Common (Vulgar) warts are an infectious disease caused by human papilloma viruses (HPV, human papilloma virus). There are 150 different types of warts, but most of them are irrelevant to humans. The spontaneous healing of warts is very likely, especially in childhood. The warts are located exclusively in the top layer of skin (epidermis) and the mucous membranes.
Introduction to Common Warts
Warts are skin changes that result from an infection with the human papillomavirus (HPV, human papilloma virus). Their host cells lie exclusively in the top layer of skin (epidermis) and the mucous membranes. Over 150 types of HPV have been identified so far; only a small part of these HPV types is relevant for humans as the causative agent of a viral infection.
The cellular immune system is important for successful healing, which is shown clinically, e.g. by persistent warts in patients with cellular immunodeficiency (e.g. after transplantation) and under immunosuppressive therapy. Depending on the localization of the body, there are differences in the clinical appearance. Microscopically, the skin changes are characterized by a reversible increase in the cornea (epithelial hyperplasia).
The spontaneous healing rate is particularly high in childhood, which must also be taken into account during treatment.
Common Warts Causes
Virus warts are usually transmitted through direct physical contact from person to person, but often also through contact with contaminated floors / surfaces or objects (e.g. by walking barefoot in sports halls, swimming pools, sharing towels, etc.). Autoinoculations (“self-infection”) are often observed and are always particularly likely when warts are arranged in stripes as a result of repeated scratching.
The time between infection and the first manifestation of symptoms (incubation period) is between four weeks and several months and depends on various factors, primarily on the patient’s immunity. Other factors that favor an infection are cold hands and feet, increased sweating in the hand and foot area (hyperhidrosis palmoplantaris), eczema (e.g. neurodermatitis), as well as existing skin infections (e.g. a fungal infection (tinea)).
The papillomaviruses reach the lowest layer of the epidermis, the stratum basale, via the smallest skin injuries. Once the cells have been infected, the HPV causes accelerated cell growth. Virus particles are released via the natural exfoliation of the cells with the subsequent further spread of the infection.
Common Warts Symptoms
Clinically, warts appear as single or multiple nodules (papules) of various sizes with a scaly, furrowed surface. The black points in the skin changes, which represent the clinical correlate of virus-induced vascular destruction in the papillary tips, are typical.
A distinction is made between the following clinical types: Warts on the back of the hands or on other areas of the body. Here the typical knots of different sizes show up. In the area of the feet, vulgar warts can manifest themselves in two clinical variants, as mosaic or plantar warts (see table). While mosaic warts do not cause subjective complaints, these can sometimes be very pronounced with plantar warts; Particularly when multiple warts appear, the complaints can lead to massive orthopedic problems due to a misalignment caused by a relieving posture.
Occasionally, warts appear as line-like protuberances (filiform warts). Another clinical peculiarity of vulgar warts, especially in adolescents and younger adults, is observed on the face in the form of verrucae planae iuvenilis. Here there is often a massive sowing of flat, reddish, yellowish or gray-brown nodes with a blunt surface.
The most common HPV types of vulgar warts are types 1, 2, 4, 27 and 57. In Verrucae planae iuvenilis, types 3 and 10 can be detected. The type of HPV detected does not affect the prognosis or response to treatment. The procedure for dealing with vulgar warts depends on a number of factors.
Common Warts Treatment
The procedure for dealing with vulgar warts depends on a number of factors. Given the high rate of spontaneous healing, non-treatment can be a real therapeutic option in childhood when the level of suffering is absent. In contrast, spontaneous healing of vulgar warts in adulthood cannot be assumed.
A single (singular) wart should be completely removed if possible, as this may prevent further spread. An exception is the surgical removal of plantar warts (in the area of the sole of the foot): Since this can lead to scarring that restricts movement, surgical removal should be avoided if possible.
If warts cause pain, the primary goal of therapy is to achieve freedom from pain. Every wart therapy must be assessed critically with regard to possible therapy-related scar development, since the spontaneous healing of warts always takes place without scars. Any therapy intervention requires the active cooperation of the patient.
Common Warts – Available Options
- Suggestive therapy
- Keratolytic-mechanical treatment (corneal detachment) in combination with active ingredients subject to prescription
- Laser treatment
- Operative removal
- Intralesional immunotherapy
- HPV-specific immunotherapy
- Supportive therapeutic measures to improve individual risk factors
Suggestive therapy in the form of “discussing warts” is well known and is a sensible therapy method in the case of distress in childhood, especially in 6 to 12 year old children. In everyday practice, addressing the warts in the evening (e.g. “You bad warts will get rid of them now, otherwise the doctor will cut you off”) has proven its worth over six weeks. This can also be combined with a keratolytic treatment.
Keratolytic treatment is carried out with preparations containing salicylic acid or lactic acid, which are applied regularly over several weeks, e.g. in the form of ointments. In addition, the mechanical removal of the softened horny layer is recommended, ring curettes being very suitable for this, as they are easy to guide and prevent unnecessary injuries. Any small bleeding that occurs can be quickly brought to a standstill by dabbing with a swab.
When visiting a dermatologist, the keratolytic-mechanical treatment can be supplemented by additional, prescription-only active ingredients such as dithranol or 5-fluorouracil. The treatment of warts using cold (cryotherapy) is still very common, but its therapeutic value is very low. In addition, various off-label methods are used, for example in the form of laser therapy (dye and erbium laser), although convincing clinical studies on the effectiveness of these methods are also lacking.
Since the cellular immune response plays a central role in healing, treatment methods that induce an immunological reaction are of particular interest. These include the injection of known antigens into the wart and vaccination with the HPV vaccine.
Intralesional Antigen Injection
An innovative approach aimed at actively eliminating warts has been practiced in the United States for over 10 years. High healing rates were found after repeated injections of various antigens already known to the immune system (including candida, trichophyton or mumps antigen), which were applied directly to the wart, triggering an immune reaction to the applied substances that destroys the wart.
The treatment protocol provides for the injection of 0.3 ml of the vaccine with an insulin cannula directly into the wart, whereby a pre-test to determine the immunogenic reaction is no longer required today. Since it is a live vaccine, it should not be used with simultaneous immunosuppressive therapy.
If there are several warts, only the largest one is treated. Since the immune stimulation is not limited to the application site, this procedure is particularly suitable in the presence of multiple warts, even on different areas of the body. The application takes place every 2 weeks until complete healing, but a maximum of 5 times.
The healing rates with this treatment are 63%. Since the pain is not insignificant with intralesional injection, the application of a pain-relieving cream before the injection should be considered. Depending on the antigen used, side effects occur occasionally in the form of slightly pronounced flu-like symptoms (as also after a usual vaccination).
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