▶Epithelial growths are induced by different subtypes of human papillomavirus (HPV).
▶Clinical wart subtypes correlate with different HPV subtypes.
▶Very common in children.
▶Most spontaneously resolve in 1 to 2 years.
▶Often recalcitrant to multiple therapies.
▶Transmission may occur person to person, from fomites, or from autoinoculation.
▶Usually asymptomatic, but large or multiple plantar lesions may be associated with pain, limitation in activities.
▶Can be disfiguring.
▶In patients who have immunodeficiency (including HIV infection), lesions may be numerous and widespread.
▶Common warts: discrete, skin-colored papules with characteristic rough (ie, verrucous) surface (Figure 13.1). Lesions exhibit tiny dark specks that represent thrombosed capillaries.
▶Plantar warts: rough or smooth papules and plaques localized to the plantar feet, most often over weight-bearing surfaces. Lesions exhibit tiny dark specks that represent thrombosed capillaries.
▶Flat warts: smooth, pink or skin-colored, flat-topped papules, 1 to 3 mm, typically seen on the face or legs, but may occur in other locations (Figure 13.2).
▶Anogenital warts (ie, condylomata acuminata): discrete papules or confluent plaques; pink to red or skin-colored; localized to genitalia or adjacent skin of inguinal, thigh, suprapubic, or perianal areas (Figure 13.3).
▶Periungual warts: often occur in association with common warts; present as papules, confluent plaques, or nodules adjacent to nails, occasionally with destructive involvement of the proximal or lateral nail fold areas. Lesions exhibit tiny dark specks that represent thrombosed capillaries.
Look-alikes
Disorder | Differentiating Features |
Plantar Warts | |
•Located over points of friction or pressure. •Lacks black specks (ie, thrombosed capillaries). •Dermatoglyphics often preserved. | |
Condylomata Acuminata | |
•Appear as moist white plaques. •Associated with secondary syphilis. | |
•White, pearly, or translucent papules that may have central umbilication. | |
Flat Warts | |
Lichen planus | •Violaceous and may have Wickham striae (ie, a lacy, white pattern) on surface. •White papules or lacy, white plaques may be present on the buccal mucosa. |
•White or skin-colored, tiny, flat-topped papules. •Atopic history common. | |
Molluscum contagiosum | •White, pearly, or translucent papules that may have central umbilication. |
•May be difficult to differentiate from flat warts. •Limited to face; rarely involves other skin surfaces. | |
Common Warts | |
Epidermal nevi | •Present since birth or shortly thereafter. •Linear or whorled distribution may be evident. |
•Papules or plaques that usually form rings. •Rough (ie, verrucous) surface absent. | |
•Plaques or papules overlying interphalangeal joints. •Rough (ie, verrucous) surface absent. | |
▶Warts are self-limited, usually asymptomatic, and do not necessarily require treatment. None of the current treatments are uniformly effective, and patients and parents should understand the potential limitations of therapy.
▶The risk to benefit ratio of therapy must be considered, and care should be exercised to avoid overly painful or traumatic treatments in young children.
▶First-line therapy is usually a topical salicylic acid plaster or liquid, with or without duct tape occlusion (Box 13.1).
▶A compounded cream of 5-fluorouracil and salicylic acid applied under tape occlusion nightly may be effective.
▶Cryotherapy with spray or cotton swab application of liquid nitrogen or other cryogen is effective if used repeatedly (with treatments separated by 2–4 weeks) but should be reserved for motivated, older children who can tolerate painful procedures. In the interval between cryotherapy treatments, any remaining wart should be treated with salicylic acid as described previously.
▶Topical imiquimod may be useful when applied daily to warts; however, its efficacy is often limited by the hyperkeratosis found in common warts, and irritant dermatitis may be seen with its use. Imiquimod is not US Food and Drug Administration (FDA) approved for treatment of common warts.
▶Cimetidine (30–40 mg/kg/d orally divided twice a day or 3 times a day) for 6 to 8 weeks or more may be effective in some children; not FDA approved for this indication.
▶Other treatment options include intralesional injection of skin test antigens (eg, Candida, Trichophyton), intralesional chemotherapy injections (eg, bleomycin), and topical immunotherapy with squaric acid; these are not FDA-approved therapies and published data are limited.
▶Treatments such as pulsed-dye laser and surgical excision are occasionally considered but do not necessarily offer greater efficacy. Surgery entails a high risk of permanent scarring and potential for recurrence.
▶Patients with symptomatic warts that have not responded to standard therapies should be referred for discussion of other treatment options.
▶Immunosuppressed patients with multiple lesions merit more aggressive therapy given the potential association between warts and an increased risk of cutaneous malignancy.
▶Anogenital warts in children may be a marker for sexual abuse, although autoinoculation, vertical transmission (a consideration primarily in children <3 years), and benign (nonsexual) modes of transmission are also possible. If the history or physical examination raises concern, referral and thorough investigation are vital.
▶American Academy of Pediatrics: HealthyChildren.org.
https://www.healthychildren.org/warts
▶American Academy of Dermatology: Warts: diagnosis and treatment.
https://www.aad.org/diseases/a-z/warts-treatment
▶MedlinePlus: Information for patients and families (in English and Spanish) sponsored by the US National Library of Medicine and National Institutes of Health.
https://www.nlm.nih.gov/medlineplus/warts.html
▶Society for Pediatric Dermatology: Patient handout on warts.
https://pedsderm.net/for-patients-families/patient-handouts/#Warts
▶WebMD: Information for families is contained in Skin Problems and Treatments.