Abstract

Warts are typically small, rough, and hard growths that are similar in color to the rest of the skin. They typically do not result in symptoms except when on the bottom of the feet where they may be painful. While they usually occur on the hands and feet they can also affect other locations. One or many warts may appear. They are not cancerous.

Warts are caused by infection with a type of human papillomavirus (HPV). Factors that increase the risk include use of public showers, working with meat, eczema, and a low immune system. The virus is believed to enter the body through skin that has been damaged slightly. A number of types exist including: common warts, plantar warts, filiform warts, and genital warts. Genital warts are often sexually transmitted.

Without treatment, most types of warts resolve in months to years. A number of treatments may speed resolution including salicylic acid applied to the skin and cryotherapy. In those who are otherwise healthy they do not typically result in significant problems. Treatment of genital warts differs from that of other types.

Warts are very common, with most people being infected at some point in their life. The estimated current rate of non-genital warts among the general population is 1–13%. They are more common among young people. Estimated rates of genital warts in sexually active women is 12%. Warts have been described at least as far back as 400 BC by Hippocrates.

Types

A range of types of wart have been identified, varying in shape and site affected, as well as the type of human papillomavirus involved. These include:

- Common wart ("Verruca vulgaris"), a raised wart with roughened surface, most common on hands, but can grow anywhere on the body. Sometimes known as a Palmer wart or Junior wart.

- Flat wart ("Verruca plana"), a small, smooth flattened wart, flesh-coloured, which can occur in large numbers; most common on the face, neck, hands, wrists and knees.

- Filiform or digitate wart, a thread- or finger-like wart, most common on the face, especially near the eyelids and lips.

- Genital wart (venereal wart, "Condyloma acuminatum", "Verruca acuminata"), a wart that occurs on the genitalia.

- Mosaic wart, a group of tightly clustered plantar-type warts, commonly on the hands or soles of the feet.

- Periungual wart, a cauliflower-like cluster of warts that occurs around the nails.

- Plantar wart (verruca, "Verruca plantaris"), a hard sometimes painful lump, often with multiple black specks in the center; usually only found on pressure points on the soles of the feet.

Cause

Warts are caused by the human papilloma virus (HPV). There are about 130 known types of human papilloma viruses. HPV infects the squamous epithelium, usually of the skin or genitals, but each HPV type is typically only able to infect a few specific areas on the body. Many HPV types can produce a benign growth, often called a "wart" or "papilloma", in the area they infect. Many of the more common HPV and wart types are listed below.

- Common warts – HPV types 2 and 4 (most common); also types 1, 3, 26, 29, and 57 and others.

- Cancers and genital dysplasia – "high-risk" HPV types are associated with cancers, notably cervical cancer, and can also cause some vulvar, vaginal, penile, anal and some oropharyngeal cancers. "Low-risk" types are associated with warts or other conditions.

- Plantar warts (myrmecia) – HPV type 1 (most common); also types 2, 3, 4, 27, 28, and 58 and others.

- Anogenital warts (condylomata acuminata or venereal warts) – HPV types 6 and 11 (most common); also types 42, 44 and others.

- Flat warts – HPV types 3, 10, and 28.

- Butcher's warts – HPV type 7.

- Heck's disease (Focal epithelial hyperplasia) – HPV types 13 and 32.

Pathophysiology

Common warts have a characteristic appearance under the microscope. They have thickening of the stratum corneum (hyperkeratosis), thickening of the stratum spinosum (acanthosis), thickening of the stratum granulosum, rete ridge elongation, and large blood vessels at the dermoepidermal junction.

Prevention

Gardasil 6 is an HPV vaccine aimed at preventing cervical cancers and genital warts. Gardasil is designed to prevent infection with HPV types 16, 18, 6, and 11. HPV types 16 and 18 currently cause about 70% of cervical cancer cases, and also cause some vulvar, vaginal, penile and anal cancers. HPV types 6 and 11 are responsible for 90% of documented cases of genital warts.

Gardasil 9, approved in 2014 protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58.

HPV vaccines do not currently protect against the virus strains responsible for plantar warts (verrucas).

Prevention | Disinfection

The virus is relatively hardy and immune to many common disinfectants. Exposure to 90% ethanol for at least 1 minute, 2% glutaraldehyde, 30% Savlon, and/or 1% sodium hypochlorite can disinfect the pathogen.

The virus is resistant to drying and heat, but killed by and ultraviolet radiation.

Treatment

There are many treatments and procedures associated with wart removal. A review of clinical trials of various cutaneous wart treatments concluded that topical treatments containing salicylic acid were more effective than placebo. Cryotherapy appears to be as effective as salicylic acid, but there have been fewer trials.

Treatment | Medication

Another product available over-the-counter that can aid in wart removal is silver nitrate in the form of a caustic pencil, which is also available at drug stores. In a placebo-controlled study of 70 patients, silver nitrate given over nine days resulted in clearance of all warts in 43% and improvement in warts in 26% one month after treatment compared to 11% and 14%, respectively, in the placebo group. The instructions must be followed to minimize staining of skin and clothing. Occasionally pigmented scars may develop.

Several randomized, controlled trials have found that zinc sulfate, consumed orally, often reduces or eliminates warts. The zinc sulfate dosage used in medical trials for treatment of warts was between 5 and 10 mg/kg/day. For elemental zinc, a lower dosage of 2.5 mg/kg/day may be appropriate as large amounts of zinc may cause a copper deficiency. Other trials have found that topical zinc sulfate solution or zinc oxide are also effective.

A 2014 study indicates that lopinavir is effective against the human papilloma virus (HPV). The study used the equivalent of one tablet twice a day applied topically to the cervices of women with high-grade and low-grade precancerous conditions. After three months of treatment, 82.6% of the women who had high-grade disease had normal cervical conditions, confirmed by smears and biopsies.

Studies of fat-soluble garlic extracts have shown clearing in greater than 90% of cases. The extract is applied twice daily and covered with an adhesive bandage. Improvements show within 2–4 weeks and total clearing in an average of 6–9 weeks.

Society and culture

According to English folk belief, touching toads causes warts; according to a German belief, touching a toad under a full moon cures warts. The most common Northern Hemisphere toads have glands that protrude from their skin that superficially resemble warts. Warts are caused by a virus, and toads do not harbor it. A variety of traditional folk remedies and rituals claim to be able to remove warts.

The acrid yellow sap of Greater Celandine is used as a traditional wart remedy. The sap can be applied directly to the wart in a similar manner to concentrated salicylic acid solution, but in more modest quantities.

In "The Adventures of Tom Sawyer", Mark Twain has his characters discuss a variety of such remedies. Tom Sawyer proposes "spunk-water" (or "stump-water", the water collecting in the hollow of a tree stump) as a remedy for warts on the hand. You put your hand into the water at midnight and say:

You then "walk away quick, eleven steps, with your eyes shut, and then turn around three times and walk home without speaking to anybody. Because if you speak the charm's busted." This is held to be superior to Huckleberry Finn's preferred remedy which involved throwing a dead cat into a graveyard. Another remedy involved splitting a bean, drawing blood from the wart and putting it on one of the halves, and burying that half at a crossroads at midnight. The theory of operation is that the blood on the buried bean will draw away the wart. Twain is recognized as an early collector and recorder of genuine American folklore.

Similar practices are recorded elsewhere. In Louisiana, one remedy for warts involves rubbing the wart with a potato, which is then buried; when the "buried potato dries up, the wart will be cured". Another remedy similar to Twain's is reported from Northern Ireland, where water from a specific well on Rathlin Island is credited with the power to cure warts.