Viral warts

Dermatology

Clinicals - History

Fact Explanation
Common wart- Initially a single smooth skin colored plaque or multiple plaques appear.As time progresses, the lesion enlarges and surface becomes irregular.The common sites are hands, face and genitals. Warts are defined as small growths (1 mm -1 cm or more in diameter) with rough surfaces.
Human Papilloma Virus(HPV) types 1,2 and 4 are the pathogens.Infection occurs, when the virus enters breaches in skin,in immunosuppression, or when virus migrates to other sites.There is hyperkeratosis in the affected areas.
Common wart- Initially a single smooth skin colored plaque or multiple plaques appear.As time progresses, the lesion enlarges and surface becomes irregular.The common sites are hands, face and genitals.
Warts are defined as small growths (1 mm -1 cm or more in diameter) with rough surfaces.
Human Papilloma Virus(HPV) types 1,2 and 4 are the pathogens.Infection occurs, when the virus enters breaches in skin,in immunosuppression, or when virus migrates to other sites.There is hyperkeratosis in the affected areas.
Planter warts- There is a solitary or few areas of rough skin with mild protrusion from the soles.There might be mild pain at the sites. This is caused by HPV 1–4, 27, 29, 57.Infection occurs when the virus enters breaches in skin, in immunosuppression, or when virus migrates to other sites.There is hyperkeratosis in the affected areas. Planter warts- There is a solitary or few areas of rough skin with mild protrusion from the soles.There might be mild pain at the sites.
This is caused by HPV 1–4, 27, 29, 57.Infection occurs when the virus enters breaches in skin, in immunosuppression, or when virus migrates to other sites.There is hyperkeratosis in the affected areas.
Mosaic warts- Multiple,small rough areas of skin on soles,palms, can be the presentation. They are not painful. Caused by HPV 2.
Infection occurs, when the virus enters breaches in skin, in immunosuppression, or when virus migrates to other sites.There is hyperkeratosis in the affected areas.
Mosaic warts- Multiple,small rough areas of skin on soles,palms, can be the presentation. They are not painful.
Caused by HPV 2.
Infection occurs, when the virus enters breaches in skin, in immunosuppression, or when virus migrates to other sites.There is hyperkeratosis in the affected areas.
Plane warts- There are multiple, smooth papules, commonly found on face, back of the hands, legs.There is mild erythema or brownish discoloration.They are usually painless. The causative virus is HPV-3,10, 28, 29,.
The erythema is due to mild inflammation following immunological reaction.
The pathogenesis is similar to other viral warts.
Plane warts- There are multiple, smooth papules, commonly found on face, back of the hands, legs.There is mild erythema or brownish discoloration.They are usually painless.
The causative virus is HPV-3,10, 28, 29,.
The erythema is due to mild inflammation following immunological reaction.
The pathogenesis is similar to other viral warts.
Anogenital warts- Papillomatous lesions resembling cauliflower is present.The lesions can be painful. The pathogen is HPV -6,11,16,18. Commonly seen on the mucous membranes of the vagina, urethra, anus, and mouth. Intra-anal warts occur in receptive anal intercourse.Pain, bleeding, or difficulty with intercourse can occur in these patients. Urethral lesions obstruct passage of urine. Anogenital warts- Papillomatous lesions resembling cauliflower is present.The lesions can be painful.
The pathogen is HPV -6,11,16,18. Commonly seen on the mucous membranes of the vagina, urethra, anus, and mouth. Intra-anal warts occur in receptive anal intercourse.Pain, bleeding, or difficulty with intercourse can occur in these patients. Urethral lesions obstruct passage of urine.
Facial warts- The lesions have a digitate appearance.They are painless and found on the beard area. This is common in adult males and it spreads with shaving. Facial warts- The lesions have a digitate appearance.They are painless and found on the beard area.
This is common in adult males and it spreads with shaving.
Risk factors History of contact with a patient- The mode of transmission is direct skin to skin contact. Indirect transmission is possible with the contact of contaminated surfaces( e.g-communal washing areas) Walking barefoot has a increased risk of plantar warts. Meat handlers are at risk of hand warts Risk factors
History of contact with a patient- The mode of transmission is direct skin to skin contact. Indirect transmission is possible with the contact of contaminated surfaces( e.g-communal washing areas) Walking barefoot has a increased risk of plantar warts. Meat handlers are at risk of hand warts
The presence of other diseases as risk factors The patient may have sexual promiscuity and may have other sexually transmitted diseases. Immunodeficiency can lead to widespread growth of warts.(HIV, Epidermodysplasia verruciformis) The presence of other diseases as risk factors
The patient may have sexual promiscuity and may have other sexually transmitted diseases. Immunodeficiency can lead to widespread growth of warts.(HIV, Epidermodysplasia verruciformis)
The presence of complications such as malignant transformation (Ex- Cervical carcinoma) Cervical cancer has been the main disease,where a pathogen responsible for warts(HPV 16,18) gives rise to malignant transformation. Others include Epidermodysplasia verruciformis has increased risk of malignent transformation,but the disease is rare. Immunocompromised patient (Renal allograft recipients) can have malignant transformation following HPV infections. The presence of complications such as malignant transformation (Ex- Cervical carcinoma)
Cervical cancer has been the main disease,where a pathogen responsible for warts(HPV 16,18) gives rise to malignant transformation. Others include Epidermodysplasia verruciformis has increased risk of malignent transformation,but the disease is rare. Immunocompromised patient (Renal allograft recipients) can have malignant transformation following HPV infections.

