Warts: Causes, Symptoms, Diagnosis, Treatment

Warts (verrucae vulgaris) are common soft epidermal formations associated with infection of human papillomavirus. They can occur on any part of the body. The diagnosis is established upon examination. Warts can be removed if excision, cauterization, cryotherapy, liquid nitrogen, injections or local treatment for warts are used.

What causes warts?

At present, no less than 60 types of the human papilloma virus have been isolated. None of them is strictly specific for a particular type of wart. However, with ordinary warts, the second type is more often found; at flat - the third; at plantar - 1st (in case of mosaic warts - 4th); with genital warts - the 6th and 11th types.

Warts are found everywhere, at any age, but most often they form in children, almost never in old age. The formation of warts causes human papillomavirus (HPV) infection, at least 70 HPV types are associated with skin lesions. Trauma and maceration facilitate initial epidermal penetration. It is believed that local and systemic immune factors affect the spread of infection. At risk are patients with low immunity, for example, with HIV and after kidney transplantation, when it is possible to develop extensive lesions that are difficult to treat. Humoral immunity provides resistance to HPV, and cellular leads to regression.

Pathomorphology of warts

Characteristic signs are hyperkeratosis, sometimes with parakeratosis, papillomatosis. Epithelial outgrowths are long and directed at their ends from the periphery to the center of the focus, are located in relation to it radially. The cells of the upper part of the spiny and granular layers are vacuolized, do not contain keratohialine granules. Their nuclei are more rounded, sharply basophilic. Surrounded by a light rim.

In electron microscopy, viral particles are found in these cells. However, such cells are not always found. In the dermis, as a rule, there is no change, but in the period of regression of the rashes, mononuclear infiltration and exocytosis appear in it, which some authors consider immune response.

Ordinary warts

The common wart differentiates with various papillomatous growths, from which it differs by the presence of the vacuolated cells described above, as well as by the radial arrangement of the epidermal outgrowths.

Flat warts

Flat warts are characterized by cytosis and hyperkeratosis with more vacuolated cells in the upper part of spiny to granular layers, as well as in the stratum corneum, which gives it the appearance of a wicker basket. In the basal layer, there is sometimes a large amount of melanin.

The flat wart differs from the ordinary absence of papillomatosis, parakeratosis and more pronounced vacuolization of the cells. The last sign makes a flat wart similar to Verwerziform Epidermodysplasia of Lewandowski-Lutz, but WF Lever (1975) notes a more pronounced pycnosis of nuclei with vertexiform dysplasia.

[1], [2], [3], [4], [5], [6], [7]

Plantar Warts

There is pronounced hyperkeratosis and parakeratosis with the presence of large, rounded, sharply basophilic nuclei in the stratum corneum. In the fresh foci of the upper part of the spiny and granular layers, a large number of vacuolated cells can be observed. The histological pattern resembles that of an ordinary wart, but it is characterized by more pronounced hyperkeratosis and parakeratosis. As well as a large number of vacuolated cells.

Genital Warts

In genital warts, the horny layer consists of parakeratotic cells, the granular layer is absent. The epidermis in the state of acanthosis and pronounced papillomatosis with thickening and elongation of branching epidermal outgrowths, which resembles pseudoepitheliomatous hyperplasia. Vacuolization of the upper layers of the epidermis is characteristic, which gives them similarity with ordinary warts. The dermis is sharply edematous, its vessels are dilated, focal inflammatory infiltrates are noted. Giant condylomas at first glance resemble a cancerous tumor due to the deep immersion of epithelial strands in the dermis, but with careful research it is possible to establish the good quality of the process.

The virus multiplies only in highly differentiated epithelium, which makes it difficult to obtain it in culture. With the help of the hybridization reaction in situ, it is shown that synthesis of viral DNA occurs in the upper layers of the spiky layer, and in the granular cells a complete ruffling of the capsids occurs. Infection is facilitated by microtraumas of the epithelial cover, a decrease in cellular immunity, which is confirmed by the increased occurrence of warts with immunodeficient conditions, including those caused by the human immunodeficiency virus. Giant warts develop due to hyperhidrosis, phimosis and other disorders.

