LEARNING

DERMATOLOGY

Warts and verrucas:

assessment and treatment
Lesions caused by human papilloma virus often do not require
treatment, but need to be assessed to rule out more serious conditions.

SAM AKRAM AND HADAR ZAMAN

W
arts are common viral skin
infections, affecting around
7–12% of the population at any
one time, and are more common in chil-
dren1. They are caused by the human pap-
illoma virus (HPV), of which there are over
150 genotypically different types; the most
common are HPVs 1, 2, 4, 27 and 57, and
HPVs 3 and 10 for plane (flat) warts.
HPV infects the keratinocytes, the most
dominant cell type in the epidermis, which
SUMMARY BOX
In this article you will learn:
• HRedowflag
to assess warts and verrucas
• requiringsymptoms for skin lesions
specialist advice
• The different wart treatments available
results in development of epidermal thick-
ening and hyperkeratinisation. HPV infec-
tion is acquired from direct contact, which
may be person-to-person or from the en-
vironment (e.g. showers and swimming
pools; skin penetration increases if the
skin is broken or wet)2.  Inspect the patient. Where on the body are
Studies suggest that the bovine papil-
loma virus (which is related) can retain
infectivity for months and possibly years,
and the same may be true for HPV3.
Verrucas are plantar warts, located
on the sole of the foot4,5. Someone with a
plantar wart should use waterproof plas-
ters in communal bathing areas; verruca
socks are also available.
This article will not discuss anogenital
warts or seborrhoeic (keratoses) warts.
Assessment
When clinically assessing skin lesions, the
following steps are useful to aid diagnosis6,7:
the lesions? How many lesions are there?
If there are multiple lesions, do they follow
a pattern or are they on a specific area?
Describe the lesions. What is the larg-
est diameter of lesion? Is there colour?
Are there any secondary changes (e.g.
lichenification, crusting, excoriation
(scratch marks), ulceration, erosion, fis-
sure (thin crack), hypertrophy (increase
NEPHRON / WIKIMEDIA COMMONS

Micrograph of a common wart, caused hyperkeratinisation following infection by the human papilloma virus

662 THE PHARMACEUTICAL JOURNAL VOL 294 NO 7867 20 JUNE 2015

 LEARNING

in skin) or granuloma?) Is there a clear

defined border? Is it regular? PHOTO GUIDE
Palpate the lesion. Feel the surface, con- Different types of warts
sistency, mobility, tenderness and temper-
L-R: BSIP SA/ALAMY / WIKIMEDIA COMMONS / JAMES HEILMAN/WKIMEDIA COMMONS / ALAMY

ature (use gloves to prevent infection). 1 2

Check the patient’s overall health. Ex-
amine the nails, scalp, hair and mucous
membranes. Is there any lymphadenopa-
thy? Does the patient have a temperature?
Any pigmented lesions should be
checked for red flags suggestive of mela-
noma. These include: asymmetry (lack of
mirror image lesion in any of the four quad-
rants of the body); irregular border; two
or more colours in the lesion; diameter of
more than 7mm. Patients presenting with
any of these symptoms should be referred
to a dermatologist for further assessment
(e.g. biopsy and histological studies). Plane wart: these are most common on the Filiform wart: long, finger-like warts that
Cutaneous warts are generally diag- backs of hands and are round and flat-topped appear on the face and neck
nosed on appearance. The characteristic
appearance of different types of warts are 3 4
as follows:

• Cwith
ommon warts are firm and raised
rough edges like a cauliflower;
• Pyellow,
lane warts are round, flat-topped and
and they are commonly seen
on the back of hands;
• Fwarts
iliform warts are long, finger-like
common on the face and neck;
• palms (palmar)
Palmar and plantar warts grow on
and soles of feet
(plantar). Often seen with thrombosed
capillaries, which appear as a central Plantar wart: these can be differentiated Mosaic warts: these are groups of palmar
black dot (these do not appear in corns from corns by the presence of black or plantar warts.
and calluses); dots (seen top centre), which are
• Periungual warts occur around
fingernails and toenails, and appear
thrombosed capillaries.