Clinicals - Examination

Fact Explanation
Common wart- Initially a single smooth skin colored plaque or multiple plaques are appears.As time progresses, the lesion enlarges and surface becomes irregular.Common sites are hands and face Human Papilloma Virus(HPV) types 1,2 and 4 are the pathogens.Infection occurs when the virus enters breaches in skin, in immunosuppression, or when virus migrates to other sites.There is hyperkeratosis in the affected areas. Common wart- Initially a single smooth skin colored plaque or multiple plaques are appears.As time progresses, the lesion enlarges and surface becomes irregular.Common sites are hands and face
Human Papilloma Virus(HPV) types 1,2 and 4 are the pathogens.Infection occurs when the virus enters breaches in skin, in immunosuppression, or when virus migrates to other sites.There is hyperkeratosis in the affected areas.
Planter warts- There is a solitary or few areas of rough skin with mild protrusion from the soles.There is a roughened margin.Paring produces bleeding capillaries. Infection occurs when the virus enters breaches in skin, in immunosuppression, or when virus migrates to other sites.There is hyperkeratosis in the affected areas. Planter warts- There is a solitary or few areas of rough skin with mild protrusion from the soles.There is a roughened margin.Paring produces bleeding capillaries.
Infection occurs when the virus enters breaches in skin, in immunosuppression, or when virus migrates to other sites.There is hyperkeratosis in the affected areas.
Mosaic warts- Multiple,small rough areas of skin on soles,palms, can be the presentation. Infection occurs when the virus enters breaches in skin, in immunosuppression, or when virus migrates to other sites.There is hyperkeratosis in the affected areas. Mosaic warts- Multiple,small rough areas of skin on soles,palms, can be the presentation.
Infection occurs when the virus enters breaches in skin, in immunosuppression, or when virus migrates to other sites.There is hyperkeratosis in the affected areas.
Plane warts- There are multiple, smooth papules, commonly found on face, back of the hand and legs.There is mild erythema or brownish discoloration. The causative virus is HPV-3.
The erythema is due to mild inflammation following immunological reaction.
The pathogenesis is similar to other viral warts.
Plane warts- There are multiple, smooth papules, commonly found on face, back of the hand and legs.There is mild erythema or brownish discoloration.
The causative virus is HPV-3.
The erythema is due to mild inflammation following immunological reaction.
The pathogenesis is similar to other viral warts.
Anogenital warts- Papillomatous lesions resembling cauliflower is present.The surface is moist and there is maceration.The lesions are vascular.These can coalesce and form fungating plaques. The pathogen is HPV -6,11,16,18. Anogenital warts- Papillomatous lesions resembling cauliflower is present.The surface is moist and there is maceration.The lesions are vascular.These can coalesce and form fungating plaques.
The pathogen is HPV -6,11,16,18.
Facial warts- The lesions have a Digitate appearance.They are painless and found on the beard area. This is common in adult males and it spreads with shaving. Facial warts- The lesions have a Digitate appearance.They are painless and found on the beard area.
This is common in adult males and it spreads with shaving.
Signs of other diseases Such as a vaginal discharge and ulcers may indicate a STI or cervical carcinoma. Signs of other infections(skin,respiratory) in immunocompromised patients. Signs of other diseases
Such as a vaginal discharge and ulcers may indicate a STI or cervical carcinoma. Signs of other infections(skin,respiratory) in immunocompromised patients.

Investigations - Diagnosis

Fact Explanation
Biopsy Usually the diagnosis is by clinical appearance. but shave biopsy can be used in diagnosing filliform warts. Indications for biopsy include: an uncertain diagnosis, an immunocompromised patient, poor response to treatment, pigmented warts, suspected malignant change(induration, fixity,ulceration) or a high risk for HPV-related malignancy (e.g. abnormal Papanicolaou smears). Histological appearance shows papilomatosis,hyperkeratosis and parakeratosis. Capillaries appear prominent and thrombosed. HPV infected keratinocytes are larger and contain pyknotic neuclei and perinucler halo. Biopsy
Usually the diagnosis is by clinical appearance. but shave biopsy can be used in diagnosing filliform warts. Indications for biopsy include: an uncertain diagnosis, an immunocompromised patient, poor response to treatment, pigmented warts, suspected malignant change(induration, fixity,ulceration) or a high risk for HPV-related malignancy (e.g. abnormal Papanicolaou smears). Histological appearance shows papilomatosis,hyperkeratosis and parakeratosis. Capillaries appear prominent and thrombosed. HPV infected keratinocytes are larger and contain pyknotic neuclei and perinucler halo.
HPV typing Performed occasionally in special circumstances. (E.g- genital warts in suspected child abuse) HPV typing
Performed occasionally in special circumstances. (E.g- genital warts in suspected child abuse)

