Last Updated: 2021-11-19
ICD11: 1E 80
Frequent cellular infection with human papilloma (HP) viruses.
- Incidence in children approx. 10%
- Affected are mainly children and adolescents
- Viral warts are caused by human papilloma viruses (HPV), which are obligatory intracellular pathogens. The viruses enter the epidermis through injuries to the skin or mucosa, where they find host cells and morphologically alter them. The viral genome is replicated and viral warts spread
- Predisposing factors: Immunosuppression, atopy, sebostasis or hyperhidrosis and acrocyanosis
Division according to morphology and localisation
- Verrucae vulgares
- Verrucae plantares (plantar warts)
- Verrucae palmares
- Verrucae paronychiales
- Verrucae subunguales
- Verrucae filiformes
- Mosaic warts
- Verrucae planae juveniles
- Epidermodysplasia verruciformis
- Mostly < 1 cm in diameter hyperkeratotic, skin-coloured or grey-yellowish, dermal, papillomatous tumours with a verrucous surface
- No pigmentation, skin-coloured to pink clods with centrally localised punctate vessel
- Clinical diagnosis
- If there is uncertainty due to unusual localisation or rapid growth, a biopsy is indicated
- In paraffin for HE staining
- Indicated in cases of resistance to therapy or atypical clinical picture
HPV subtyping by PCR
- Only necessary in exceptional cases
- It is possible from paraffin material
- Request: Note on histology slip or order via histology assistants
Palmoplantar, on the backs of the hands, periunguinal and rarely on the tip of the nose.
Severe acanthosis, papillomatosis, hyperkeratosis, hypergranulosis, vacuolated cells, koilocytes, widening of the stratum granulosum (absent in condylomata acuminata).
- Very high recurrence rates
- Educate patients about the importance of adherence
- There is no vaccination, as there is for other HPV-induced diseases
- Prior to therapy, the patient must be informed about possible adverse effects (redness, pain)
- Healthy skin should always be protected, e.g. with pasta zinci mollis
- Disinfection of footwear is effective
- Avoid barefoot locomotion
- Nicotine abstinence to avoid vasoconstriction
- Before starting therapy, it usually makes sense to ablate the hyperkeratoses
- A new medical consultation should be made before ending the therapy, as the high recurrence rate is mainly associated with ending the therapy too early. All therapies should, in our experience, be used for at least 4 weeks beyond symptom relief.
Exacerbation stage I:
Step 1: Keratolysis, e.g. with salicylic acid patches, change every 3 days. At each change, warm soft soap bath and mechanical keratolysis (pumice stone, file) by the patient. Therapy duration: Approx. 14 days, depending on the thickness of the hyperkeratosis. Alternative: Salicylic acid and lactic acid solution: Apply twice daily with a spatula. AI: Use on the face, genital area, moles and hairy warts. Use in children from the age of 3 years.
Step 2: Mechanical removal by the patient after warm soft soap bath every 3 days.
Step 3: Cryotherapy (NO2 spray or sticks, 3x 5-10 seconds) and mechanical ablation. Performed by the nurse at every check-up. Control interval 14 days. Caution: Joint and tendon areas, immunosuppressed persons, diabetes mellitus, dark-skinned persons
Step 4: 5-fluorouracil & salicylic acid , 2x/d on the warts by the patient, contraindications: Pregnancy
Exacerbation stage II:
Diphenylcyclopropenone (DCP) or imiquimod
Step 1: Sensitisation on warts with DCP 0.5% in Duofilm, over which occlusive dressing for 24h.
Step 2: After 1 week, apply DCP 0.05% in Duofilm to the warts, over which an occlusive dressing is applied for 24 hours. Repetition by the patient 1x/week.
Step 3: Check and apply DCP 0.05% in Duofilm in the dressing room every 4 weeks.
Contraindications: Pregnancy/breastfeeding, vitiligo, children < 8 years old, dark-skinned
Application 3x per week or until inflammation is clinically visible, maintain for 8-16 weeks.
Exacerbation stage III:
Step 1: Keratolysis (see step 1 of standard therapy)
Step 2: Apply nitric acid solution to warts with glass pipette and rub in. Treatment every 3 weeks in the dressing room.
Step 3: Dabbing of treatment site with 80% alcohol 2-3x/d by patient.
Caveat: Treatment area should not be larger than 2 cm in diameter
Comments on individual therapies:
- Surgical excision: is obsolete (CAVE: ↑ recurrence rate)
- Cryotherapy: effective, fast and inexpensive. Ideally not on the legs to avoid ulcers
- Laser: both CO², erbium and dye lasers have established themselves as very effective treatment options. AI: Verrucae plantares (scarring)
- Electrocoagulation: only with local anaesthesia. The base of the wart must also be ablated. The expected scarring appears to be the main limiting factor here
- Salicylic acid patch: Apply to the wart for 12-24 hours, then ablate the softened skin. Ablation can be done by scalpel, sharp spoon or pumice
- Berner Warts Ointment: Only available as a magistral prescription. The ointment should only be applied to the verruca. Protect the surrounding skin well. Then an occulsion treatment should be attempted. After daily change, ablation of the skin can take place after about 2-3 days
- Combination of 0.5% fluorouracil-Lsg and 10% salicylic acid as lotion: apply 2-3x daily for approx. 6 weeks. CAVE: Do not use brivudine at the same time
- Imiquimod 3x weekly for 12 weeks, off-label-use, use: 5x/week for several weeks, maximum 16 weeks. Ablation of the wart surface necessary beforehand. NW: Redness, itching, burning, erosion of the skin. Patients must be informed about this before the start of the therapy!
- Nitric acid solution: Due to the low pH, pronounced keratolysis occurs. The first application must be done by the doctor. Patient education is important. Disinfection to degrease the skin is important before application.
- Formic acid: 1x daily application until symptomless. According to the manufacturer, 90% of patients are wart-free after 12 days
- Monochloroacetic acid: 1x/week, application for 2-3 weeks on the hands and for 3-4 weeks on the feet. Spot application and covering with a plaster. After 4-6 days, removal of the entire verruca. AI: Face, genital area, pregnancy, lactation
- Silver nitrate / silver nitrate sticks: Here, chemical cauterisation takes place. After moistening the head of the wooden stick with water, the wart surface is wetted. This can be done 1-2 times a week (max. 3x in total, 6x for plantar warts)
- Podophyllin/Podophyllotoxin: Apply 2x daily for 3 consecutive days. Repeat if necessary
- Bleomycin only available as a magisterial prescription. 15 mg (15 IU) bleomycin in 50 ml 1% lidocaine solution (≙ a concentration of 0.03%) intralesionally. Prior to this, removal of the horny layer using a ring curette, then application using Dermoject in several shots (painful for a short time). The resulting necrosis is removed by the doctor after 2 weeks. KI: no application to the hands
- Photodynamic therapy (PDT): After removal of the hyperkeratoses, the application of 5-aminolevulinic acid cream is to be carried out. 3 hours later, a 7-minute PDT can be performed at a distance of 7 cm. Pain may occur during the treatment. In the following days, redness in the area must be expected
- Interferon: has been tried in a wide variety of applications (intralesional or externally). However, the practical benefit is limited due to the high costs
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