Warts

Medical Student Core Curriculum in Dermatology Last updated July 29, 2011 1

Module Instructions

  The following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary , an illustrated interactive guide to clinical dermatology and dermatopathology.

We encourage the learner to read all the hyperlinked information.

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Goals and Objectives

  The purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with warts.

By completing this module, the learner will be able to: • Identify and describe the morphology of various types of warts • Discuss the pathogenesis of warts • Develop an initial treatment plan for a patient with warts • Describe the technique of cryotherapy • List the side effects of cryotherapy 3

Case One

Megan Driskell 4

Case One: History

       HPI: Megan is an 8-year-old girl who presents to her pediatrician’s office with bumps on her fingers and hands. They have been present for 3 months without change and are asymptomatic.

PMH: no chronic illnesses or prior hospitalizations Allergies: no known allergies Medications: none Family history: no affected family members Social history: lives at home with parents and attends school ROS: negative 5

Case One: Skin Exam

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Case One: Question 1

 How would you describe these lesions?

a. Hyperkeratotic and umbilicated papules and nodules b. Hyperkeratotic, endophytic papules and nodules c. Hyperkeratotic, exophytic papules and nodules d. Smooth and umbilicated papules and nodules e. Smooth, exophytic papules and nodules 7

Case One: Question 1

Answer: c

 How would you describe these lesions?

a. Hyperkeratotic and umbilicated papules and nodules (these papules are not umbilicated) b. Hyperkeratotic, endophytic papules and nodules (these papules are growing outward, not inward)

c. Hyperkeratotic, exophytic papules and nodules

d. Smooth and umbilicated (marked by a depressed spot) papules and nodules (more characteristic of molluscum contagiosum) e. Smooth, exophytic papules and nodules (these papules are not smooth) 8

Clinical Features of Verruca Vulgaris

• Hyperkeratotic , exophytic (growing outward), dome shaped papules or nodules • Most common on fingers, dorsal hands, knees or elbows but may occur anywhere • Punctate black dots representing thrombosed capillaries • May koebnerize skin trauma – spread with 9

Epidemiology

 One of the top three skin problems in children  Cutaneous warts occur in 20% of school-aged children; also commonly found in young adults  Males and females are equally affected 10

Case One: Question 2

 Verruca vulgaris is caused by: a. Human immunodeficiency virus b. Human papillomavirus c. Pox virus d. Herpes virus e. Varicella-zoster virus 11

Case One: Question 2

Answer: b

 Verruca vulgaris is caused by: a. Human immunodeficiency virus

b. Human papillomavirus

c. Pox virus d. Herpes virus e. Varicella-zoster virus 12

Human Papillomavirus (HPV): Overview

    Warts are caused by HPV HPV infects skin and mucosal epithelia HPV causes a variety of wart morphologies • Verruca vulgaris: common warts • Verrucae planae: flat warts • Palmoplantar warts • Condylomata acuminata: external genital warts The type of HPV determines the wart morphology 13

Role of HPV in Cutaneous Disease

  HPV can be transmitted by skin-to-skin contact or through contaminated surfaces or objects • Patients can also spread virus from lesion to unaffected skin HPV infects the basal keratinocytes of cutaneous and mucosal epithelium 14

Clinical Features of Verrucae Planae: Flat Warts

• Skin-colored or pink • Smooth-surfaced, slightly elevated, flat topped papules • Dorsal hands, arms, face (exposed surfaces) 15

Clinical Features of Palmoplantar Verruca

• Thick, endophytic papules • Central depression • Plantar warts may be painful when walking • Mosaic warts: plantar warts coalescing into large plaques 16

General Treatment Principles

     Majority of all warts will spontaneously resolve in 1-2 years without scar Therefore important to choose a therapy with low toxicity and low risk of scarring No specific antiviral therapy for cure Most treatments are destructive or aim at stimulating the immune response to HPV Recurrence rates are high 17

Common Wart Treatment Options

    Watchful waiting – majority of all warts will spontaneously resolve in 1-2 years without scarring Cryotherapy – liquid nitrogen (see following slide for more information) Salicylic acid – with occlusion and removal of the dead skin (filing, pumice stone) For patients who do not respond to the above therapies, refer to a dermatologist 18

Cryotherapy

  Click here for an instructional video on cryotherapy Side effects of cryotherapy include: • PIPA (post-inflammatory pigment alteration) – In individuals with darker skin types, more likely to cause hypopigmentation (see pre and post-cryo photos below) • Scar • Pain • Blister • Nail dystrophy 19

Side Effects of Cryotherapy

Post inflammatory hyperpigmentation Wart ring post cryotherapy 20

Flat Wart Treatment Options

 Common 1 st line tx: • Cryotherapy • Salicylic acid (caution using on face) • Topical tretinoin 21

Palmoplantar Wart Treatment Options

  1 st line treatment is the same as common wart therapy (often requires stronger dosing, e.g. 40% salicylic acid vs. 17% salicylic acid) Referral to a dermatologist may be made for chemotherapeutic agents (e.g. topical 5-Fluorouracil) 22

Case Two

Jonathan Cohen 23

Case Two: History

       HPI: Mr. Cohen is a 21-year-old man who comes into the STD clinic because of an increasing number of bumps on his penis over the last year. PMH: no chronic illnesses or prior hospitalizations Allergies: no known allergies Medications: none Family history: noncontributory Social history: studying economics at a nearby university ROS: negative 24