Investigations - Management

Fact Explanation
Gynecological procedures such as PAP smear, colposcopy guided biopsy. HPV 16,18 is a risk factor in cervical carcinoma. The tests mentioned are useful in detecting cervical cancer. Gynecological procedures such as PAP smear, colposcopy guided biopsy.
HPV 16,18 is a risk factor in cervical carcinoma. The tests mentioned are useful in detecting cervical cancer.
Complete blood count (CBC) with differential leukocyte count. This is done as a part of immunological investigations in suspected immunodeficiency. Complete blood count (CBC) with differential leukocyte count.
This is done as a part of immunological investigations in suspected immunodeficiency.
Leukocyte function tests, and lymphocyte subsets. Performed in the further investigation of immunosupression, if the patient's CBC is suggestive in addition to clinical findings. Leukocyte function tests, and lymphocyte subsets.
Performed in the further investigation of immunosupression, if the patient's CBC is suggestive in addition to clinical findings.

Management - Supportive

Fact Explanation
Patient education Following should be highlighted : warts are not harmful, they are usually asymptomatic and resolve without treatment, though they are contagious, the risk of transmission is low. Patient education
Following should be highlighted : warts are not harmful, they are usually asymptomatic and resolve without treatment, though they are contagious, the risk of transmission is low.
Steps to minimize transmission Advise patient on the following: a waterproof plaster should cover the wart when the patient is swimming, avoid sharing personal belongings such as footwear and clothing. Steps to minimize transmission
Advise patient on the following: a waterproof plaster should cover the wart when the patient is swimming, avoid sharing personal belongings such as footwear and clothing.
Steps to limit auto-inoculation Should avoid scratching, avoid biting nails or sucking fingers that have warts, keep feet dry and change socks daily. Steps to limit auto-inoculation
Should avoid scratching, avoid biting nails or sucking fingers that have warts, keep feet dry and change socks daily.

Management - Specific

Fact Explanation
Topical treatment for palmoplantar warts. Topical salicylic acid (applied daily for up to 12 weeks) can be used. Salicylic acid solubilize the cell surface proteins and act as a keratolytic agent. Following salicylic acid treatment, viricidals such as formaldehyde or glutaraldehyde paint should be applied. Topical treatment for palmoplantar warts.
Topical salicylic acid (applied daily for up to 12 weeks) can be used. Salicylic acid solubilize the cell surface proteins and act as a keratolytic agent. Following salicylic acid treatment, viricidals such as formaldehyde or glutaraldehyde paint should be applied.
Non pharmacological treatments for non-genital warts. Cryotherapy causes tissue necrosis by freezing.
This is done once every 3 or 4 weeks for up to four cycles. Liquid nitrogen, carbon dioxide snow, dimethyl ether and propane are the agents used in cryotherapy. Other treatment options include photodynamic therapy with aminolevulinic acid , ablation therapy, laser therapy and surgical removal of the wart.
Facial warts are best treated with electrocautery, a Hyfrecator or by cryotherapy.
Non pharmacological treatments for non-genital warts.
Cryotherapy causes tissue necrosis by freezing.
This is done once every 3 or 4 weeks for up to four cycles. Liquid nitrogen, carbon dioxide snow, dimethyl ether and propane are the agents used in cryotherapy. Other treatment options include photodynamic therapy with aminolevulinic acid , ablation therapy, laser therapy and surgical removal of the wart.
Facial warts are best treated with electrocautery, a Hyfrecator or by cryotherapy.
Podophyllotoxin or Imiquimod cream Used commonly for genital warts. Imiquimod acts as a immune response modifier that induces Keratinocytes to produce cytokines and cause wart regression. Podophyllotoxin or Imiquimod cream
Used commonly for genital warts. Imiquimod acts as a immune response modifier that induces Keratinocytes to produce cytokines and cause wart regression.
Non-pharmacological treatment for genital warts Cryotherapy, electrosurgery and laser treatment are effective treatment options. Non-pharmacological treatment for genital warts
Cryotherapy, electrosurgery and laser treatment are effective treatment options.
Specialist referral Consider referring to a dermatologist or a plastic surgeon in the following situations: facial warts, uncertain diagnosis, multiple recalcitrant warts in a immunocompromised patient, extensive growth, unresponsive to topical treatment or cryotherapy. Specialist referral
Consider referring to a dermatologist or a plastic surgeon in the following situations: facial warts, uncertain diagnosis, multiple recalcitrant warts in a immunocompromised patient, extensive growth, unresponsive to topical treatment or cryotherapy.

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