Transcript Topical Fungal Infections

Chapter 34: Warts
Revised 8/15/10
Wart Prevalence
• School children: 2-20%
• Children and young adults: 10%
• General population: 16%
• U.S. adults: 75%
Epidemiology of Warts
• Immunocompromised: HIV, meds, lymphoma,
leukemia, Hodgkin’s
• Peak ages: 12-16 years
• Male: female ratio of 58:72
• Family members at high risk
• Having warts: 3X greater risk
• Raw meat workers (butcher, etc.): trauma and
maceration
• Diabetic
Etiology of Warts
• Not from frog urine (based on old
“Doctrine of Signatures”)
• Human Papilloma Virus (HPV), a circular
DNA virus
• 200 Subtypes
• Stimulate basal cells to produce skin
hyperkeratosis
Wart Transmission
• HPV only affects humans
• Must have an epidermal break
• Skin-to-skin contact with infected person
or their shed skin cells
• The long incubation period (1-8 months)
makes it difficult to identify the geographic
location where the wart was contacted
Wart Transmission
• Virus is stable in environment for long
periods, resistant to desiccation, heat,
detergents, and prolonged storage: allows
fomite spread via towels, clothing, tanning
beds, finger-puncture devices
Plantar Wart Transmission
• Swimming facilities
• Perhaps the carpets of hotels leading to
the pool
• Showers at the pool
• Bathtubs and showers in hotels
• Small foot skin break + wet environments
Koebnerization of Warts
• Intact skin is best barrier to warts
• All people have skin microabrasions
• Virus + microabrasion + maceration allows
virion to contact replicating epidermal layer
• Damaged skin becomes wart-prone
Wart Autoinoculation
• Having warts makes one 3X more likely to
have more warts
• Autoinoculation: trauma to original wart
• Intentional: biting or picking
• Accidental
• Viral particles contact uninfected skin and
penetrate skin breaks
Common Warts (Verruca
Vulgaris)
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70% of warts are common warts
Rough papules/nodules; cauliflower look
Dorsum of fingers; hands
Knees in children
Flesh-colored exophytic (growing outward)
or endophytic (growing inward)
• May extend to nailbeds
• Single or grouped
Common Warts
Common Warts
Flat Warts (Verruca Plana)
• Face, hands, legs of children
• Crops of lesions; Koebnerization
• Small, hard growths, surface resembles a
cauliflower
• Flesh-colored; tan/pink, gray, or brown
• Endophytic, slightly elevated, small
• Shaving can spread them
• Possible fingerlike projections
Flat Warts
Flat Warts
Flat Warts
Plantar Warts (Verruca
Plantaris)
• 24% are plantar
• Sole of foot, where it contacts surfaces;
weight-bearing areas
• May see black dots across surface
(referred to as “seed warts” by lay public)
• Exquisite pain upon ambulation
• Usually endophytic in ambulatory patients
• May coalesce to form mosaic warts
Plantar Warts
Plantar Warts
Anal, Genital Warts
• 1% of warts
• Any genital surface
• An STD
Extracutaneous Wart Sites
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Usually from finger contact with surfaces
Hard palate
Intranasal mucosa
Inside the conjunctiva
Laryngeal area
Cervical surfaces
Prognosis of Warts
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Usually benign, unsightly
81% of patients are embarrassed by them
Painless, except for plantar
Plantar can restrict activities
May transform into malignant lesions
(squamous cell carcinoma)
Spontaneous Regression
• Data from study of institutionalized
children
• 66% of warts in children disappear in 2
years
• Flat warts turn red, itch, and swell while
shrinking
• Plantars seldom regress
• Don’t rely on spontaneous regression
Wart-Free Periods
• May occur after regression
• Wart-free periods may last for days or
years
• Reasons unknown
Self-Care for Warts
• Plantar and common warts only
• No improvement in 12 weeks? See Dr.
