Warts

Symptoms Of Warts

Warts are lesions/bumps in the skin and the thin skin that covers the inside surface of parts of the body, such as the nose and mouth.  

Warts have a very long incubation period (the period from virus exposure to the onset of symptoms). It generally ranges from 1 to 6 months but can even take up to 12 months. 

These lesions appear as skin growth with an irregular surface. Their size can range from 1 mm to several cm.

The other general signs and symptoms of warts include: 

• The presence of small and rough bumps on skin
• Appearance of long threads or thin fingers on the skin
• The presence of black dots that appear like seeds
• Mild bleeding from bumps
• Itching
• Tightness or feeling of pressure
  
  

The lesions can appear alone (solitary) or in groups (mosaic). The most common sites of these warts are hands and feet. However, they occur in other body parts, depending on the type.

The characteristic of these lesions depends upon the type of the warts and include:

1. Common warts (vurruca vulgaris)

• Dome shaped nodules 

• Mainly located on fingers, hands, knees, elbows, or any other sites of trauma

• It can also appear as thin and long outgrowths around the eyelids and lips

2. Genital warts

• Small bumps in and around the genital area

• Cause burning sensation and itching/irritation in the genital area

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3. Foot warts (plantar warts)

• Deep penetrating bumps on the soles of the feet

• Cause pain and difficulty while walking

• Create a feeling of having something in the shoes

4. Anal warts

• Tiny spots or growths around and inside the anus

• Additional symptoms include itching, bleeding, mucus discharge, and a feeling of a lump in the anal area

5. Flat warts

• Flat topped nodules with only a slight elevation

• Can grow anywhere

6. Filiform warts

• Long threads or thin finger like projections that stick out

• Usually grow on the face, around the mouth, eyes, and nose

• Grows very quickly

7. Butcher's warts 

• The main characteristic of these warts is their cauliflower-like appearance

• They commonly affect the knees and hand

• These are primarily seen in individuals who handle raw meats

8. Focal epithelial hyperplasia 

• Soft smooth, flat-topped slightly in the oral mucosa

• Often present in multiple lesions of less than 1cm in diameter

9. Cystic warts

• Presence of generally smooth bumps 

• Appear on the weight bearing surfaces of the body

Causes Of Warts

Warts are caused by Human Papillomavirus (HPV). Although HPV has over 100 subtypes, only a few cause skin warts. 

Warts can be transmitted easily through direct or indirect contact. The transmission of the virus is fast through disrupted and soft skin.
The mode of transmission includes: 

• Touching the skin of the infected person

• Doing unprotected sexual intercourse

• Touching contaminated objects such as towels and razor

• Using communal bathrooms and swimming pools

• Sharing sex toys

What happens after the exposure?

Once HPV has infected the skin, it spreads to other parts through scratching, shaving, or injuries. The virus can enter the skin and multiply in its uppermost layer. It makes the outer layer of the skin thick and complex, and it protrudes as a wart.

A few subtypes of HPV have the potential to induce cancer. These strains include type 6, 11, 16, 18, 31, and 35. Individuals who are immunocompromised are more prone to transformation of warts into cancer. 

Risk Factors For Warts

People in close contact with someone with warts are likely to develop warts. The other possible risk factors include: 

1. Weakened immune system

Individuals with low immunity cannot fight the virus effectively. This makes them more susceptible to viral infection, including warts. It also includes people who have undergone organ transplantation or have medical conditions such as cancer or HIV infection. 

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2. Age

Children and teenagers are at high risk of catching warts. The incidence of warts peaks between the ages of 12 and 16.

3. Race

White people are more likely to develop warts as compared to Blacks or Asians. Focal epithelial hyperplasia is more commonly observed in Inuit and American Indians. 

4. Medical conditions

Several skin diseases, such as eczema and dermatitis, increase the risk of warts. 

5. Occupation

Frequent meat handlers are more exposed to HPV infection and, thus, more likely to develop warts. People who bite their nails or pick at hangnails also have an increased chance of developing warts. 

6. Unprotected sexual intercourse

Having unprotected oral, anal, or vaginal sex with an infected partner increases the risk of genital warts. 

7. Smoking

Some studies suggest that smoking is associated with an increased risk of contracting genital warts. 

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Diagnosis Of Warts 

The diagnosis of warts include:

1. Clinical examination 

Each type of wart has a characteristic feature and location.  Almost all cases of warts are diagnosed through physical examination by a trained clinician. 

2. Dermoscopy

It refers to the examination of skin using a high quality magnifying lens and a powerful lighting system (a dermatoscope). It reveals abnormalities of the skin. 

3. Immunohistochemical (IHC) detection 

It uses antibodies to detect the location of proteins and other antigens in a sample of skin tissue. It confirms the presence of virus in a lesion. 

4. Southern blot hybridization 

It is used to identify the specific HPV type present in tissue. It has higher sensitivity than IHC. 

5. Polymerase chain reaction

It is another confirmatory method to detect the virus present in a lesion. In this, the genetic material of the virus is amplified. 

