White warts on the skin: what they look like and how to treat them

"White warts" on the hands and feet are usually common viral warts caused by the human papillomavirus, which appear whitish due to pronounced keratinization, air bubbles in the thickened horn, and maceration after water. Plantar and palmar warts often appear light gray-white, especially after showering or swimming, and the fingers may have milky-white "caps" of dense keratin. Clinically, these are benign epidermal growths, but they must be distinguished from calluses, corns, and some skin tumors. [1]

Infectivity is due to direct contact and autoinoculation: the virus enters through microcracks, anchors itself in the basal layer of the epidermis, and stimulates excessive keratinocyte proliferation. The whitish color intensifies where the skin is thicker and vascular signs are less visible, such as on the heels and pads of the fingers; dermatoscopy reveals thrombosed capillaries as dark spots, which helps distinguish a wart from a callus. [2]

Warts behave unpredictably: some regress spontaneously, while others persist for years or multiply in nests. The rate of growth and severity of keratinization are influenced by friction, humidity, exercise, atopic dermatitis, and immune system fluctuations. For this reason, an assessment of daily factors is a mandatory part of the consultation, even if the lesion appears "simple." [3]

It's important to remember that the term "white wart" is descriptive and not a specific diagnosis. In rare cases, a "whitish wart" may mask another condition, so if there are rapid changes, pain, bleeding, or an atypical location, an in-person evaluation and, if indicated, histological examination are necessary. [4]

Code according to ICD-10 and ICD-11

In the International Classification of Diseases, Tenth Revision, the most common code for viral warts is B07, with the following specifications: B07.0 for plantar wart, B07.8 for other viral warts, and B07.9 for unspecified viral wart. These codes are used for clinical documentation, statistics, and insurance reporting, regardless of whether the lesion appears whitish or more pigmented. [5]

The International Classification of Diseases, Eleventh Revision, includes more detailed headings: 1E80 "Common Warts," 1E80.0 "Periungual Warts," and 1E80.1 "Plantar Warts." This level of detail is useful for identifying the location, which determines clinical presentation and treatment tactics, particularly on the feet, where the prominent stratum corneum gives the lesions a characteristic whitish appearance. [6]

In practice, coding is determined based on the clinical form and location. When the morphology is atypical or doubt remains, the diagnosis is confirmed by dermatoscopy or removal with histology, and then the coding is refined. This helps avoid errors when a wart disguises another condition. [7]

Table 1. ICD codes for viral warts

Classifier	Chapter	Formulation
ICD-10	B07	Viral warts. [8]
ICD-10	B07.0	Plantar wart. [9]
ICD-10	B07.8	Other viral warts.[10]
ICD-10	B07.9	Viral wart, unspecified. [11]
ICD-11	1E80	Common warts. [12]
ICD-11	1E80.0	Perungual warts. [13]
ICD-11	1E80.1	Plantar warts. [14]

Epidemiology

Viral warts are extremely common: the estimated prevalence of warts in the population is 7-12%, and among schoolchildren, 10-20%, with a peak at ages 12-16. These figures vary between studies, but they consistently confirm the high prevalence of carpal and plantar warts. [15]

Environmental and lifestyle factors influence the risk. The incidence is higher in children, those involved in sports with close skin-to-skin contact, those who use swimming pools and gyms, and workers who frequently injure their hands. Immunodeficiency dramatically increases the likelihood of multiple and recurrent lesions. [16]

Spontaneous regression is common, especially in adolescents, but the timeframe is unpredictable—from months to years. Regression on the feet is usually slower due to pressure and hyperkeratosis, which also makes the lesions appear whitish. This should be taken into account when choosing a treatment plan and the family's expectations. [17]

Among the human papillomavirus types of hand and foot, types 1, 2, 4, 27, and 57 predominate; the type distribution correlates with clinical subtypes, such as deep, painful plantar lesions and dome-shaped carpal lesions. This information is important for understanding pathogenesis and explaining clinical differences to patients. [18]

Table 2. Epidemiological landmarks

Indicator	Range
Proportion of population with warts	7-12%. [19]
Schoolchildren	10-20%, peak 12-16 years. [20]
Immunodeficiency	Significantly increases the risk of multiple foci. [21]
Spontaneous regression	Often in adolescents, the timing varies. [22]

