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Warts, Emergency Medicine

Basics

Description

- 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

- 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)

- 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

- 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

- 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 wart: - Condyloma latum (secondary syphilis) - Herpes simplex - Prominent glands around head of penis - Benign or malignant neoplasm - Molluscum contagiosum

- 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

- 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

- Cervarix: Targets HPV types 16, 18: - 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

  • 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 mo2/3 within 2 yr90% within 5 yrLikely due to cell-mediated immune response
  • Cutaneous warts:Verrucae vulgaris (common warts):Dorsum of handsSides of fingersAdjacent to nailsUsually asymptomaticVerrucae plantaris (plantar warts):Weight-bearing parts of sole: Heels, metatarsal headsOften symptomatic and painfulMore common in adolescents and young adultsFlat (juvenile) warts:Primarily on light-exposed areasHead, face, neck, legs, dorsum of handsSmall in sizeRange from a few to hundreds
  • Anogenital warts:Known as condyloma acuminata or venereal wartsMost are asymptomatic and may go unrecognizedHPV types 6 and 11 account for 90% of anogenital warts
  • HPV types 16 and 18 account for 70% of cervical cancers

Etiology

  • HPV is host-specific to humansCause infection of epithelial tissues and mucous membranesInfects 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 skinIndirect: Contaminated surface to skinAutoinoculation: 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

Signs and Symptoms

History

  • Complete sexual history
  • Prior history of warts and treatment
  • HIV status
  • Cutaneous warts:Common warts:Usually asymptomatic unless on a pressure pointMay present with bleeding secondary to minor traumaPlantar warts:Often painful with weight bearingFlat (or juvenile) warts:On light-exposed areas of skinMay spread with shaving face, neck, legs
  • Anogenital warts:In men, usually on glans penis, shaft, scrotum, or anusIn women, found on labia, vagina, cervix, or anusMay extend into urethra, bladder, or rectum:DysuriaPain, itching, and/or bleeding with bowel movementsMay have symptoms involving mouth or throat if oral sexual contact

Physical Exam

  • Cutaneous warts:Common warts:Hard, rough, raised, dome-shaped lesionsObscure normal skin markingsHypervascular and may bleed with minor traumaPlantar warts:Soles of the feetObscure normal skin markingsHypervascular and may bleed with gentle scrapingFlat (or juvenile warts):Flesh coloredFlat top and smoothSmall: Range from pinpoint to size of pencil eraser
  • Anogenital warts:Pedunculated growths often with cauliflower-like appearanceLesions are soft and usually present in multiplesFlesh colored to slightly pigmented or red

Essential Workup

Diagnosis made by characteristic appearance of lesions

Diagnosis Tests & Interpretation

Lab

  • 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

Diagnostic Procedures/Surgery

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

Differential Diagnosis

  • Cutaneous warts:Common wartPlantar wart:Flat (or juvenile) wart:Moles, skin tag, lichen planus
  • Anogenital wart:Condyloma latum (secondary syphilis)Herpes simplexProminent glands around head of penisBenign or malignant neoplasmMolluscum contagiosum

Treatment

Initial Stabilization/Therapy

None required

Ed Treatment/Procedures

  • Cutaneous warts:Occlusion with duct tape:Least invasiveMaintain on wart for 6 daysGentle debridement with pumice stone or nail file on day 7Good for young childrenMay also enhance other topical treatmentsSalicylic acid:Inexpensive, mild side effectsOTC is 17% salicylic acidPrescription strength has up to 70% salicylic acidSoak wart in warm water for 10 " 20 minApply salicylic acid overnightGently debride in morningPatches are also availableResolution may take weeks to monthsMay be more effective combining with cryotherapy
  • Anogenital warts:May use imiquimod, podofilox, podophyllin, trichloroacetic acid (TCA), bichloroacetic acid (BCA), or alternative therapies listed belowNonintervention may be best course in children, as treatment has not been well studied
  • Alternative treatments:Cryotherapy with liquid nitrogen or dry iceOTC cryotherapy kitsElectrocauteryLaser therapySurgical excisionInterferon for use by subspecialists
  • Provide appropriate referral

