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Cutaneous warts

Background knowledge ๐Ÿง 

Definition

  • Cutaneous warts are benign skin growths caused by human papillomavirus (HPV) infection
  • Most commonly affect the hands, feet, and face
  • Transmission occurs through direct contact with infected skin or contaminated surfaces
  • Warts can be classified into different types based on their appearance and location

Epidemiology

  • Common in children and young adults
  • Peak incidence in school-aged children
  • Higher prevalence in individuals with immunosuppression
  • Occupational exposure risk in butchers and fish handlers (butcher’s warts)
  • Can spontaneously resolve within months to years

Aetiology and Pathophysiology

  • Caused by human papillomavirus (HPV) infection
  • HPV types 1, 2, 4, 27, and 57 commonly cause cutaneous warts
  • Virus infects the basal layer of the epidermis through microabrasions
  • Leads to hyperplasia and hyperkeratosis of the skin
  • Warts spread by autoinoculation or contact with contaminated surfaces
  • Immunosuppression increases susceptibility and persistence

Clinical Features ๐ŸŒก๏ธ

Symptoms

  • Usually asymptomatic, but can cause pain or discomfort
  • Plantar warts may be painful when walking
  • Itching or irritation can occur
  • Bleeding if warts are traumatized
  • Cosmetic concerns due to appearance

Signs

  • Raised, rough-surfaced lesions
  • Black dots (thrombosed capillaries) within the wart
  • Interrupt skin lines
  • Plantar warts are often flattened due to pressure
  • Filiform warts: Finger-like projections, often on the face
  • Mosaic warts: Cluster of small warts on the hands or feet

Investigations ๐Ÿงช

Tests

  • Clinical diagnosis based on appearance and history
  • Dermatoscopy may help in difficult cases
  • Histopathology in atypical or refractory cases
  • PCR testing for HPV in research settings
  • Consider testing for immunosuppression in recurrent or extensive cases
  • Exclude differential diagnoses such as calluses, molluscum contagiosum, or squamous cell carcinoma

Management ๐Ÿฅผ

Management

  • Topical treatments: Salicylic acid, cryotherapy, imiquimod
  • Physical removal: Cryotherapy, laser therapy, surgical excision
  • Chemical treatments: Cantharidin, podophyllin
  • Immunotherapy: Topical sensitizers, intralesional immunotherapy
  • Watchful waiting: Many warts resolve spontaneously within 1-2 years
  • Follow UK guidelines (e.g., NICE) for treatment protocols
  • Educate patients on avoiding autoinoculation and spreading to others

Complications

  • Secondary bacterial infection
  • Recurrence after treatment
  • Scarring or pigmentation changes post-treatment
  • Pain and discomfort affecting daily activities
  • Psychosocial impact due to cosmetic concerns
  • Rarely, malignant transformation in immunosuppressed individuals

Prognosis

  • Good prognosis with appropriate treatment
  • High likelihood of spontaneous resolution
  • Persistence or recurrence possible, especially in immunocompromised
  • Regular follow-up may be needed for refractory cases
  • Patient education important to prevent spread and recurrence

Key points

  • Cutaneous warts are caused by HPV and commonly affect hands and feet
  • Diagnosis is clinical based on appearance and history
  • Treatment includes topical and physical methods, with many warts resolving spontaneously
  • Preventive measures include avoiding direct contact and maintaining good hygiene
  • Follow UK guidelines (e.g., NICE) for treatment recommendations
  • Monitor for complications and recurrence, particularly in immunocompromised patients

References

  • NICE guidelines on warts and verrucae (https://www.nice.org.uk/guidance/cg59)
  • BNF – British National Formulary (https://bnf.nice.org.uk/)
  • NHS Inform – Warts and verrucae (https://www.nhsinform.scot/illnesses-and-conditions/skin-hair-and-nails/warts-and-verrucas)
  • BMJ Best Practice – Warts (https://bestpractice.bmj.com/topics/en-gb/1150)

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