• Don’t treat warts on mucous membranes,
face, genitals
• Keep hands & feet as dry as possible
during treatment (except for presoak)
• Stay away from moles, birthmarks, hairy
warts--all may be premalignant
Self-Care for Warts
• Don’t apply to irritated, infected, or
reddened skin
• Discontinue if irritation occurs
• Keep away from eyes
• Not for diabetics or those with poor
circulation
• Recap bottles tightly
• Don’t use bottles with crystals
How To Detect Total Cure
• Examine skin ridges if on feet or palms
• If ridges are restored, the area is
considered cured
Salicylic Acid
• Only safe and effective wart ingredient
• Keratolytic & occlusive>water collecting
under the collodion/patch macerates the
skin and induces inflammation
• 12-40% plasters
• 5-17% collodions
• Presoak the wart for 5 minutes and dry
skin before application
Salicylic Acid Liquids/Gels
• Apply 1-2 times daily
• Keep away from surrounding healthy skin
by circling it with a ring of petrolatum
(Vaseline)
• If dropper, apply one drop at a time until
wart covered, then allow to dry
Liquids
Compound W Fast-Acting
Gel
• Initially, thought to prevent running down
to healthy skin
• But, comes out in a blob, can’t
see where product
is (opaque tube), so more
likely to get on healthy skin
Salicylic Acid Plaster
• Cut to size of wart
• Apply and keep on for 48 hours
• Replace with new patch
Plasters
Plasters
Plasters
Salicylic Acid Karaya
Plaster
• Also FDA-approved
• Apply at H.S. after smoothing wart with an
emery file
• Leave on for 8 hours
• Remove in the morning
• Repeat each night for up to 12 weeks
Trans-Ver-Sal
• Glycol-Karaya
OTC Freezing Therapies
• Marketed in 2003
• Safety/Efficacy questionable due to
marketing method as a device similar to
another device already marketed rather
than as a true OTC medication; not proven
safe or effective
OTC Freezing Therapies
• Physician freezing requires several painful
applications of liquid nitrogen-the patient
may need reappointments
• For small children with multiple warts, the
pain limits its use
• Several companies have marketed OTC
freezing therapies
OTC Freezing Therapies
• OTC products are only butane/dimethyl
ether/propane--can they possibly achieve
the same level of tissue penetration and
viral death with 10-40 seconds of use at
home?
Freezing Therapies
• Numerous directions for safe use
• Not under the age of 4 years
• Only treat one side of a finger or toe to
avoid freezing arteries/veins
• Do not use on thin skin (breasts, face,
axillae, area) to prevent burns and
permanent scarring
Freezing Therapies
• Discard applicators after the single use
• Use will cause stinging, pain, burning,
itching, aching
• Companies promise most common/plantar
warts will disappear after 2 weeks
Wartner was the first
OTC freezing therapy
Dual action also has a bottle of salicylic acid
Cimetidine?
• Anecdotal evidence that oral cimetidine
may help
Suggestion Therapy?
• Engaged in by some dermatologists
• Relies on making the patient become
engaged in the process in some way
Wart Charmers?
• Same category as suggestion therapy
Immune System
Manipulation?
• Apply dinitrochlorobenzene, squaric acid
dibutylester, or Toxicodendron to the wart
to cause an allergic dermatitis
• Wart is attacked using the “innocent
bystander” therapy
Duct Tape
• 2002 Study--Enrolled 61 children with common
warts
• Half got liquid nitrogen--the others had the warts
covered with duct tape for 2 months
• Measured complete resolution of warts
• Response rate with nitrogen=60%
• Response rate with duct tape=85%
Prevention of Warts
• Avoid skin-to-skin contact with infected
individuals
• Treat existing warts immediately
• Never bite, scratch, or pick warts
• If warts on body, use separate towels and wash
clothes for affected skin
• Never attempt to remove warts with any kind of
device; damaged warts may spread
Prevention of Plantar Warts
• Always stand on a personal bath mat
• Always dry with a clean, personal towel
• Keep feet covered at all times when in a
public place