregular scaly macules on trunk
Development of Bowens disease and invasive squamous cell carcinoma is
frequent on photoexposed parts

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24. ANOGENITAL WART
Anogenital Warts: 6, 11, 16, 18, 31, 33
Sexually Transmitted Disease
Transmitted both hetero and hemosexually and vertically during
vaginal delivery
Frequently on glans, perianal region, vulva and cervix
Laryngeal papillomas in children
Papillomatous cauliflower-like lesions with a moist macerated
vascular surface

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27. CLINICAL FEATURES
Morphological types
 Condyloma acuminata – most common type
Soft, fleshy, sessile/pedunculated, pinkish or skin coloured papules,
initially small
Enlarge to form cauliflower tumours
 Other types include – Papular anogenital warts, Bowenoid
papulosis, giant anogenital warts (Buschke – Lowenstein tumor)
 Site of predilection
• Males – Frenulum, coronal sulcus and inner lining of prepuce (all moist
areas)
• Females – Cervix, vulva, vagina

28. Condylomata acuminata: Cauliflower like, Bulky & Dry (contrast to
condylomata lata which are smooth, flat & moist)
Differentials of condylomata acuminata (anogenital warts) also include molluscum contagiosum,
pearly penile papules & neoplastic lesions.

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30. DIAGNOSIS
Usually clinical (rough, dry stippled surface)
Presence of pseudo Koebner’s phenomenon especially in verruca plana
Typical histology (hyperkeratosis, acanthosis, koilocytes, papillomatosis,
dilated vessels)
Presence of HPV DNA and specific HPV types can be determined on
smears and lesional biopsy specimens by in situ hybridization
Serologic tests for syphilis should be obtained on all patients with
anogenital warts to rule out co-infection
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31. DIFFERENTIAL DIAGNOSIS
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Smooth, dome shaped pearly white papules
with central umbilication
Located at pressure points, skin markings
uninterrupted, central keratinous core

32. TREATMENT
The aim of treatment is removal of the wart and amelioration of
symptoms, if present
Treatment of anogenital warts should be guided by wart size,
number, and anatomic site; patient preference; cost of treatment;
convenience; adverse effects; and provider experience
Treatment regimens are classified as either patient-applied or
provider-administered modalities

34. MANAGEMENT OF WARTS
Topical agents:
 Salicylic acid (10-25%): Keratolytic, so reduces thickness of wart and induces an
inflammatory response, stimulate local immunity. A 2012 meta-analysis of
randomized trials found salicylic acid superior to placebo for clearance of warts (0
to 80%).
 Wart paint: Contains salicylic acid and lactic acid in a quick drying collodion or
acrylate base. Treatment of choice for palomoplantar and periungual warts,
especially in children. Should not be used on facial lesions and anogenital warts.
May need to be used daily for 3 months.
 Retinoic acid (0.05-0.1%): Topically is used in plane warts because of keratolytic
action.

35. Cryotherapy
by thermal-induced cytolysis
Cryogens: Liquid nitrogen, carbon dioxide and nitrous oxide. Pain
and post- treatment depigmentation can occur
Cure rates from cryotherapy in randomized trials range from 14 to
more than 90 percent
If no improvement after six treatment cycle, transition to an
alternative therapy
Electric cautery and radiofrequency ablation (RFA): Treatment of
choice in filiform warts, verruca vulgaris if small and medium sized
warts.

36. LESS COMMON TREATMENT
MODALITIES Topical immunotherapy with contact
allergens — such as squaric acid
dibutylester (SADBE),
dinitrochlorobenzene (DNCB), and
diphenylcyclopropenone (DPCP)
 Intralesional bleomycin
 Topical or intralesional fluorouracil (FU)
 Cantharidin
 Duct tape
 Pulsed dye laser
 Oral cimetidine
 Topical 1 to 3% cidofovir
 Formaldehyde 0.5 to 3% solution 36
Glutaraldehyde 10 to 20% solution or
gel
Intralesional cidofovir
Intradermal Bacillus Calmette-Guérin
vaccine
Oral acitretin
Oral zinc sulfate
 Carbon dioxide laser therapy
Thermotherapy
Photodynamic therapy
Topical viable Bacillus Calmette-Guérin