Reasons

The primary cause is infection of the skin with the human papillomavirus through microdamage to the barrier. The virus infects cells of the basal layer and persists locally, without entering the bloodstream, so there are no systemic symptoms. The type of virus partially determines the clinical presentation, depth, and painfulness of the lesion. [23]

Mechanical friction and maceration play a significant role, facilitating viral penetration. Heavy gloves, tight shoes, and activities that involve gripping equipment or supporting oneself on the palms or feet increase the risk of infection and worsen the course of the disease. Therefore, prevention begins with habit adjustments. [24]

Autoinoculation explains the appearance of "clusters" near the original lesion: picking, cutting the horn with blades, and biting the skin around the nails spread viral particles throughout the area. These everyday activities intensify the "whiteness" due to new layers of hyperkeratosis and microinflammation. [25]

Immune fluctuations contribute to escalation and relapse. People with atopic dermatitis, those who have colds, are chronically stressed, or are taking immunosuppressants are more likely to have persistent flare-ups and have a lower response to standard treatments. This explains the differences in outcomes with the same treatment regimens. [26]

Risk factors

Classic risk factors include age under 18, close family and social contacts, increased skin moisture, and frequent injuries. On the feet, prolonged stress and sweating are also significant, leading to thickening of the horn and a "whitish cap" of the lesion. [27]

Occupations and occupations that pose a risk of microtrauma to the hands and contact with raw food are also associated with increased incidence. Food industry workers and manicurists report more periungual and digital lesions, which are often painful due to pressure and nail deformation. [28]

Immunodeficiency of any origin is a significant predictor of multiple, rapidly growing, and recurrent lesions. In such cases, the surveillance plan is more intensive, and the biopsy threshold is lower to exclude mimicking processes. [29]

Finally, improper home care—cutting, burning with harsh products—not only traumatizes the skin but also increases the risk of autoinoculation. Correcting these habits often speeds recovery more than changing the treatment method. [30]

Table 3. Risk factors for white warts on hands and feet

Factor	Why does it increase the risk?
Microtrauma and friction	Facilitate the penetration of the virus. [31]
Humidity, maceration	They increase keratinization and the “white” appearance of the lesion. [32]
Age 12-16 years	The highest prevalence. [33]
Immunodeficiency	Multiple and persistent lesions. [34]

Pathogenesis

After the human papillomavirus (HPV) penetrates the basal layer of the epidermis, viral DNA supports the production of viral proteins that disrupt cell cycle control and trigger hyperplasia. Clinically, this manifests as papules and plaques with an uneven surface and pronounced hyperkeratosis. On the soles of the feet and palms, the stratum corneum is particularly thick, causing the lesions to appear whitish. [35]

The vascular loops of the papillary layer dilate and thrombose, forming characteristic dark spots. This feature is revealed by dermatoscopy and helps distinguish a wart from a callus, where the skin pattern is preserved and there are no vascular spots. Morphologically, papillomatous architecture and parokeratosis are typical. [36]

The immune system is capable of eliminating the infection over time, but the virus uses localized evasion mechanisms, which explains the prolonged persistence of foci. This is the basis of modern immune-based treatment approaches—an attempt to "prompt" the immune system to recognize the lesion, including through intralesional injections of antigens. [37]

The phenomenon of "mosaic" plantar warts is associated with mechanical fragmentation of the lesion and autoinoculation in pressure zones. Here, the whitish color is more pronounced, as keratin builds up in layers and traps air bubbles and moisture. This justifies the need for regular keratolytic preparation before treatment. [38]

Symptoms

On the hands, dome-shaped papules with a rough surface and a whitish horny "sheath" are typical, especially on the extensor surfaces of the fingers. Moderate pain may occur with pressure, and with trauma, pinpoint bleeding from thrombosed capillaries. Perungual lesions may deform the nail plate. [39]

The soles of the feet are dominated by flat or depressed, painful areas under pressure, sometimes with a mosaic pattern of numerous small whitish "islands." The pain intensifies with walking and subsides with lateral pressure, which distinguishes a wart from a callus. The whitish appearance intensifies after bathing. [40]

Itching is not always present, but scratching and trauma increase the spread. In children and adolescents, "clusters" may quickly appear near the original wart, which is associated with everyday habits and contact at social gatherings. The clinical picture varies from a single, barely noticeable papule to multiple lesions. [41]

