Childhood warts: an update

Warts are benign intraepidermal neoplasms that are caused by infection with human papillomavirus and commonly affect children and adolescents. The 4 most common types of cutaneous warts are common warts, plantar warts, flat warts, and genital warts. Although they rarely pose a serious health problem, warts can result in physical impairment and psychosocial discomfort. A variety of treatment modalities are employed to treat these growths in children.     

Pulsed dye laser treatment for viral warts: a study of 120 patients

A prospective, non-blinded, non-randomized study on 120 wart patients treated with pulsed dye laser was performed to evaluate the efficacy and safety of pulsed dye laser treatment for viral warts and to demonstrate the proper application and effective technique of this method. The overall clearance rate was 49.5%. The clearance rates of flat warts, periungual warts, plantar warts and common warts were 67.6%, 51.1%, 47.6% and 44.3%, respectively. Overall, the response rates of pediatric warts, recalcitrant warts and old warts were superior to those of adult warts, simple warts and non-old warts, respectively; however, those trends were not statistically significant. We concluded that pulsed dye laser treatment is a safe, tolerable and relatively effective treatment method for viral warts. Pulsed dye laser treatment may be a more efficacious method for flat warts and recalcitrant periungual warts, and it can be an effective modality for newly-developed warts. The highest clearance rate was noted at a fluence of 9.5 J/cm2 (P < or = 0.05) and it is recommended that practitioners perform pulsed dye laser treatments for viral warts at the fluences of 9.0-9.5 J/cm2. A replacement of pulsed dye laser treatment should be considered unless prominent improvement is observed after three treatment sessions.     

Therapeutic evaluation for intralesional injection of bleomycin sulfate in 143 resistant warts

A 1 U/ml solution of bleomycin sulfate in physiologic saline solution was injected intralesionally in 38 patients, and was compared with physiologic saline solution injection into paired warts in the same patient. No patient received more than 2 ml of bleomycin. Ninety-seven of 143 warts (67.8%) showed complete resolution after one or two bleomycin injections, while 25 warts (17.5%) showed incomplete resolution. Bleomycin local injection failed to elicit any therapeutic response in 21 warts (14.7%). The cure rate was 77% for warts on the extremities, 71.4% for periungual warts, and 47.6% for the plantar warts. The responsive warts showed hemorrhagic eschars that healed without scarring. It is concluded that this form of treatment for resistant warts, up to the dose used, is safe, reliable, and accepted by the patient.     

Intralesional injection of bleomycin sulphate into resistant warts in renal transplant recipients versus non-transplant warty patients.

Sixteen adult renal transplant patients and 20 non-transplant patients with warts underwent intralesional therapy with bleomycin sulphate. One unit/ml bleomycin sulphate was injected in 93 warts in renal transplant recipients and 100 warts in non-transplant patients with proven resistance to conventional treatment for at least 6 months. The treatment was compared with a normal saline placebo injected into the paired warts in the same patient. Thirty-four out of 93 warts (37%) in renal transplant recipients vs. 59 out of 100 warts (59%) in non-transplant patients were completely cured after one to three injections. We found bleomycin completely ineffective in 56 warts (60%) in renal transplant recipients, but ineffective in only 17 warts (17%) in non-transplant warty patients. None of the patients treated experienced any side effects except for local pain which was well tolerated, especially by non-transplant patients.     

Treatment of disseminated facial warts through contact immunotherapy with diphenylcyclopropenone (DPCP)

This paper highlights the effect of diphenylcyclopropenone (DPCP) sensitization on warts resistant to other treatments and is interesting in views of the fact that all the facial warts apparently responded. To analyze the efficacy and side-effects of DPCP treatment of viral warts, a prospective study was designed to follow six patients with chronic and resistant facial warts through immunotherapy sensitization with diphenylcyclopropenone for 10 weekly sessions. Patients were first sensitized with 2 percent DPCP and then followed by weekly maintenance of 0.001-1 percent DPCP in acetone on facial warts until mild contact dermatitis was obtained. After application of DPCP to the warts of the face, all of the facial warts became inflamed and resolved. DPCP appears to be a valuable, safe, and well-tolerated treatment for resistant and chronic facial warts.     