Case Two: Skin Exam

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Case Two: Question 1

 How would you describe these lesions?

a. Pearly, vesicular papules b. Smooth, indurated plaques c. Verrucous exophytic papules d. Waxy, stuck-on plaques

Case Two: Question 1

Answer: c

 How would you describe these lesions?

a. Pearly, vesicular papules b. Smooth, indurated plaques

c. Verrucous exophytic papules

d. Waxy, stuck-on plaques

Clinical Features of external genital warts

• Sessile, exophytic papules • May be broad-based papules or large confluent plaques • External genitalia, perineum, perianal, inguinal fold, mons pubis 28

Comparison of molluscum and genital warts

Molluscum Contagiosum (smooth, dome-shaped papules with central umbilication) External Genital Warts (hyperkeratotic, exophytic papules and plaques)

Case Two: Question 2

 What further elements in the patient’s history would you need to complete your evaluation?

a. Medications b. Sexual history c. Surgical history d. Allergies 30

Case Two: Question 2

Answer: b

 What further elements in the patient’s history would you need to complete your evaluation?

a. Medications

b. Sexual history

c. Surgical history d. Allergies 31

HPV Infection

Clinical Presentation

External genital warts

Frequently Associated HPV Type

6, 11 High grade intraepithelial neoplasia 16, 18,31, 33-35, 40, 45 Genital infection with HPV is transmitted by sexual contact from partners with clinical or subclinical infection 32

External Genital Warts (EGW)

   HPV infection is one of the most common STIs • Risk factors: sexual intercourse at an early age, numerous partners, unprotected exposure • Patients should receive counseling about condom usage, STI prevention, and potential STI testing for sexual partners Effective prophylactic HPV vaccine is available for prevention of genital warts Immunosuppression from HIV infection, organ transplant, etc. can lead to: • Increased frequency of HPV infection • Persistent infection • More difficulties in treatment 33

Back to Case Two

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Case Two: Question 3

 What is the most likely HPV type leading to this patient’s disease?

a. 2 b. 6 c. 16 d. 31 e. 34 35

Case Two: Question 3

Answer: b

 What is the most likely HPV type leading to this patient’s disease?

a. 2

b. 6

c. 16 d. 31 e. 34 36

Case Two: Question 4

 Which of the following treatments could you use for external genital warts?

a. Cryotherapy b. Imiquimod c. Salicylic acid d. All of the above 37

Case Two: Question 4

Answer: d

 Which of the following treatments could you use for external genital warts?

a. Cryotherapy (liquid nitrogen is used to freeze the tissue at the cellular level) b. Imiquimod (a cream of this interferon inducer can be applied 3x per week, response takes up to 12 weeks) c. Salicylic acid (this beta hydroxy acid is applied, occluded for 5-6 days, the wart is pared down, and then the cycle is repeated)

d. All of the above

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Treatment (cont.)

  Other destructive methods can be used as well to treat EGW • Laser • Electrocautery and curettage • Surgical debulking Always use protective mask 39

Imiquimod: True or False

 Imiquimod therapy is an off label use for treatment of external genital warts.

• True • False 40

Imiquimod: True or False

False

 Imiquimod is FDA approved for treatment of EGW  Interacts with Toll-like receptors 7 and 8 to increase cytokines from macrophages  Clearance of 50% EGW compared to placebo of 11%  A disadvantage to this treatment is cost 41

Prevention Reminder: HPV Vaccine

   Two HPV vaccines are licensed by the FDA and recommended by the CDC • Gardasil ™ and Cervarix ™ Both vaccines are effective against HPV types 16 and 18, which cause most cervical cancers Gardasil is also effective against HPV types 6 and 11, which cause most genital warts in females and males • 100% protection in prevention of genital warts during 5-year follow up period studied 42

Take Home Points

    Warts are caused by human papilloma viruses Numerous morphologies exist: common, flat, palmoplantar, external genital Treatment is difficult and there are many options available A vaccine of certain HPV types has proven effective in reducing external genital warts 43

Acknowledgements

    This module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup from 2008-2012.

Primary authors: Kari L. Martin, MD; Susan K. Ailor, MD, FAAD.

Peer reviewers: Renee M. Howard, MD, FAAD; Erin F. D. Mathes, MD, FAAD, FAAP, Timothy G. Berger, MD, FAAD.

Revisions and editing: Sarah D. Cipriano, MD, MPH; Meghan Mullen Dickman. Last revised July 2011.

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References

    Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; 2007. Available from: www.mededportal.org/publication/462.

Gibbs S, Harvey I. “Topical treatments for cutaneous warts.” Cochrane Rev. Vol 1. 2009. Online at eMedicine:http://emedicine.medscape.com/article/1131981-overview. Updated 12/2009.

Kirnbauer R, Lenz P, Okun MM. “Chapter 78. Human Papillomavirus” (chapter). Bolognia JL, Jorizzo JL, Rapini R: Dermatology. 2 nd ed. Mosby Elsevier; 2008. 1183-1198.

Silverberg NB. “Human papillomavirus infections in children.”

Current Opinion in Pediatrics

. 16:402-409. 2004.

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