How are warts manifested?

Warts are called at the site of their localization and clinical manifestations, different forms are associated with different types of HPV.

The formation of common warts (vulgar warts) causes HPV 1, 2, 4, 27 and 29. There are no symptoms, sometimes there is slight soreness, especially if the warts are located in places subjected to pressure, for example, on the feet. Warts have a clearly defined, round or uneven shape. Elements - coarse, solid, light gray, yellow, brown or gray-black, 2-10 mm in diameter, often appear on the fingers, elbows, knees, face. Warts of unusual shape, for example on the stalk, most often occur on the head, neck, especially on the chin.

Threadlike warts (papillomas) are long, narrow, usually formed on the eyelids, face, neck or lips. Also occur asymptomatically. This type is benign and easy to treat.

The flat warts caused by HPV 3, 10, 28 and 49 are smooth, yellow-brown papules with a flat apex, most often on the face. Most common in children and young adults. Usually do not cause anxiety, but are difficult to treat.

Palmar and plantar warts caused by HPV1 are flat due to the pressure of the lesion, surrounded by denser skin. Lesions are often sensitive, which causes discomfort when walking. Warts can be distinguished from bone calluses and corns by the presence of spot bleeding when they are damaged. It is believed that the warts are painful when pressed from the sides, and corns - with direct pressure, but this is an unreliable sign.

Mosaic warts are papules formed by the union of a myriad of small, closely spaced warts on the feet.

Like other plantar warts, they are often painful.

Okolonogevye warts appear as thickened, slit-like, reminiscent of cauliflower lesions around the nail plate. Often the cuticle is damaged and the paronychia develops. This type of wart prevails in patients who nail.

Pointed warts (condylomas) appear as smooth or velvety papules in the anogenital and pararectal area, on the labia or penis. Types of IPH 16 and 18 are the main causes of cervical cancer. Usually they are asymptomatic.

Types of warts

Ordinary warts are single or small multiple, dense, sharply delineated nodular elements with no signs of inflammation, with uneven papillomatous surface, normal skin color or grayish-yellow. They are located mainly on the back of the hands and feet, including around the nail plates and under them, but can be in any part of the skin, on the red border of the lips, the mucosa of the oral cavity. The wart that appears first is larger.

Flat warts, unlike ordinary ones, are more numerous, smaller, have a smooth surface, develop mainly in children and young women. Are located mainly on the face and hands, knee joints, often linearly, as a consequence of the phenomenon of Kebner.

Plantar warts are characterized by sharp soreness, deep disposition, large dimensions (diameter up to 2 cm), pronounced horny layers, after removal of which a papillary, often bleeding surface is found. These warts are usually few. Located in the places of greatest pressure. The skin pattern in the area of the warts is broken. With a close arrangement of individual warts, the focus can take a mosaic character.

Pointed condylomas are soft papillomatous growths, located, as a rule, in the anogenital region, resembling cauliflower, often with a macerated surface. Giant forms can be observed, representing verrux sprouts, which, merging with each other, form a large pink or red spot in the form of cauliflower, soft consistency with a lobed, moist, macerated surface, often with bleeding cracks. Develop on the genitals, around the anus. There are giant condylomas, located mainly on the head of the penis. Clinically, they may resemble carcinoma. Such condylomata can be transformed into cancer. WF Lever and G. Schaumburg-Lever (1983) consider giant condyloma as verruccus epithelioma. PO Simmons (1983), however, believes that giant condylomas, although they can destroy tissues, but histologically remain benign.

How to recognize warts?

The diagnosis is based on clinical manifestations, biopsy is rarely required. The main sign of warts is the absence of a dermal pattern on their surface, the presence of black dots (clogged capillaries) or bleeding in case of surface damage. Diagnosis should distinguish corns, lichen planus, seborrheic keratosis, polyps and squamous cell carcinoma. DNA typing is available in some medical centers, but this is usually not necessary.