6. Biopsy

In case of a suspicion of cancer, a sample of skin tissue is taken for biopsy. 

Prevention Of Warts

It is not possible to completely prevent warts as the virus is highly contagious. However, the following measures minimize the chances of infection to some extent. 

1. Vaccinate yourself

HPV vaccines protect against anal and genital warts to a greater extent. All people ages 9 to 45 can get the HPV vaccine to protect against genital warts and different types of cancer-causing HPV. Optimal protection starts early. That's why it's advisable to get the HPV vaccine sooner rather than later.

What is the schedule?

• A 2-dose schedule is recommended for people who get the first dose before their 15th birthday.
• In a 2-dose series, the second dose should be given 6–12 months after the first dose (0, 6–12-month schedule)
• A 3-dose schedule is recommended for people who get the first dose on or after their 15th birthday and those with certain immunocompromising conditions.
  
  

2. Ensure foot care

Plantar warts can be prevented by maintaining a good foot hygiene routine. The following measures can help you achieve it:

• Wash your feet daily with soap and water.
• Dry them thoroughly, especially between the toes. 
• Wear clean, dry, moisture-wicking socks. Change them regularly.
• Prefer open footwear like floaters that allow the skin to breathe. 
• Regularly rotate shoes to air them out.
• Use shower sandals on wet locker room floors and public showers.
• Avoid used instruments such as pumice stones or nail files 

3. Take proper care of the wounds

Wounds are the leading cause of infection. Proper care of wounds and injuries can help prevent viral infections. The following measures should be taken to keep the wounds away from the virus:

• Wash hands with soap and water more frequently
• Use an alcohol-based hand rub if washing is not possible
• Keep the draining or open wounds clean 
• Keep the wounds and injuries covered with the dressings until they heal
• Avoid hot tubs, swimming pools, and other water bodies such as lakes, rivers, and oceans till the wound heals completely.

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4. Maintain hand hygiene

Washing your hands more often is always advisable, especially after coughing and sneezing. Hand hygiene should also be maintained before preparing foods and during eating. 

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5. Keep the skin moisturized

HPV quickly infects dry and cracked skin, increasing the chances of warts. It is always advisable to apply moisturizer within 5 minutes of bathing or whenever the skin feels dry.

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6. Maintain skin barrier

The skin barrier should be maintained through timely management of skin conditions such as atopic dermatitis and eczema. Any allergen or irritant to the skin should be avoided.  

7. Avoid nail biting and cuticle chewing

Excessive nail and cuticle biting causes sores and tears in the skin, which makes the entry of HPV easy. Avoiding this habit minimizes the risk of warts.  

8. Get treated for excessive sweating

Excessive sweating increases the chances of developing warts as the virus grows more in damp skin. Managing and treating this condition can help prevent warts. 

9. Go for regular skin examination

Individuals with diabetes or obesity should undergo regular skin screening. Early management can help prevent infection. Diabetics should also check their feet daily for signs of injury or infection.

Specialist To Visit 

Most of the cases of warts can be treated with over-the-counter medications and home remedies. The health care provider should be consulted in case of:

• Suspicion that the growth is not a wart
• Presence of wart on your face or genitals
• Presence of many warts
• Itching and burning on the affected site
• Painful warts
• Low immunity
• Diabetes

The doctors that might help include:

• General Physician
• Dermatologist
• Cosmetologist

A general physician will examine your symptoms and initiate treatment.

Dermatologists have expertise in diagnosing and treating skin disorders. 

Cosmetologists are trained and licensed to perform cosmetic treatments of the skin, nails, and hair. They help manage the skin's appearance and also perform in-office treatments. 

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Treatment Of Warts

No treatment for wart can permanently cure the condition. Recurrences are very common. Various treatment options include:

1. Topical agents

These agents are available in creams, gels, and lotions and are applied over the warts. The common medications include:

• Salicylic acid is the first-line agent for most of the common warts. 

• Tretinoin is used in treating flat warts.

• Dibutyl squaric acid, also known as squaric acid dibutyl ester (SADBE), and diphenylcyclopropenone (DCP) are contact sensitizers. They activate the immune system, which provides symptomatic relief.

• Imiquimod targets the body's immune system and helps fight viruses. It is available in gel form and effectively manages genital and common warts. 

• 5-Fluorouracil is an anticancer medication that has been reported to be effective in treating warts.

• Cidofovir, an antiviral agent, has proven beneficial for unresponsive warts.

2. Intralesional injections 

It involves injecting the medication into the lesions. Examples include:

• Skin test antigen involves injecting the viral and fungal extract. The extract acts as an antigen that stimulates the immune system, helping to produce antibodies that eradicate the virus.

• Bleomycin, an anticancer agent, is used to inhibit the growth of the wart virus.

• Interferon-alfa is an immunomodulator with additional antiviral, antibacterial, and anticancer properties. It is used in warts that do not respond to standard treatments. 

3. In-clinic treatments

It involves slightly invasive procedures performed by trained healthcare professionals in clinics or hospitals. 

