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Emergency and Acute Medicine: Warts
Warts are benign proliferative lesions of the skin and mucous membranes caused by infection with the Human papillomavirus. The virus infects the basal layer of epithelial tissue, leading to cellular proliferation and increased vascularity, which gives rise to the characteristic verrucous, hyperkeratotic appearance. Warts are extremely common, particularly in children and adolescents, and most resolve spontaneously due to a cell-mediated immune response—about one-third within 6 months, two-thirds within 2 years, and up to 90% within 5 years.
There are several clinical types of warts depending on location and HPV subtype. Verruca vulgaris (common warts) typically occur on the dorsum of the hands, fingers, and around nails and are usually asymptomatic. Verrucae plantaris (plantar warts) occur on weight-bearing areas of the feet such as the heels and metatarsal heads and are often painful due to pressure. Flat (juvenile) warts appear as small, smooth, flesh-colored lesions on sun-exposed areas such as the face, neck, and extremities and may spread with shaving. Anogenital warts, also known as condyloma acuminata, are sexually transmitted and commonly caused by HPV types 6 and 11, while types 16 and 18 are associated with cervical cancer. These lesions are often soft, multiple, and have a cauliflower-like appearance.
Transmission of HPV occurs through direct skin-to-skin contact, indirect contact via contaminated surfaces, or autoinoculation, especially in children who scratch or bite affected areas. The incubation period is variable, ranging from weeks to over a year. In pediatric cases, warts are common, but the presence of anogenital warts should raise concern for possible sexual abuse, particularly in younger children.
Diagnosis is primarily clinical, based on the characteristic appearance of lesions. Common and plantar warts disrupt normal skin lines and may show pinpoint bleeding when scraped. Flat warts are smooth and subtle, while anogenital warts are soft and pedunculated. Laboratory testing is generally unnecessary, although application of acetic acid can help highlight lesions by causing whitening. Biopsy is reserved for atypical, persistent, or suspicious lesions, especially in immunocompromised patients.
Management depends on the type, location, and patient preference. Many warts require no treatment, especially in children, due to high rates of spontaneous resolution. For cutaneous warts, first-line therapy includes topical salicylic acid, typically 17% over-the-counter or up to 70% prescription strength, applied after soaking the wart for 10–20 minutes, left on overnight, and followed by gentle debridement. Treatment is repeated regularly and may take weeks to months. Another simple method is duct tape occlusion therapy, which may be particularly useful in children.
For anogenital warts, treatment options include patient-applied therapies such as Imiquimod (5% cream applied three times per week for up to 16 weeks) and Podofilox (0.5% solution or gel applied twice daily for 3 days followed by 4 days off, repeated up to 4 cycles). Provider-administered treatments include podophyllin (10–25% weekly application), trichloroacetic acid (80–90% weekly for 6–10 weeks), and cryotherapy with liquid nitrogen every 1–2 weeks. These treatments require caution, especially in pregnancy or when applied to sensitive mucosal areas.
Preventive strategies include vaccination with Gardasil, which protects against HPV types 6, 11, 16, and 18 and is given as a 3-dose series over 6 months. This vaccine significantly reduces the risk of genital warts and HPV-related cancers. Another vaccine, Cervarix, targets oncogenic strains associated with cervical cancer.
Most patients can be managed as outpatients, but referral to dermatology or gynecology is appropriate for treatment-resistant cases, atypical lesions, or anogenital involvement. Follow-up is important to ensure treatment response and monitor for recurrence. Patients should be advised to return if lesions change, become painful, or fail to improve.
A key clinical pearl is that HPV vaccines do not protect against all HPV types, and patients may still develop warts despite vaccination. Additionally, clinicians should always consider the broader clinical context, including the possibility of immunosuppression or, in pediatric cases with anogenital lesions, safeguarding concerns.
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