How to get rid of warts?

Warts can suddenly disappear, or exist for years, or occur again in the same or other places, even after treatment. In patients prone to frequent trauma (athletes, mechanics, butchers), the course of HPV can acquire a stubborn nature. HPV in the genital area is usually malignant.

The treatment of warts is aimed at stimulating the immune response to HPV. In most cases this is achieved by the use of stimuli (salicylic, trichloroacetic acid, 5 fluoruracil, tretinoin, cantharidin, podophyllin).

These compounds can be used in combination or together with cryosurgery, electrocautery, curettage, laser. A direct antiviral effect has bleomycin and interferon a2b, but this treatment should be used in the persistent course of the disease. Topical application of 5% cream imiquimod stimulates cells to produce antiviral cytokines. For local treatment, cidofovir, vaccines and contact immunotherapy are used. Oral medications include cimetidine, isotretinoin, zinc. In most cases, it is necessary to combine different forms of treatment so that the probability of success increases.

How to get rid of vulgar warts?

Vulgar warts can disappear within 2 years, but some exist for years. Various therapies are available. Get rid of warts can be using electrocautery, cryosurgery with liquid nitrogen, drugs with salicylic acid. The application of these methods varies depending on the location and severity of the lesion. For example, 17% liquid salicylic acid is used for finger damage, and 40% can be used on the soles.

Of the local drugs most often used salicylic acid, which is available in liquid form, as part of the patch. Salicylic acid is applied overnight and left for 8-48 hours, depending on the site of the lesion.

Cantharidin can be used alone or in combination (1%) with salicylic acid (3%) podophilin (2%) based on collodion. Cantharidin is removed with soap and water after 6 hours, cantharidinum with salicylic acid or podophyllin is removed after 2 hours. With prolonged contact with the skin, the possibility of the formation of vesicles increases.

To get rid of warts it is possible, applying cryosurgery; it is painful, but extremely effective. Electro-evaporation using curettage and / or laser surgery is effective and is used for isolated lesions, but scarring is possible. Warts occur again or form new ones in 35% of patients during the year, thus, methods that cause scarring should be avoided.

How to get rid of papillomas?

The treatment uses scalpel removal, curettage or liquid nitrogen. When using liquid nitrogen, the 2 mm surrounding skin wart should become white. After 2448 hours after the treatment, bubbles may develop. Care must be taken when treating warts on the face, neck, since after the use of liquid nitrogen, hypopigmentation may develop.

How to get rid of flat warts?

The daily use of tretinoin (retinoic acid 0.05% cream) is used in the treatment. If this is not enough, you need to add 5% benzoyl peroxide or 5% salicylic acid cream. Imiquimod 5% cream can be used alone or in combination with local medications. In general, flat warts do not respond well to treatment and get rid of warts is difficult.

How to get rid of plantar warts?

For treatment, thorough softening is necessary. A 40% patch of salicylic acid is used, which is not removed for several days. The wart softens and then breaks down by freezing or using caustic substances (3070% trichloroacetic acid). Also effective is the use of CO2 laser, of various acids.

How to get rid of okolonogtevyh warts?

You can effectively get rid of warts by using a combination treatment with liquid nitrogen and 5% imiquimod cream, tretinoin or salicylic acid.

How to get rid of resistant warts?

There are several methods for the treatment of resistant warts. Injection of 0.1% solution of bleomycin is used for plantar and perennial warts, but it is possible to develop the Reino phenomenon or damage to blood vessels (especially when inserted into the base of the finger). It is possible to use interferon (3 times a week for 35 weeks). Oral administration of isotretinoin or acitretin leads to the improvement or disappearance of major lesions. The use of cimetidine in a dosage of up to 800 mg orally 3 times a day has been successfully used in treatment, but this type of therapy is more effective in combination with other drugs.