Risk factors for genital and anal warts in a prospective cohort of HIV-negative homosexual men: the HIM study

OBJECTIVE: The objective of this study was to determine the prevalence, incidence, and risk factors for genital and anal warts in HIV-negative homosexual men in Sydney. STUDY DESIGN: The authors conducted a prospective cohort study. Participants were asked whether they had had genital and anal warts at each interview. Details of lifetime sexual contacts and sexual behaviors in the last 6 months were collected. RESULTS: Among 1,427 men recruited, 8.9% and 19.6% reported a history of genital and anal warts at baseline, respectively. Incidence rates for genital and anal warts were 0.94 and 1.92 per 100 person-years, respectively. In multivariate analysis, both incident genital and anal warts were associated with younger age. In addition, incident genital warts was associated with insertive fingering (P trend = 0.018), whereas incident anal warts was associated with insertive fingering (P trend = 0.007) and insertive fisting (P trend = 0.039). CONCLUSIONS: Anal warts were twice as common as genital warts. Fingering and other manual sexual practices may be an important transmission route for both.     

Treatment of recalcitrant plantar warts with imiquimod

Myrmecia are viral warts that result from the coalescence of plantar or palmar warts into large plaques. Treatment of these warts involves physical or chemical destruction of the verrucae, potent keratolytics or immunotherapy. Imiquimod 5% cream is a novel topical immunomodulator that has been used successfully in the treatment of genital and common warts. We report its successful use in a 35-year-old immunocompetent man who had had resistant plantar warts for 15 years.     

Common Association of HPV 2 with Anogenital Warts in Prepubertal Children

Abstract: Anogenital (AG) warts in 31 prepubertal children were HPV typed by nonisotopic in situ hybridization (NISH) using digoxigenin labeled probes for human papilloma virus (HPV) types 1–5, 6,11,16,18, 31, and 33. Mode of transmission was determined from historical, clinical, and laboratory data independent of HPV typing. HPV 2 was detected most commonly (13/31 warts) followed by HPV 6 (7/31), HPV 11 (5/31), and HPV 16 (1/31). Although not reaching statistical significance, our results suggested that a mucosal HPV type (6,11,16) in a child's AG warts implied transmission from mucosal warts and conversely cutaneous HPV 2 transmission from warts at a cutaneous site. HPV typing provided no helpful information regarding actual mode of transmission of AG warts In these children. The high prevalence of HPV 2 in children's AG warts and the low prevalence of sexual abuse (2 of 31 children) found in this study suggest innocent auto- or heteroinoculation from cutaneous warts may be a common means by which children acquire AG warts.     

Local hyperthermia cleared multifarious viral warts in a patient with Cushing's syndrome

A female Cushing's syndrome patient had been suffering from extensive viral warts for months. She was diagnosed with flat warts, common warts and plantar warts. The plantar warts on her right foot were initially treated using local hyperthermia at 44°C for 30 min according to a defined protocol, followed by treatment targeting a common wart on her left thumb. In response to hyperthermia, the flat warts on her eyelid dissipated within 12 weeks, and when combined with a 1 week administration of imiquimod, the common warts and plantar warts completely disappeared within 8 weeks. There were no signs of recurrence and during this treatment her Cushing's syndrome was alleviated. This pioneer trial suggests that local hyperthermia may serve as an effective mean for treating multiple cutaneous warts under the conditions of a systemic immuno‐compromised disease.     

Severe intractable common warts associated with human papillomavirus 2, 3 and 20

A 26-year-old male had had numerous common warts on the feet and hands since childhood. They had repeatedly undergone etretinate cryosurgery, always responding well to it. However, the warts reappeared. Human papillomavirus (HPV) 2, 3 and 20 were detected in the warts using Southern's blot hybridization technique with HPV DNA. Histologically, the warts showed swollen, clear keratinocytes with vacuolated degeneration not found in common warts. The findings are presented in this paper.     

Bleomycin in the treatment of recalcitrant warts

Bleomycin is gaining increasing popularity in the treatment of warts, but its efficacy has not been examined in well-controlled studies. We evaluated bleomycin in a double-blind placebo-controlled crossover study in recalcitrant warts treated unsuccessfully by conventional methods. Patients were assigned alternately to placebo or bleomycin groups and treated by intralesional injections of bleomycin, 1 U/ml, or saline, at 2-week intervals. If warts persisted, patients were changed after two injections to the alternate group and retreated with up to two further injections. Forty patients entered the study. Of 151 warts treated with intralesional bleomycin, 123 were cured after one or two injections (81%). The cure rate for plantar warts (60%) was lower than that for periungual warts (94%) and warts elsewhere on the extremities (95%). Fifty-five warts were injected with normal saline; none was cured. Responding warts showed a hemorrhagic eschar and healed without scarring, atrophy, or pigmentary change. Pain was usually mild and patient acceptance superior to that with liquid nitrogen. There was no evidence of systemic toxicity. Bleomycin is highly efficacious in the treatment of recalcitrant warts, is convenient, and has high patient acceptance. Long-term safety requires further study.     