as thickened, cauliflower-like skin;

•
Mosaic warts are multiple palmar
or plantar warts that coalesce on
hands or feet.
The presentation can be similar to other
lesions. Possible differential diagnoses
for warts on the hands or feet include5:
actinic keratosis; seborrheic keratosis;
knuckle pads; squamous cell carcinoma;
lichen planus; corns or calluses; and ma-
lignant melanoma.
If the diagnosis is in doubt, paring down
a wart with a file will result in pinpoint
bleeding from thrombosed capillaries5.
Paring should be performed with caution,
as the bleeding contains active viral DNA
that can infect the clinician or further the
spread of infection4. If in doubt, the patient
should be referred to a clinician specialis-
ing in dermatology to confirm diagnosis.
Patients should also be referred if they
have a facial wart or extensive areas of the
skin are affected (usually mosaic warts on
the hands and feet).
Warts can last longer in patients who
are immunocompromised, especially those
with cell-mediated immunodeficiency. In
“
Paring down a wart
with a file will result
in pinpoint bleeding
from thrombosed
capillaries
patients with severely impaired immune
function (e.g. patients treated with immuno-
suppressants after organ or bone marrow
transplant), warts may be large, extensive
and resistant to treatment. Warts can also be
a presenting complaint of patients with un-
diagnosed conditions such as HIV, lympho-
ma and CD4 lymphocytopenia. All patients
with warts who are immunocompromised
should be referred to a dermatologist.
HPV infection is associated with squa-
mous cell carcinoma and pre-malignancy.
The likelihood of squamous cell carci-
noma is increased in mild immunodefi-
ciency and carriers of certain HPV types.
HPV types 5 and 8 are also associated with
epidermodysplasia verruciformis, an ex-
tremely rare skin disorder that results in
the growth of scaly macules and papules.
Treatment
No treatment is required in most cases,
especially if the warts cause no function-
al impairment. Most warts will resolve
spontaneously within two years, although
some cases can take five to ten years to
resolve. Treatment should be considered
when the wart is uncomfortable, function
is impaired or if the warts affect appear-
ance (e.g. warts on the face).
Most warts and verrucae can be treat-
ed in primary care. In some cases, refer-
ral to a hospital specialist may be neces-
sary (e.g. if persistent warts show a poor
response to treatment), however local
policies may restrict treatment to symp-
tomatic warts only4.
Treatment options include salicylic
acid, often in combination with lactic
acid, formaldehyde, glutaraldehyde and
cryotherapy.
Topical salicylic acid (15–50% w/w), ap-
plied to the wart daily for 12 weeks, is the