Systemic symptoms are not characteristic. Fever, severe weakness, and generalized skin changes indicate a different nature of the process or a complication and require a revision of the diagnosis. [42]

Classification, forms and stages

Based on location, carpal, periungual, and plantar forms are distinguished. Perungual forms are often painful and prone to recurrence due to constant microtrauma around the nail, plantar forms are deeper and whitish due to hyperkeratosis, and carpal forms are often dome-shaped and respond more quickly to therapy. [43]

Clinically, lesions are classified as solitary, multiple, and mosaic. Mosaic lesions on the foot appear as a "tile" of confluent whitish papules and require sequential debridement and combination therapy. This classification helps determine the intensity of treatment and prognosis. [44]

Based on the progression of the disease, fresh soft lesions, mature hyperkeratotic lesions, and regressing lesions with areas of disappearance of vascular dots are distinguished. The effectiveness of treatments varies at different stages: early lesions respond better to keratolytics, while older lesions require more aggressive tactics. [45]

Virologically, types 1, 2, 4, 27, and 57 predominate for the hands and feet, which is partially reflected in the clinical picture, but routine skin typing is not required. It is indicated extremely rarely, as it does not change standard therapy. [46]

Complications and consequences

The main problems are plantar pain, nail deformation in periungual lesions, cosmetic discomfort, and functional limitations in sports and work. The whitish horn cracks and becomes damaged, which contributes to inflammation and pain. Timely care reduces these consequences. [47]

Bacterial infections are rare, especially with self-trimming. In this case, pus, increased pain, and peripheral redness appear; the problem is resolved with local antiseptics and, if necessary, antibiotics prescribed by a doctor. [48]

Scars most often occur after aggressive removal methods in areas of skin tension and around the nail folds. Therefore, in aesthetically significant areas, the treatment plan chosen is as gentle as possible, with targeted keratolytic preparation and gentle cryotherapy. [49]

Malignant transformation is extremely uncommon for carpal and plantar warts; caution is required in cases of rapid growth, ulceration, spontaneous bleeding, and dense infiltrate - in these cases, a biopsy is indicated to exclude tumors. [50]

When to see a doctor

An in-person assessment is necessary if the lesion rapidly enlarges, pain occurs at rest, bleeding occurs without trauma, color or shape changes occur, or if it is located under the nail or in the periungual area. These signs may indicate a different diagnosis or the need for more intensive therapy. [51]

If a home keratolytic regimen fails to produce noticeable results within 8-12 weeks, the treatment plan should be reconsidered: cryotherapy should be added, immune injections should be considered, or other methods should be considered. Delays in treatment can lead to chronicity and the spread of lesions. [52]

Patients with immunodeficiency and young children are recommended to have a lower threshold for a visit: these groups have a higher risk of multiple infections, pain, and relapses. The doctor will also help correct household factors that trigger autoinoculation. [53]

A suspected callus or corn that does not have vascular points on dermatoscopy also requires clarification of the diagnosis, so as not to treat a “wart” that does not exist, and vice versa. [54]

Diagnostics

The first step is a clinical examination and palpation. On the hands, look for dome-shaped papules with interrupted skin patterns, and on the feet, for depressed, painful lesions under pressure with a whitish horn. The number, size, and location of lesions, as well as pain and signs of secondary infection, are assessed. [55]

The second step is dermatoscopy. Warts are typically characterized by dark spots of thrombosed capillaries, discontinuous dermatoglyphs, and yellowish-white areas of the horn; calluses are characterized by preserved skin lines and the absence of vascular spots. This is quick, painless, and significantly improves accuracy. [56]

The third step is a histological decision. A biopsy is indicated in cases of atypical findings, rapid growth, ulceration, suspected tumor, or failure to respond to appropriate therapy. Histology reveals papillomatosis, hyperkeratosis, and signs of viral infection, confirming the diagnosis. [57]

Laboratory testing for the type of human papillomavirus (HPV) is generally unnecessary for skin warts, as it does not change management. Exceptions apply to research purposes and certain immunodeficiency conditions; in routine practice, clinical presentation and response to treatment are the primary focus. [58]

Table 4. Differential diagnosis of "white wart"

State	What is the difference?	What to look at
Callus, corns	The dermatoglyphic pattern is preserved, pain is at the center of pressure	Dermoscopy without vascular points. [59]
Keratoacanthoma, squamous cell carcinoma	Rapid growth, ulceration, bleeding	Urgent biopsy. [60]
Seborrheic keratosis	"Adhered" plaque, horny cysts	Dermatoscopic structures. [61]
Dermatophytosis of the feet	Annular plaques with active ridge	Mycology in Doubt. [62]