Regression of plantar warts following treatment with diphencyprone

Therapy-resistant plantar warts of 8 patients have been topically treated with diphencyprone, a new potent contact allergen. Three of the patients showed only one single aggregation of warts, which completely disappeared within two or three months after start of treatment. In the other five patients who had multilocular warts, a controlled trial was performed. In three of these patients only the treated warts resolved whereas the untreated ones persisted. In one case all warts disappeared already during the period of sensitization, and in the fifth patient the warts persisted without any change.     

Risk factors for cutaneous wart onset in transplant recipients

INTRODUCTION: Transplant recipients are at increased risk for cutaneous warts. We have investigated the delay of their onset warts and some possible risk factors for their occurrence. PATIENTS AND METHODS: Clinical data were summarized on a standard question and examination sheet. Warts were diagnosed on clinical grounds and course duration assessed on patients' report. Immunosuppressive therapy and HLA group were collected from clinical transplantation records. An actuarial curve was used to evaluate the delay of onset of warts. To compare associated risk factors among the two groups (patients with warts and patients without warts) at 1 year and 3 years following transplant, single variate analysis was performed. RESULTS: At the time of transplant, the prevalence of warts was 16 p. 100. It was increased with the duration of immunosuppression: 23 p. 100 at 1 year, 35 p. 100 at 3 years, 45 p. 100 at 5 years and 54 p. 100 at 7 years. Warts were multiple and principally localized on the hands. Transplant recipients without cutaneous warts 3 years after transplant had less intensive immunosuppressive therapy than the group with cutaneous warts. No association was found between age, sex, HLA markers, actinic keratosis and wart onset. DISCUSSION: The prevalence of warts increases with the duration of transplantation. Cutaneous warts are generally multiple and have a chronical course without spontaneous remission. More intensive immunosuppressive therapy increases their occurrence. This trial cannot evaluate the association between carcinoma and warts. On the basis of our study, there is no relationship between actinic keratosis and warts, nor HLA markers and warts.     

Morphological characteristics and human papillomavirus genotype predict the treatment response in cutaneous warts

Skin warts are highly prevalent in both children and adults. They are caused by a virus called ‘human papilloma virus’ (HPV). Only around half of skin warts disappear after treatment. This study was performed to predict the type of HPV in warts and more importantly, to predict which warts are likely to disappear after treatment. Therefore, features both of patients and their warts were studied. A new standard tool for warts (the CWARTS diagnostic tool) was used to score the appearance of the wart and 23 different virus types were tested. The treatments that were used were monochloroacetic acid, cryotherapy or a combination of cryotherapy and salicylic acid. In total, 311 warts of 159 patients were studied. Black dots in a wart suggested presence of HPV. If warts contained HPV2, HPV27 or HPV57 they responded less often to most treatments. However this did not apply to warts located on the hands or body if they were treated with cryotherapy. Warts that show callus or are deeper located on the skin were less responsive to cryotherapy. To summarize, the appearance of warts and the type of HPV they contain influence the chance of healing. Therefore, in the future it might be important for medics to take this into account when choosing a treatment option for common and plantar warts.     

扁平疣和寻常疣的治疗

扁平疣、寻常疣是由人乳头瘤病毒感染所致.目前扁平疣和寻常疣尚无统一的治疗方法,本文从循证医学角度对皮肤扁平疣和寻常疣治疗的新进展进行了综述.     

Immunotherapy for recalcitrant warts in children using intralesional mumps or Candida antigens

Intralesional injection of mumps and Candida skin test antigens has been shown to be effective in the treatment of warts. Warts are generally difficult to treat in children. To determine the efficacy of intralesional skin test antigen injection for the treatment of resistant warts in children, we treated 47 pediatric patients with one or more warts with intralesional injection of mumps or Candida skin test antigen into one wart. Twenty-two patients (47%) with resistant warts experienced complete resolution of treated warts. An average of 3.78 treatments were necessary. An additional 34% of children had a greater than 25% improvement in their warts. Sixty-eight percent of subjects with more than one wart also noted at least partial resolution (greater than 25% resolution) of untreated warts at distant sites, with 34% experiencing complete resolution. We concluded that intralesional injection of skin test antigens is an effective therapy for children who have recalcitrant, nongenital, cutaneous warts.     

