Rosen & Barkin's 5-Minute Emergency Medicine Consult (781 page)

• 286.59 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
  
• V58.61 Long-term (current) use of anticoagulants
  

BASICS

• Warts are caused by the human papillomaviruses (HPV)
  
• Causes cellular proliferation and vascular growth
  
• Lesions are typically verrucous and hyperkeratotic
  
• Lesions resolve spontaneously in most cases:
  
  • 1/3 within 6 mo
    
  • 2/3 within 2 yr
    
  • 90% within 5 yr
    
  • Likely due to cell-mediated immune response
    
• Cutaneous warts:
  
  • Verrucae vulgaris (common warts):
    
    • Dorsum of hands
      
    • Sides of fingers
      
    • Adjacent to nails
      
    • Usually asymptomatic
      
  • Verrucae plantaris (plantar warts):
    
    • Weight-bearing parts of sole: Heels, metatarsal heads
      
    • Often symptomatic and painful
      
    • More common in adolescents and young adults
      
  • Flat (juvenile) warts:
    
    • Primarily on light-exposed areas
      
    • Head, face, neck, legs, dorsum of hands
      
    • Small in size
      
    • Range from a few to hundreds
      
• Anogenital warts:
  
  • Known as condyloma acuminata or venereal warts
    
  • Most are asymptomatic and may go unrecognized
    
  • HPV types 6 and 11 account for 90% of anogenital warts
    
• HPV types 16 and 18 account for 70% of cervical cancers
  

• HPV is host-specific to humans
  
  • Cause infection of epithelial tissues and mucous membranes
    
  • Infects the basal layer of skin or mucosa
    
• There are >100 types of HPV that variably infect different body sites
  
• HPV transmission is:
  
  • Direct: Skin to skin
    
  • Indirect: Contaminated surface to skin
    
  • Autoinoculation: Scratching, sucking (especially in young children)
    
• Incubation period can range from weeks to >1 yr
  

• 10–20% of children will have warts
  
• Peak incidence between 12 and 16 yr
  
• May produce laryngeal papillomatosis in infants from viral exposure at birth
  
• Must consider sexual abuse in children with anogenital warts
  

DIAGNOSIS

• Complete sexual history
  
• Prior history of warts and treatment
  
• HIV status
  
• Cutaneous warts:
  
  • Common warts:
    
    • Usually asymptomatic unless on a pressure point
      
    • May present with bleeding secondary to minor trauma
      
  • Plantar warts:
    
    • Often painful with weight bearing
      
  • Flat (or juvenile) warts:
    
    • On light-exposed areas of skin
      
    • May spread with shaving face, neck, legs
      
• Anogenital warts:
  
  • In men, usually on glans penis, shaft, scrotum, or anus
    
  • In women, found on labia, vagina, cervix, or anus
    
  • May extend into urethra, bladder, or rectum:
    
    • Dysuria
      
    • Pain, itching, and/or bleeding with bowel movements
      
  • May have symptoms involving mouth or throat if oral sexual contact
    

• Cutaneous warts:
  
  • Common warts:
    
    • Hard, rough, raised, dome-shaped lesions
      
    • Obscure normal skin markings
      
    • Hypervascular and may bleed with minor trauma
      
  • Plantar warts:
    
    • Soles of the feet
      
    • Obscure normal skin markings
      
    • Hypervascular and may bleed with gentle scraping
      
  • Flat (or juvenile warts):
    
    • Flesh colored
      
    • Flat top and smooth
      
    • Small: Range from pinpoint to size of pencil eraser
      
• Anogenital warts:
  
  • Pedunculated growths often with cauliflower-like appearance
    
  • Lesions are soft and usually present in multiples
    
  • Flesh colored to slightly pigmented or red
    

Diagnosis made by characteristic appearance of lesions

• Pregnancy test for females
  
• Biopsy and viral typing not recommended for typical lesions
  
• If difficult to see, add acetic acid to suspected area, which will cause infected areas to whiten and become more visible
  
• Screen for other sexually transmitted diseases
  

Biopsy indicated if failing therapy, patient immunocompromised, or warts are pigmented, indurated, fixed, or ulcerated

• Cutaneous warts:
  
  • Common wart
    
    • Callus; will not bleed
      
  • Plantar wart:
    
    • Callus, corn, bunion
      
  • Flat (or juvenile) wart:
    
    • Moles, skin tag, lichen planus
      
• Anogenital wart:
  
  • Condyloma latum (secondary syphilis)
    
  • Herpes simplex
    
  • Prominent glands around head of penis
    
  • Benign or malignant neoplasm
    
  • Molluscum contagiosum
    

TREATMENT

None required

• Cutaneous warts:
  
  • Occlusion with duct tape:
    
    • Least invasive
      
    • Maintain on wart for 6 days
      
    • Gentle debridement with pumice stone or nail file on day 7
      
    • Good for young children
      
    • May also enhance other topical treatments
      
  • Salicylic acid:
    
    • Inexpensive, mild side effects
      
    • OTC is 17% salicylic acid
      
    • Prescription strength has up to 70% salicylic acid
      
    • Soak wart in warm water for 10–20 min
      
    • Apply salicylic acid overnight
      
    • Gently debride in morning
      
    • Patches are also available
      
    • Resolution may take weeks to months
      
    • May be more effective combining with cryotherapy
      
• Anogenital warts:
  
  • May use imiquimod, podofilox, podophyllin, trichloroacetic acid (TCA), bichloroacetic acid (BCA), or alternative therapies listed below
    
  • Nonintervention may be best course in children, as treatment has not been well studied
    
• Alternative treatments:
  
  • Cryotherapy with liquid nitrogen or dry ice
    
  • OTC cryotherapy kits
    
  • Electrocautery
    
  • Laser therapy
    
  • Surgical excision
    
  • Interferon for use by subspecialists
    
• Provide appropriate referral
  

• Topical medications (patient applied):
  
  • Imiquimod 5% cream:
    
    • Apply 3 times/wk for up to 16 wk
      
    • Cream may weaken diaphragms and condoms
      
  • Podofilox 0.5% gel or solution:
    
    • Apply BID for 3 days, then rest 4 days; may repeat for 4 cycles
      
    • Do not use on perianal, rectal, urethral, or vaginal lesions
      
  • Salicylic acid:
    
    • Wash off 6–10 hr later
      
    • May be repeated weekly
      
• Topical medications (provider administered):
  
  • Podophyllin 10–25% in benzoin:
    
    • Weekly topical application:
      
    • Protect surrounding normal tissue with petroleum jelly
      
    • Wash off 1–4 hr later
      
    • Do not use in pregnancy: Highly toxic and teratogenic
      
    • Do not use on cervix, vagina, or anal canal as may cause dysplastic changes
      
  • TCA or BCA 80–90%
    
    • Apply weekly for 6–10 wk
      
  • Cryotherapy with liquid nitrogen or cyroprobe
    
    • May be repeated every 1–2 wk
      
• Vaccine:
  
  • Gardasil: Targets HPV types 6, 11, 16, 18:
    
    • Recommended for girls >9 yr
      
    • 3-shot series over 6 mo
      
    • For the prevention of cervical cancer, vulvar and vaginal cancer, genital warts, and other low-grade cervical lesions
      
  • Cervarix: Targets HPV types 16, 18:
    
    • 3 shots over 6 mo
      
  • Universal vaccination may provide significant reduction of cervical cancer in developing countries without well-established screening
    
  • Both vaccines are 96% effective
    
  • There are still controversies surrounding routine use and acceptance
    

FOLLOW-UP