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Warts
Diagnosis/Definition
- Warts are benign tumors of the skin and other epithelial tissues.
- They appear as discrete keratotic papules or plaques and can be classified by their location (plantar, genital, periungual, etc.).
- They are most common in children and young adults.
- The etiologic agents for these infections are a class of double-stranded DNA viruses called papillomaviruses.
Initial Diagnosis and Management
- The initial diagnosis is generally clinical based on physical exam. Location, duration and extent should be noted. If there are lesions near a mucous membrane, these should be examined as well. If the diagnosis is not obvious a biopsy may be indicated.
Treatment options include:
- Acids – Salicylic acid preparations on formulary are Occlusal (17%) and Mediplast (40%); with some instructional assistance, patients can use these at home. Similar Over-The-Counter (OTC) preparations are readily available.
- Cryotherapy – Liquid Nitrogen applied as spray or cotton applicator, with frost lasting for 20-30 seconds. Goal is to treat visible wart plus a millimeter “halo”. After thawing, a second treatment may be applied.
- Caustics (Podophyllin) – For genital warts (condyloma acuminata), in-office podophyllin may be used, with or without light cryotherapy. Avoid use in occlusive (under foreskin, ventral penis, etc.) environment. Condylox is on the formulary and patient applies gel twice a day for 3 consecutive days a week, repeating up to 4 weeks for external genital warts only.
- Immune modulator (Imiquimod 5% [Aldara] cream) – Is on the formulary and may be selected for patients who fail cryotherapy and podophyllin therapy options (mention in “comments” section of CHCS when orderinging). Apply once at bedtime, wash off after 6-10 hours 3x/week every other day; treat for 16 weeks maximum.
- Duct tape—Shown to actually work. Apply duct tape cut to the size of the wart and leave in place for 5 days. Replace it if it comes off. Remove on the 5th day and let it air out over night. Repeat for another 5 days until the wart resolves.
Ongoing Management and Objectives
- Patients may be followed up at 2-4 week intervals. Again, it should be emphasized that although they are often refractory to therapy, most warts eventually resolve with persistent treatment.
- Self-treatment between visits is important to increase the rate of success.
Indications for Specialty Care Referral - Periungal Warts, if large or refractory to the conservative management noted above.
- Markedly extensive warts (may indicate underlying immunodeficiency or disease).
- Large or numerous warts that are resistant to therapy for 6 months.
Criteria for Return to Primary Care
Warts have resolved and/or a suitable treatment plan has been established.