The treatment of common warts with infrared coagulation

Treatment of warts can involve medical and surgical methods. Infrared coagulation is a surgical method very rarely used in the treatment of warts. We planned an open-labeled prospective study to research the effect of infrared coagulation in the treatment of common warts, comparing it with electrocoagulation, and discussing its applicability as an alternative therapy regimen. Eighteen patients with common warts were included in this study. There were 49 warts of various sizes (1 mm to 1 cm) in these 18 patients. Twenty-seven warts were treated with infrared coagulation, and 22 warts were treated with electrocoagulation. Sixteen patients were treated with both infrared coagulation and electrocoagulation; two patients were treated with only infrared coagulation. The patients were followed-up for six months after treatment. Changes in sizes of warts, healing times, and cure rates were compared by Mann-Whitney U test. The mean healing time was 35.5 +/- 5.7 days with infrared coagulation and 32.9 +/- 4.0 days with electrocoagulation. There was not any significant difference between healing times (p > 0.05). Bacterial infection was seen on seven (31.8%) warts treated with electrocoagulation, but no side effects were seen with infrared coagulation. There was a significant difference between side effect rates in two groups (p < 0.01). Nine (33.3%) of the warts treated with infrared coagulation and seven (31.8%) of the warts treated with electrocoagulation recurred in the six-month follow-up period. The overall cure rates at the end of the follow-up period were 66.7% and 68.2% respectively. There was not any significant difference between the cure rates in the two groups (P > 0.05). We conclude that infrared coagulation is a safe and cheap method and should be kept in mind as an alternative modality for the treatment of common warts.     

Warts in primary schoolchildren: prevalence and relation with environmental factors

Background  Warts are very common in primary schoolchildren. However, knowledge on wart epidemiology and causes of wart transmission is scarce.
Objectives  To determine the prevalence of warts in primary schoolchildren and to examine the relation with environmental factors in order to provide direction for well-founded recommendations on wart prevention.
Methods  In this cross-sectional study, the hands and feet of 1465 children aged 4–12 years from four Dutch primary schools were examined for the presence of warts. In addition, the children's parents completed a questionnaire about possible environmental risk factors for warts.
Results  Thirty-three per cent of primary schoolchildren had warts (participation rate 96%). Nine per cent had hand warts, 20% had plantar warts and 4% had both hand and plantar warts. Parental questionnaires (response rate 76%) showed that environmental factors connected to barefoot activities, public showers or swimming pool visits were not related to the presence of warts. An increased risk of the presence of warts was found in children with a family member with warts [odds ratio (OR) 1·9, 95% confidence interval (CI) 1·3–2·6] and in children where there was a high prevalence of warts in the school class (OR per 10% increase in wart prevalence in school class 1·6, 95% CI 1·5–1·8).
Conclusions  One-third of primary schoolchildren have warts. This study does not find support for generally accepted wart prevention recommendations, such as wearing protective footwear in communal showers and swimming pool changing areas. Rather, recommendations should focus on ways to limit the transmission of wart viruses within families and school classes.     

Clinical features and outcome of first presentation anogenital warts in men and women

Objective Correlation of clinical features of patients on initial presentation of anogenital warts to outcome of treatment. Setting Outpatient genitourinary medicine clinic. Method Retrospective cohort analysis. Subjects Eighty-three male and 60 female patients attending the clinic with first episode anogenital warts within a 3-month period. Main outcome measures Relapse of warts following treatment. Total time for which treatment was given. Results Following one course of treatment, warts relapsed in 15% of the men, hut in only 37% of the women. After two courses, further relapse occurred in 31% of males and 18% of females (P < 0.001). Treatment for more than 6 months was required for 39% of men, but only 22% of women. Poorer outcome of treatment was related to larger size of warts at presentation. No significant relation was found between outcome and number, site or type of treatment used for warts, or for sexual behaviour or orientation of patients. A previously diagnosed sexually transmitted disease (STD) was reported by 34% of men and 28% of women: 28% of men and 23% of women had an STD diagnosed at the time of presentation with warts. No significant relation was found between outcome and STDs past or concurrent, including HIV. Female patients tended to have smaller warts than men but their better outcome remained significant after controlling for the size of warts. Conclusions Treatment outcome for genital warts is poor and significantly predicted by size of warts at presentation. Female patients have a better outcome from treatment of genital warts than male patients.     

A comparative study on peripheral blood lymphocyte subpopulations in different kinds of warts

Peripheral blood T-cell subpopulations were evaluated in 36 patients with clinically different types of warts, subdivided in 4 groups (common, genital, flat and plantar warts). A significant decrease was found in OKT3 and OKT4 subsets total count and in OKT4/OKT8 ratio in patients with common and genital warts as compared with controls. Only in common and genital warts did we also observe a significant decrease of percentage of OKT4 subset. No significant difference of considered parameters was observed in flat and plantar warts as compared to controls, apart from a significant increase in number of OKT8 subset in flat warts. We then discuss this different status of C.M.I. in patients with different clinical warts, stressing the importance of various types of HPV.