Understanding Chronic Warts
By Christina N. Kraus, MD
It's summer and with the warm weather comes the urge to visit the local pool and stroll around barefoot. Unfortunately, this is the perfect environment for contracting or spreading warts. Warts are a common and often troublesome problem; at least 10% of the population is infected with the viruses that cause warts. These viruses thrive in warm and moist conditions, which is why a visit to the community pool increases the chance of warts spreading. We'll talk about how to prevent warts below, but firstly, what are warts?
What are warts?
Warts are benign lesions (not cancerous) caused by viruses known as human papillomaviruses (HPV). They are contagious, spread through direct contact and small breaks in the skin. Warts can appear anywhere on the skin, including the genitals. While they are more commonly seen in the pediatric population as well as in immunocompromised adults, warts can affect anyone. Warts can be painful and embarrassing if they are cosmetically disfiguring. When tender, plantar warts (warts on soles of the feet) can make it difficult to walk. Warts may resolve on their own or may develop into a chronic condition. Chronic warts (warts present for over six months) can be incredibly difficult to treat and often recur or spread. The body site involved appears to affect treatment response, with plantar warts being particularly challenging to treat.
What are the treatment options?
Warts can resolve on their own and it may be reasonable to adopt the watch-and-wait method, particularly for newly-acquired warts. However, for chronic warts, those that are cosmetically unappealing or symptomatic, and for immunocompromised patients, treatment should be initiated early. Treatment focuses on direct destruction of the wart or altering the immune system to destroy the virus causing the wart.
The most common treatment methods are application of salicylic acid and cryotherapy (freezing) or a combination of both. Salicylic acid is thought to work by softening the wart and allowing the cells to shed while also playing a role in stimulation of the immune system. Cryotherapy is usually performed with liquid nitrogen. This works by directly destroying cells and may initiate an immune response. Cryotherapy is more expensive than salicylic acid. Additionally, cryotherapy is more painful and is associated with more side effects such as blistering and scarring.
Local destructive therapies include the treatments discussed above as well as electrosurgery/curettage (burning and scraping), surgical excision, and laser treatments. Cell-killing therapies with some reported success for treatment of resistant warts include bleomycin injections and 5-fluorouracil injections. Cantharadin (a substance produced by beetles) can be used to form a blister under the wart, such that the dead wart can be clipped off.
Diphencyprone (DCP) is a type of immunotherapy that uses the patient’s immune system to destroy the warts. Other types of immunotherapy include Imiquimod, intra-lesional injection of Candida albicans antigen. Cidofovir is an anti-viral agent that has shown some efficacy in certain groups of patients. Retinoids, which disrupt growth of skin cells, have also been reported to have some success.
Currently, there is no cure for chronic warts and further research is needed to determine which treatments are best.
How to prevent warts from spreading
Do not walk barefoot in community areas, particularly on wet surfaces (bring a pair of flip-flops, sandals, or water shoes). After visiting the pool or gym, wash your hands and feet thoroughly. Do not pick/scratch or bite existing warts. If you have plantar warts, keep feet dry. Use a different nail clipper or nail file for areas with warts. And if you have open breaks or cuts in the skin, take extra precaution to practice good hygiene and cover these areas when in public settings.
Even with treatment, chronic warts often recur or spread. To successfully manage this condition, it is important to adhere to therapies recommended by your doctor, practice prevention, and understand that chronic warts are difficult to treat and may require constant vigilance to keep at bay.
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Ockenfels HM. Therapeutic management of cutaneous and genital warts. J Dtsch Dermatol Ges. 2016;14(9):892-9.
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