37. ANOGENITAL WARTS TREATMENT
Patient Applied
Imiquimod 5% or 3.75% topically active immune enhancer that stimulates production of interferon
and other cytokines
Imiquimod 5% cream should be applied once at bedtime, three times a week for up to 16 weeks 3.75% cream should be
once at bedtime, every night.
Treatment area should be washed with soap and water 6–10 hours after the application.
Podofilox (podophyllotoxin) 0.5% solution or gel is a patient-applied antimitotic drug that causes
wart necrosis
Podofilox solution (using a cotton swab) or podofilox gel (using a finger) should be applied to anogenital warts twice a day for
days, followed by 4 days of no therapy. This cycle can be repeated, as necessary, for up to four cycles. The total wart area
should not exceed 10 cm2, and the total volume of podofilox should be limited to 0.5 mL per day.
Sinecatechins 15% is a patient-applied, green-tea extract with an active product (catechins) that
induces apoptosis, mediated by cell cycle deregulation
Sinecatechins 15% ointment should be applied three times daily (0.5 cm strand of ointment to each wart) using a finger to
ensure coverage with a thin layer of ointment until complete clearance of warts is achieved. This product should not be
continued for longer than 16 weeks. The medication should not be washed off after use.
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38. ANOGENITAL WARTS TREATMENT
Provider Administered
Cryotherapy with liquid nitrogen or cryoprobe
Surgical removal either by tangential scissor, tangential shave excision, curettage, laser or
electrosurgery
Trichloroacetic acid (TCA) and Bichloroacetic acid (BCA) 80-90% solution destroy warts by
chemical coagulation of proteins. A small amount should be applied only to the warts and
allowed to dry (i.e. develop white frost on tissue) before the patient sits or stands.
If pain is intense or an excess amount of acid is applied, the area can be covered with sodium
bicarbonate (i.e. baking soda), washed with liquid soap preparations, or be powdered with talc to
neutralize the acid or remove unreacted acid.
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39. SPECIAL CONSIDERATIONS
Salicylic acid and cryotherapy is usually avoided in facial flat warts
because of risk of excessive skin irritation and hypopigmentation
respectively
Podofilox (podophyllotoxin), podophyllin, and sinecatechins should not
be used during pregnancy
Imiquimod appears to pose low risk but should be avoided until more
data are available.
 Rarely, HPV types 6 and 11 can cause respiratory papillomatosis in
infants and children, although the route of transmission (i.e.,
transplacental, perinatal, or postnatal) is not completely understood
Whether cesarean section prevents respiratory papillomatosis in infants
and children is unclear

40. PROGNOSIS
In healthy individuals, most warts resolve spontaneously (30% in 6 months
and 60% in 1 year). Recurrence is common.
Spontaneous remission of warts occurs in two-thirds of children within two
years. Spontaneous resolution in adults tends to be slower and may take up
to several years or longer.
During the resolution process, punctate areas of blackish discoloration,
secondary to capillary thrombosis appears on the surface. Warts resolve
without a sequelae.
Mosaic warts, however have intractable course
In immunocompromised individuals, warts are persistent, extensive and may
have an oncogenic potential
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41. COMPLICATIONS
Some HPV (16,18) – frequently associated with anogenital
squamous atypia, less frequently with invasive carcinoma.
Oncogenic potential enhanced in presence of HIV induced
immune suppression
Obstruction of labour by large vulval warts
Vertical transmission – laryngeal papillomas
Epidermodysplasia verruciformis – Bowen’s disease and invasive
carcinoma in photo exposed parts

42. REFERENCES
• Andrew’s Diseases of the Skin, Clinical Dermatology, 12th edition
• Illustrated Synopsis of Dermatology and Sexually Transmitted diseases, Neena
Khanna, 5th Edition
• Rook’s Textbook of Dermatology, 8th Edition
• Clinical Dermatology, John Hunter, 3rd Edition
• Human papillomavirus infections: Epidemiology and disease associations, P. Joel
et al.
• Cutaneous warts (common, plantar, and flat warts), Goldstein B et al
• Condylomata acuminata (anogenital warts): Management of external
condylomata acuminata in men, Rosen Ted et al.

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