Differential diagnosis

A callus forms due to chronic pressure and friction, so pain is greatest with direct pressure from above and decreases with lateral pressure. The opposite is true for a wart: pain intensifies with lateral pressure, and is not always pronounced from above. Dermoscopy confirms the difference in vascular signs. [63]

Seborrheic keratosis may appear whitish due to the thick horn, but typically appears as a "glued-on" plaque with keratinized cysts. It is painless, has no vascular pits, and does not disrupt the skin pattern on the feet and hands. When in doubt, dermatoscopic criteria are used. [64]

Tumors are suspected in the presence of rapid growth, ulceration, spontaneous bleeding, and a dense base. These are rare situations, but it is precisely here that a biopsy is essential before any destructive procedures, so as not to delay proper treatment. [65]

Athlete's foot infections sometimes have whitish edges due to maceration, but produce annular lesions with active ridges and scaling. When nails and skin are affected, mycological examination and antifungal therapy are both advisable, rather than destruction of the "wart." [66]

Treatment

The basic strategy for palmar and plantar warts begins with salicylic acid-based keratolytics. This is an affordable and evidence-based method with moderate efficacy, comparable to cryotherapy in some studies. The regimen includes daily steaming, gentle removal of loose warts, and application of the medication to the lesion and a narrow perimeter around it. The course lasts 8-12 weeks, with progress assessed every 2-4 weeks. [67]

Liquid nitrogen cryotherapy is used in courses spaced 2-3 weeks apart and is more effective on the hands than on the feet, where thick horns prevent cold damage. In some studies, cryotherapy was superior to salicylic acid for warts on the hands, while the benefits for the feet are unclear. The pain of the procedure and the risk of blisters are considered when choosing a treatment strategy, especially in children. A combination of cryotherapy and keratolytics increases the chance of success. [68]

Keratolytic preparation is the key to the success of any foot treatment. Regular softening and gentle removal of the white corn reduces pain, improves drug penetration, and allows for less traumatic cryotherapy. Without preparation, deep plantar lesions often recur, even if they appear to have healed. Therefore, training in care is as important as choosing the right method. [69]

Intralesional immune therapy has become an important option for recalcitrant cases. Injections of Candida antigen demonstrate superior results to saline and are comparable to vitamin D injections or the measles, mumps, and rubella vaccine in achieving complete clearance, often with a "remote" effect on adjacent lesions. Side effects are typically mild and short-lived. This method is particularly useful for multiple and periungual lesions. [70]

Intralesional vitamin D3 and other immune agents are being explored as ways to "reverse" the local immune response. Reviews indicate that this method holds promise for recalcitrant warts, including whitish hyperkeratotic plantar lesions. The choice of agent, dose, and injection frequency is individualized, and the quality of evidence is gradually increasing. These approaches are being discussed after standard therapy fails. [71]

Topical cytostatics and antimetabolites, such as fluorouracil cream, are applied topically to limited lesions outside of high-cosmetic-risk areas. They are prescribed as indicated and under a physician's supervision, taking into account the risk of irritation and hyperpigmentation. For whitish plantar lesions, fluorouracil is combined with keratolytics for improved penetration. This method is a backup when keratolytics and cryotherapy have failed. [72]

Laser methods and surgical excision are used for solitary, recurrent, or painful lesions, especially in the periungual area. The advantages are rapid removal and the possibility of histological confirmation; the disadvantages include the risk of scarring and pain. In aesthetically significant areas, laser is preferable to electrodestruction due to more predictable depth control. The decision is made after discussing the risks. [73]

Adhesive tape therapy, oxygen-ozone methods, and numerous "home" remedies lack a convincing evidence base. Their use may delay the use of effective treatments and increase the area of the whitish keratinized layer. If a patient nevertheless wishes to try adjunctive approaches, they should only be done in conjunction with proven therapy and under the supervision of a physician. [74]

For multiple, painful, and stubborn warts, it's advisable to combine treatments: daily keratolytics, scheduled cryotherapy, and, if necessary, intralesional injections to "reset" the immune response. Discipline is essential: missed treatments and trauma to the horn lead to autoinoculation and return the patient to normal. A personalized plan, taking into account lifestyle and footwear, improves the sustainability of results. [75]