20 JUNE 2015 NO 7867 VOL 294 THE PHARMACEUTICAL JOURNAL 663


treatment of choice for adults and older
children. Its exact mechanism of action is
not known but it acts as a keratolytic, re-
sulting in the removal of epidermal cells
infected by HPV. It is also effective at re-
moving corns and calluses.
A Cochrane review of treatments
found the chance of clearance of warts
with salicylic acid was 1.56 times greater
compared with placebo. Removal was
most effective on hands (relative risk 2.67)
compared with feet (relative risk 1.29)8.
Salicylic acid preparations are avail-
able in a range of treatments, including
gels, paints, solutions and ointments, and
they often also include lactic acid; in the
UK, these are available over the counter.
Gel treatments may also contain coloph-
ony, which may cause an allergic reaction
in some patients9.
Salicylic acid should not be applied
to warts on the face, intertriginous ar-
eas (where skin rubs together, such as the
axilla), anogenital warts, moles or birth-
marks, warts with hair or red edges, or to
open lesions or broken skin4. When using
salicylic acid, patients should be advised to
protect the surrounding skin to avoid irri-
tation; this can be done by coating the area
with soft paraffin or by using plasters.
Salicylic acid is not recommended to
treat plantar warts in patients with dia-
betes, as these patients often have pe-
ripheral neuropathy and poor circulation,
leading to poor wound healing4. The NHS
states that salicylic acid can be used to
treat warts in pregnancy but only on a
small area for a limited period of time.
Formaldehyde and glutaraldehyde are
applied in a similar way to salicylic acid.
Glutaraldehyde can stain the skin brown,
and should be discontinued if skin irrita-
tion is severe.
Patients using over-the-counter treat-
ments can be advised to debride the sur-
664 THE PHARMACEUTICAL JOURNAL VOL 294
LEARNING
face of the wart gently with a file (e.g. em-
ery board) or pumice stone once weekly.
However, this should be done carefully
as there is a risk of further spread of the
infectious material. Patients should also
soak the wart for five minutes before
treatment to soften it.
Cryotherapy with liquid nitrogen is
suitable for adults and older children who
are able to tolerate it. It causes rapid cool-
ing of cells, causing ice crystals to form
outside of cells, and disrupts membranes.
When thawing occurs, extracellular fluid
becomes hypertonic, with the rapid flow
of water into cells causing cell death10.
Treatment usually involves exposure to
liquid nitrogen every two weeks for three
to four months. A session takes between
5–15 minutes, and may be painful. After
treatment a blister forms, followed by a
scab, which falls off around a week later.
Cryotherapy can cause local irritation to
unaffected skin3. Other side effects in-
clude scarring (rare), hyperpigmentation,
which usually improves with time but may
be permanent, and paraesthesia caused by
freezing a superficial nerve cell; this will
return to normal after two to three months.
There are no defined age limits for cryo-
therapy. It can be used to treat younger chil-
dren, although it is not usually recommend-
ed. Each treatment should be no longer than
five to ten seconds in these patients.
Cryotherapy is not recommended for
areas with a tendon, as aggressive treat-
ment can cause tendon damage. Onych-
odystrophy (malformation of the nails)
may occur if periungual warts are treated
with cryotherapy4.
Silver nitrate pencils are also available
to treat cutaneous warts; however, there
is no good evidence that this is effective3.
The Cochrane review also found no ev-
idence that using duct tape to treat warts
was more effective than placebo8.
NO 7867 20 JUNE 2015
References:
1. Lynch MD, Cliffe J & Morris-Jones R.
Management of cutaneous viral warts. The BMJ
2014;348:g3339. doi:10.1136/bmj.g3339.
2. Sterling JC. Virus infections. In: Burns.
Breathnach S, Cox N & Griffiths C. (Eds.) Rook’s
textbook of dermatology. 8th ed. Chichester:
Wiley-Blackwell; 2010. 33.1–33.81.
3. Sterling J, Gibbs S, Hussain S et al. British
Association of Dermatologists’ guidelines for
the management of cutaneous warts 2014.
Br J Dermatol 2014;171(4):696–712.
4. National Institute for Health and Care Excellence.
Clinical Knowledge Summaries. (2014). Warts
and Verrucae. Available at: http://cks.nice.org.
uk/warts-and-verrucae#!references (accessed
May 2015).
5. Dinulos JGH. Warts. Available at:
http://www.merckmanuals.com/professional/
dermatologic-disorders/viral-skin-diseases/
warts (accessed May 2015).
6. Macleod J.Macleod’s Clinical Examination.
12th ed. London: Churchill Livingstone; 2009.
7. British Association of Dermatologists. Medical
Students Edition. 2015. Software application.
8. Kwok CS, Gibbs S, Bennett C et al. Topical
treatments for cutaneous warts. Cochrane Datab
Syst Rev. doi:10.1002/14651858.CD001781.pub3. 
9. Royal Pharmaceutical Society and British Medical
Association. British National Formulary 69.
London: RPS 2015.
10. Nguygen NV & Burkhart CG. Cryosurgical
treatment of warts: dimethyl ether and
propane versus liquid nitrogen — case
report and review of the literature.
J Drugs Dermatol 2011;10:1174–117.
About the authors
Sam Akram is a senior lecturer
at Anglia Ruskin University and GP
practice-based pharmacist. Hadar
Zaman is a lecturer at University of
Bradford and community pharmacist.