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43Aesthetic Medicine • November 2015

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Dr Patrick Treacy shares some of his most challenging cases. This month he talks about treating cutaneous warts

Dr Treacy’sCASEBOOK

A 32-year-old Irish male patient presented with a large frond-like lesion on the middle phalanx area of his second finger. The outgrowing mass was not painful but sometimes bothered him when riding his speed bike and was present

for over six months. The patient said it had started off as a smaller lesion and had got rapidly bigger recently. He also had numerous similar lesions on his right foot. The lesions were immediately clinically identified as warts and histopathology was not indicated. Liquid nitrogen was used to treat the digital warts and CO2 laser for his foot.

Warts are a common skin disease worldwide. Infection is common in childhood, but can occur at any age. Small cohort observational studies have suggested that five to 30% of children and young adults have warts.1,2 HPV can spread from one individual to another by direct contact or via the environment. Warts can persist for years with little or no sign of inflammation.3

HPV-associated warts are subdivided on anatomical or morphological grounds into (i) common wart (Verruca vulgaris); (ii) wart on the sole of the foot, plantar wart (Verruca plantaris); (iii) flat wart or plane wart (Verruca plana) and (iv) genital wart (Condyloma accuminatum).4

DIAGNOSIS Diagnosis of common hand and foot warts is usually not difficult. Warts need to be distinguished either clinically or histologically from other keratotic lesions on the hands or feet, such as actinic keratoses, knuckle pads or, more rarely, squamous cell carcinoma.5 The term “plantar warts” is used for those that occur on the soles of the feet (the “plantar” surface). They are also known as verrucas.

Warts are one of the most common skin

infections and can persist for many years, but the evidence base for treatment is sometimes weak.

Treatments should be used as advised by the manufacturers or under

direction by appropriate qualified personnel who are aware of

contraindications and side-effects

MANAGEMENT(a) No therapy Depending on their site and size, warts may be just a

minor nuisance. There is no antiviral treatment that is specific for HPV, but some of the available therapies interfere with the viral life cycle.

(b) Salicylic acid The most commonly used, over-the-counter products

are SA paints. These contain SA at concentrations of between 10% and 26% in either a collodion or a polyacrylic base; they are often mixed with lactic acid. Plasters containing 40% SA and ointments containing 50% SA are also widely available.

(c) Cryotherapy A range of devices and techniques are used to induce

targeted cold injury to warts. Liquid nitrogen, delivered by cryospray or cotton bud, is the most commonly used method in medical practice. Techniques differ between practitioners, with variations in freeze times, mode >

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of application and intervals between treatments. Paring before cryotherapy can improve results in plantar warts, but not hand warts.6 The reported cure rate of cryotherapy for warts at all sites from randomized trials is highly variable, ranging from 0% to 69% with a mean of 49%.7

(d) Lasers PDL (585 nm) is the laser used most frequently and acts by

destroying wart vessel vasculature through haemoglobin’s absorption peak at 585–595 nm. Direct thermal injury to the heat-sensitive HPV virus may also play a role. CO2 laser, neodymium-doped yttrium aluminium garnet (Nd:YAG), Er:YAG, infrared and potassium titanyl phosphate laser have also been used. The author prefers a fractional CO2 set at very high wattage.

(e) Photodynamic therapy. Studies show there was a significant difference in wart clearance after 14 weeks in 45 patients with palmar and plantar lesions treated with 20% aminolaevulinic acid photodynamic therapy (ALA-PDT).8

(f) Formaldehyde soaks have been used to treat verrucas, and they were reported to give a cure rate of 80% in an open study of 646 children.9

(g) Podophyllotoxin can inhibit cell division by interfering with the mitotic spindle, and will affect normal skin as well as warts. It can have dangerous systemic effects if used in high concentrations or over large areas, and its use is contraindicated in pregnancy.

(h) Topical 5-FU has been used with effect to treat both plane warts and common warts on the hands and feet. 5-FU blocks DNA synthesis and damages dividing basal layer cells. When used topically or intralesionally, it produces inflammation and occasionally erosions.

(i) Bleomycin is a cytotoxic agent used in systemic chemotherapy, but it has been recognized and applied as a therapy for warts for 40 years (10).

( j) Imiquimod is a well-established treatment for genital and perianal warts. It stimulates a proinflammatory response through the induction, synthesis and release of interferon (IFN)-a, tumour necrosis factor-a and interleukin (IL)-12, as well as promoting natural killer (NK) cell activation.

>> Dr Patrick Treacy is CEO Ailesbury Clinics, chairman of the Irish Association of Cosmetic Doctors and Irish regional representative of the British College of Aesthetic Medicine (BCAM). He is also president of the World Trichology Association. Dr Treacy has won a number of awards for his contributions to facial aesthetics and hair transplants including the AMEC Award in Paris in 2014. Dr Treacy also sits on the editorial boards of three international journals and features regularly on international television and radio programmes. He is scientific committee for AMWC Monaco 2015, AMWC Eastern Europe 2015, AMWC Latin America 2015, RSM ICG7 (London) and Faculty IMCAS Paris 2015 and IMCAS China 2015.

REFERENCES 1. van Haalen FM, Bruggink SC, Gussekloo J et al. Warts in primary schoolchildren:

prevalence and relation with environmental factors. Br J Dermatol 2009; 161:148–52.

2. Kyriakis K, Pagana G, Michailides C et al. Lifetime prevalence fluctuations of common and plane viral warts. J Eur Acad Dermatol Venereol 2007; 21:260–2.

3. Kilkenny M, Merlin K, Young R, Marks R. The prevalence of common skin conditions in Australian school students: 1. Common, plane and plantar viral warts. Br J Dermatol 1998; 138:840– 5.

4. Am Fam Physician. 2010 Nov 15;82(10):1209-13. Human papillomavirus: clinical manifestations and prevention. Juckett G, Hartman-Adams H.

5. Guidelines for Management of Cutaneous Warts (JC Sterling, S Handfield-Jones, PM Hudson). BJD, Vol. 144, No.1, January 2001 (p4) – British Association of Dermatologists

6. Berth-Jones J, Hutchinson PE. Modern treatment of warts: cure rates at 3 and 6 months. Br J Dermatol 1992; 127:262–5.

7. Kwok CS, Holland R, Gibbs S. Efficacy of topical treatments for cutaneous warts: a meta-analysis and pooled analysis of randomized controlled trials. Br J Dermatol 2011; 165:233–46.

8. Stender IM, Na R, Fogh H et al. Photodynamic therapy with 5-aminolaevulinic acid or placebo for recalcitrant foot and hand warts: randomised double-blind trial. Lancet 2000; 355:963–6.

9. Vickers CF. Treatment of plantar warts in children. BMJ 1961; 2:743–5.

10. Lewis TG, Nydorf ED. Intralesional bleomycin for warts: a review. J Drugs Dermatol 2006; 5:499–504.

DISCUSSIONWarts are one of the most common skin infections and can persist for many years, but the evidence base for treatment is sometimes weak. Treatments should be used as advised by the manufacturers or under direction by appropriate qualified personnel who are aware of contraindications and side-effects. The author gets good results with cryotherapy and CO2 lasers and feels combination of cryotherapy with laser or possibly a topical agent can improve clearance rates.

Plantar warts are caught by contact with virally-infected skin scales; these are usually encountered on such surfaces as the floors of public locker rooms, shower cubicles and the tiled areas around swimming pools. However, the virus is not highly contagious, and it is unclear why some people catch plantar warts while others do not. The virus enters the skin through tiny breaks in the skin surface, and moistness and maceration of the skin on the feet probably make infection with the wart virus easier. AM