Finally, after removal, maintain a preventative regimen for another 4-6 weeks: care for the skin barrier, avoid dry-cutting, and protect against maceration and friction. This reduces the risk of recurrence and helps the skin recover, while the color of the lesion normalizes as the horn remodels. If a recurrence occurs, repeat treatment is not delayed to prevent further growth of the mosaic field. [76]

Table 5. Comparison of key treatment methods

Method	Effectiveness according to reviews	Special Notes
Salicylic acid	Moderate, comparable to cryotherapy in some studies	First line basis, keratolytic preparation is important. [77]
Cryotherapy	Better for hands, questionable for feet	Combination with a keratolytic increases success. [78]
Candida intralesional antigen	Better than saline, comparable to other immune injections	A "remote" effect is possible. [79]
Intralesional Vitamin D Tri	Promising for resistant lesions	The protocols are varied and selection is individual. [80]
Laser excision	Quick result, histology	Risk of scarring; carefully in the periungual area. [81]

Prevention

Prevention begins with protecting the skin barrier: moisturizing dry areas, avoiding razor-sharp cutting, and carefully filing after steaming. On the feet, it's important to wear ventilated footwear, change socks, and wear non-slip flip-flops in the pool. These measures reduce trauma and maceration, which give the lesions a whitish appearance. [82]

Gloves are useful for working with household chemicals and other materials that pose a risk of microtrauma. Children are taught not to pick or "tear" the horn, as this spreads the virus and creates new outbreaks. Short nails and bandages on vulnerable areas reduce autoinoculation. [83]

Moisture management is important for athletes and people with plantar hyperhidrosis: use absorbent insoles, change shoes throughout the day, and dry them daily. For frequent relapses, discuss an individualized strategy with a doctor, including early initiation of a keratolytic at the first sign of a new lesion. [84]

Prophylactic vaccination against oncogenic types of human papillomavirus reduces the risk of anogenital warts and has indirect population effects, but is not a treatment for skin warts and is not used for this purpose in an individual patient. [85]

Forecast

The prognosis is favorable: in some patients, lesions resolve spontaneously, while in others, they require consistent therapy. Clearance is achieved more quickly on the hands, while on the feet, due to hyperkeratosis and pressure, the course is usually longer. Given the recurrence rate, an "early intervention" strategy for fresh lesions is useful. [86]

With proper technique and discipline, combination plans provide a high rate of clinical clearance, including whitish hyperkeratotic lesions. Pain relief and restoration of function occur as the horn thins and healthy epithelium grows. It is important to continue care for several weeks after visible clearance. [87]

In immunocompromised patients with significant risk factors, the prognosis depends on control of the underlying condition and adherence to prophylaxis. These groups more often require immune injections and closer surveillance with a low threshold for biopsy in the presence of atypia. [88]

Cosmetic outcomes are improved by using gentle techniques, adequate horn preparation, and avoiding aggressive self-treatment. Proper patient education is an important part of achieving a lasting result. [89]

Table 6. Red Flags and Tactics

Sign	Possible problem	Actions
Rapid growth, ulceration, bleeding	Tumor process	Urgent dermatoscopy and biopsy. [90]
Severe pain in the foot without vascular points	Callus, foreign body	Change diagnostics and tactics. [91]
Multiple relapses in immunodeficiency	Persistent current	Immune methods and close surveillance. [92]
No effect from keratolytic after 12 weeks	Wrong tactics	Combination with cryotherapy or injections. [93]

FAQ

Why does a wart appear white? This is due to a thick layer of dead skin cells and maceration from water, especially on the palms and soles. The whiteness doesn't change the diagnosis, but it does influence the choice of treatment and care. [94]

Is it possible to do without cauterization? Yes. Salicylic acid, when used correctly, demonstrates moderate effectiveness, comparable to cryotherapy, and a combination of methods increases the chances of success. [95]

What to do with stubborn warts around the nail. Consider intralesional injections of Candida antigen or vitamin D3, which show promising results and can clear even adjacent lesions. The choice is made by a doctor. [96]

When a biopsy is needed: in cases of atypical appearance, rapid growth, ulceration, spontaneous bleeding, or failure to respond to well-designed therapy. This helps detect tumor processes and adjust treatment. [97]