• Cantharidin: It is a fatty substance that the beetle secretes. It removes the outer layer of skin that contains warts. 

• Trichloroacetic acid: It causes immediate death of the superficial tissue. 

• Cryosurgery: It involves the application of liquid nitrogen using a cotton bud applicator around the wart. The procedure is repeated every 1-4 weeks for approximately three months. 

• Curettage: It involves scraping off the wart using a knife. 

• Excision: In this, the wart is excised cut.

• Photodynamic therapy: This therapy uses light and photosensitizing agents to treat warts. The procedure involves injecting the agent and staying in light for a particular duration, which kills the cells containing warts.  

• Laser treatment: Laser light is directed towards the affected part. This treatment option is usually used for large and severe warts. 

Home-care Of Warts

Some home remedies for warts can be tried. However, it is essential to consult your healthcare provider before initiating any of these:

1. Garlic (Lehsun): Garlic is used to treat several skin conditions. Its antimicrobial properties also help treat warts. 

How to use it?

A garlic extract can be prepared by crushing a clove and mixing it with water. It must be applied daily for three to four weeks. 

2. Orange peel: Orange peels are also known to remove warts. 

How to use it?

Rubbing an orange peel on the wart daily helps it fall off.

3. Pineapple: The active ingredient bromelain helps remove dead and damaged cells, including warts. 

How to use it?

Pineapple juice can be applied to the warts. 

4. Honey (Sehad): It is a potent antibacterial and antiviral agent. 

How to use it?

Apply a small quantity of honey over the wart and let it sit for 15-20 minutes. 

5. Green Papaya: Papaya is a source of an enzyme that peels away dead skin and helps get rid of warts.

How to use it?

Cut a green papaya in half and collect the white sap that runs out from the skin. Mix that with a teaspoonful of the papaya pulp mash and water to make a smooth paste. Apply this paste to the warts twice daily and leave it on for 15-20 minutes. This mixture grazes the dead tissue and gradually makes the wart disappear.

6. Aloe vera: It has a whole host of skin benefits, wart removal being one of them. It acts as a natural antioxidant and anti-infective. 

How to use it?

Apply the Aloe vera gel to the warts and let it stay for 30-45 minutes before washing it off.

7. Apple cider vinegar: It can help peel off the affected skin, removing the warts.

How to use it?

A cotton ball dipped in diluted apple cider vinegar can be used to apply it to the wart.

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Complications Of Warts

Approximately two-thirds of warts resolve on their own over several years. But some warts can lead to scarring as a result of topical treatment. 

Certain strains of HPV have been associated with the development of cervical cancer, vulvar cancer, anal cancer, and, rarely, cancer of the penis. It is usually seen in genital warts. 

Occasionally, the occurrence of warts on the vaginal wall may pose a challenge to the vaginal elasticity required for childbirth. In these instances, a cesarean delivery may be advised.

Alternative Therapies For Warts

Some alternative therapies might be effective in tacking warts. Do consult your doctor before initiating any of these:

1. Podophyllin resin

It is the extract that is derived from the roots of May apple plant. The topical application of this extract is known to treat genital and plantar warts. It works by inhibiting the growth and multiplication of viruses. 

Podofilox is another less irritating form of podophyllin available in the market. 

2. Duct tape therapy

In this, the duct tape is applied to the wart. This creates an environment that helps in the detachment of warts. 

3. Hypnosis

In this, the brain is controlled through various activities. It is used to treat unresponsive warts. The hypnosis can be induced through various ways such as the application of an imaginary freezing agent to the wart. The success rate is reported from 27-55% in children.

4. Hyperthermia 

In this, the affected part is immersed in the surface of hot water for 30-45 minutes. This should be done 2-3 times per week.

Living With Warts

Living with warts can be bothersome due to their chronic nature. It is essential to understand that most warts resolve on their own. The following measures help in faster recovery and reduce transmission. 

1. Keep the warts covered

Keeping warts covered helps prevent the transmission of warts to other body parts and other people. 

2. Wash your hands after touching the wart

When it comes to warts, maintaining good personal hygiene is not just a suggestion, it's a necessity. Every time you handle a wart, whether it's for dressing or any other reason, it's crucial to wash your hands thoroughly. 

3. Avoid shaving over a wart

Shaving over a wart can create microtears, which, in turn, increases the spread of warts. To avoid this, it's advisable to refrain from shaving over a wart. By being cautious and aware of such potential harm, you can better manage and prevent the spread of warts. 

Preventing the transmission

The virus of warts spreads very fast from one person to another. The significant complications develop due to the intra-transfer of the virus from one body part to another. These transmissions can be minimized through a more conscious approach. The following measures may help prevent transmission:

• Avoid touching the wart
• Use a waterproof plaster to cover the warts while swimming
• Avoid sharing towels, shoes, gloves, and socks
• Keep washing your hands frequently, especially after touching the wart 
• Avoid scratching or picking at warts
• Wear flip-flops or pool shoes in public showers, locker rooms, and pool areas