Warts, Emergency Medicine

Basics

Description

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 mo
- 2/3 within 2 yr
- 90% within 5 yr
- Likely due to cell-mediated immune response
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
- Flat (juvenile) warts:
  - Primarily on light-exposed areas
  - Head, face, neck, legs, dorsum of hands
  - Small in size
  - Range from a few to hundreds
Anogenital warts:
- Known as condyloma acuminata or venereal warts
- Most are asymptomatic and may go unrecognized
- HPV 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 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)
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 point
  - May present with bleeding secondary to minor trauma
- Plantar warts:
  - Often painful with weight bearing
- Flat (or juvenile) warts:
  - On light-exposed areas of skin
  - May spread with shaving face, neck, legs
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
- May have symptoms involving mouth or throat if oral sexual contact

Physical Exam

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 warts:
- Pedunculated growths often with cauliflower-like appearance
- Lesions are soft and usually present in multiples
- Flesh 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 wart
  - Callus; will not bleed
- Plantar wart:
  - Callus, corn, bunion
- Flat (or juvenile) wart:
  - Moles, skin tag, lichen planus
Anogenital wart:
- Condyloma latum (secondary syphilis)
- Herpes simplex
- Prominent glands around head of penis
- Benign or malignant neoplasm
- Molluscum contagiosum

Treatment

Initial Stabilization/Therapy

None required

Ed Treatment/Procedures

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
Provide appropriate referral

Medication

Topical medications (patient applied):
- Imiquimod 5% cream:
  - Apply 3 times/wk for up to 16 wk
  - Cream may weaken diaphragms and condoms
- Podofilox 0.5% gel or solution:
  - Apply BID for 3 days, then rest 4 days; may repeat for 4 cycles
  - Do not use on perianal, rectal, urethral, or vaginal lesions
- Salicylic acid:
  - Wash off 6 " 10 hr later
  - May be repeated weekly
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
- TCA or BCA 80 " 90%
  - Apply weekly for 6 " 10 wk
- Cryotherapy with liquid nitrogen or cyroprobe
  - May be repeated every 1 " 2 wk
Vaccine:
- Gardasil: Targets HPV types 6, 11, 16, 18:
  - Recommended for girls >9 yr
  - 3-shot series over 6 mo
  - For the prevention of cervical cancer, vulvar and vaginal cancer, genital warts, and other low-grade cervical lesions
- Cervarix: Targets HPV types 16, 18:
  - 3 shots over 6 mo
- 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

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.

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)

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