Medication

  • Topical medications (patient applied):Imiquimod 5% cream:Apply 3 times/wk for up to 16 wkCream may weaken diaphragms and condomsPodofilox 0.5% gel or solution:Apply BID for 3 days, then rest 4 days; may repeat for 4 cyclesDo not use on perianal, rectal, urethral, or vaginal lesionsSalicylic acid:Wash off 6 " 10 hr laterMay be repeated weekly
  • Topical medications (provider administered):Podophyllin 10 " 25% in benzoin:Weekly topical application:Protect surrounding normal tissue with petroleum jellyWash off 1 " 4 hr laterDo not use in pregnancy: Highly toxic and teratogenicDo not use on cervix, vagina, or anal canal as may cause dysplastic changesTCA or BCA 80 " 90%Apply weekly for 6 " 10 wkCryotherapy with liquid nitrogen or cyroprobeMay be repeated every 1 " 2 wk
  • Vaccine:Gardasil: Targets HPV types 6, 11, 16, 18:Recommended for girls >9 yr3-shot series over 6 moFor the prevention of cervical cancer, vulvar and vaginal cancer, genital warts, and other low-grade cervical lesionsCervarix: Targets HPV types 16, 18:Universal vaccination may provide significant reduction of cervical cancer in developing countries without well-established screeningBoth vaccines are 96% effectiveThere are still controversies surrounding routine use and acceptance

Follow-Up

Disposition

Admission Criteria

Disseminated cases in immunocompromised patients may require admission

Discharge Criteria

Most patients can be treated as outpatients

Issues for Referral

  • All medication-based therapies require follow-up and subsequent dosing. Should not initiate treatment unless follow-up can be secured
  • For treatment failures, referral to PMD or dermatology should be made for alternative treatment options
  • Refer sexually active teenage girls to pediatrician or primary care for HPV vaccination

Follow-Up Recommendations

  • Pain, burning, redness, or other changes in symptoms require prompt re-evaluation
  • Arrange follow-up with appropriate provider: Pediatrician, gynecologist, dermatologist, primary care physician

Pearls and Pitfalls

  • Pregnancy test must be done before initiation of medical therapy
  • HPV vaccine does not protect from all forms of HPV, just those most commonly associated with cervical cancer
  • Consider sexual assault in children with anogenital warts

Additional Reading

  • Gilson RJ, Ross J, Maw R, et al. A multicentre, randomised, double-blind, placebo controlled study of cryotherapy versus cryotherapy and podophyllotoxin cream as treatment for external anogenital warts. Sex Transm Infect. 2009;85(7):514 " 519.
  • Herman BE, Corneli HM. A practical approach to warts in the emergency department. Pediatr Emerg Care. 2008;24:246 " 251.
  • Hutchinson DJ, Klein KC. Human papillomavirus disease and vaccines. Am J Health Syst Pharm. 2008;65:2105 " 2112.
  • Kwok CS, Gibbs S, Bennett C, et al. Topical treatments for cutaneous warts. Cochrane Database Syst Rev. 2012;12(9):CD001781.
  • Markowitz LE, Dunne EF, Saraiya M, et al. Quadrivalent Human Papillomavirus Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56:1 " 24.
  • Workowski KA, Berman SM. Centers for Disease Control and Prevention, Sexually transmitted diseases treatment guidelines, Clin Infect Dis. 2011;53(suppl 3):S59 " S63.

See Also (Topic, Algorithm, Electronic Media Element)

  • Herpes, Genital
  • HIV/AIDS
  • Molluscum Contagiosum

Codes

ICD9

  • 078.10 Viral warts, unspecified
  • 078.12 Plantar wart
  • 078.19 Other specified viral warts
  • 078.11 Condyloma acuminatum
  • 078.1 Viral warts

ICD10

  • B07.0 Plantar wart
  • B07.8 Other viral warts
  • B07.9 Viral wart, unspecified
  • A63.0 Anogenital (venereal) warts
  • B07 Viral warts

SNOMED

  • 57019003 Verruca vulgaris (disorder)
  • 240534005 hand wart (disorder)
  • 63440008 Verruca plantaris (disorder)
  • 240542006 Anogenital warts (disorder)
  • 240539000 Plane wart (disorder)
  • 302812006 Anogenital human papilloma virus infection (disorder)