Warts

Warts are lesions or bumps on the skin and the thin skin that covers the inside surfaces of parts of the body, such as the nose and mouth. Warts have a long incubation period, generally ranging from 1 to 6 months, but it can take up to 12 months. These lesions appear as skin growths with an irregular surface, and their size can range from 1 mm to several cm. The general signs and symptoms of warts include:

• The presence of small and rough bumps on the skin
• Appearance of long threads or thin fingers on the skin
• The presence of black dots that resemble seeds
• Mild bleeding from bumps
• Itching
• Tightness or a feeling of pressure

The lesions can appear alone (solitary) or in groups (mosaic). The most common sites for these warts are hands and feet; however, they can occur in other body parts depending on the type. The characteristics of these lesions depend upon the type of warts and include:

1. Common warts (verruca vulgaris)
   • Dome-shaped nodules
   • Mainly located on fingers, hands, knees, elbows, or any other sites of trauma
   • Can also appear as thin and long outgrowths around the eyelids and lips
2. Genital warts
   • Small bumps in and around the genital area
   • Cause burning sensation and itching or irritation in the genital area
3. Foot warts (plantar warts)
   • Deep penetrating bumps on the soles of the feet
   • Cause pain and difficulty while walking
   • Create a feeling of having something in the shoes
4. Anal warts
   • Tiny spots or growths around and inside the anus
   • Additional symptoms include itching, bleeding, mucus discharge, and a feeling of a lump in the anal area
5. Flat warts
   • Flat-topped nodules with only a slight elevation
   • Can grow anywhere
6. Filiform warts
   • Long threads or thin finger-like projections that stick out
   • Usually grow on the face, around the mouth, eyes, and nose
   • Grow very quickly
7. Butcher's warts
   • Cauliflower-like appearance
   • Commonly affect the knees and hands
   • Primarily seen in individuals who handle raw meats
8. Focal epithelial hyperplasia
   • Soft, smooth, flat-topped lesions in the oral mucosa
   • Often present in multiple lesions of less than 1 cm in diameter
9. Cystic warts
   • Generally smooth bumps
   • Appear on the weight-bearing surfaces of the body

Warts are caused by Human Papillomavirus (HPV). Although HPV has over 100 subtypes, only a few are responsible for skin warts.

Warts can be transmitted easily through direct or indirect contact. The transmission of the virus occurs rapidly through disrupted and soft skin. The modes of transmission include:

• Touching the skin of an infected person
• Engaging in unprotected sexual intercourse
• Touching contaminated objects such as towels and razors
• Using communal bathrooms and swimming pools
• Sharing sex toys

What happens after the exposure?

Once HPV has infected the skin, it spreads to other areas through scratching, shaving, or injuries. The virus can enter the skin and multiply in its uppermost layer, causing the outer layer of the skin to thicken and protrude as a wart.

A few subtypes of HPV have the potential to induce cancer. These strains include types 6, 11, 16, 18, 31, and 35. Individuals who are immunocompromised are at a higher risk of warts transforming into cancer.

People in close contact with someone with warts are likely to develop warts. The other possible risk factors include:

• Weakened immune system: Individuals with low immunity cannot effectively fight the virus, making them more susceptible to viral infections, including warts. This includes people who have undergone organ transplantation or have medical conditions such as cancer or HIV infection. Boost your immunity. Check out our extensive range of immunity boosters.
• Age: Children and teenagers are at high risk of developing warts. The incidence of warts peaks between the ages of 12 and 16.
• Race: White individuals are more likely to develop warts compared to Blacks or Asians. Focal epithelial hyperplasia is more commonly observed in Inuit and American Indians.
• Medical conditions: Several skin diseases, such as eczema and dermatitis, increase the risk of warts.
• Occupation: Frequent meat handlers are more exposed to HPV infection and, thus, more likely to develop warts. Additionally, people who bite their nails or pick at hangnails also have an increased chance of developing warts.
• Unprotected sexual intercourse: Engaging in unprotected oral, anal, or vaginal sex with an infected partner increases the risk of genital warts.
• Smoking: Some studies suggest that smoking is associated with an increased risk of contracting genital warts. Want to quit smoking? Try our wide range of tobacco cessation products.

The diagnosis of warts includes:

• Clinical examination: Each type of wart has characteristic features and locations. Almost all cases of warts are diagnosed through physical examination by a trained clinician.
• Dermoscopy: This refers to the examination of the skin using a high-quality magnifying lens and a powerful lighting system (a dermatoscope). It reveals abnormalities of the skin.
• Immunohistochemical (IHC) detection: This method uses antibodies to detect the location of proteins and other antigens in a sample of skin tissue, confirming the presence of the virus in a lesion.
• Southern blot hybridization: This technique is used to identify the specific HPV type present in tissue and has higher sensitivity than IHC.
• Polymerase chain reaction: This is another confirmatory method to detect the virus present in a lesion, where the genetic material of the virus is amplified.
• Biopsy: In cases of suspected cancer, a sample of skin tissue is taken for biopsy.

It is not possible to completely prevent warts as the virus is highly contagious. However, the following measures can minimize the chances of infection to some extent.

1. Vaccinate yourself
   HPV vaccines protect against anal and genital warts to a greater extent. All individuals ages 9 to 45 can receive the HPV vaccine to protect against genital warts and various types of cancer-causing HPV. Optimal protection starts early; therefore, it is advisable to get the HPV vaccine sooner rather than later.
   What is the schedule?
   A 2-dose schedule is recommended for individuals who receive the first dose before their 15th birthday. In a 2-dose series, the second dose should be given 6–12 months after the first dose (0, 6–12-month schedule). A 3-dose schedule is recommended for individuals who receive the first dose on or after their 15th birthday and those with certain immunocompromising conditions.
2. Ensure foot care
   Plantar warts can be prevented by maintaining a good foot hygiene routine. The following measures can help you achieve this:
   
   • Wash your feet daily with soap and water.
   • Dry them thoroughly, especially between the toes.
   • Wear clean, dry, moisture-wicking socks and change them regularly.
   • Prefer open footwear like floaters that allow the skin to breathe.
   • Regularly rotate shoes to air them out.
   • Use shower sandals on wet locker room floors and in public showers.
   • Avoid used instruments such as pumice stones or nail files.
3. Take proper care of wounds
   Wounds are the leading cause of infection. Proper care of wounds and injuries can help prevent viral infections. The following measures should be taken to keep wounds away from the virus:
   
   • Wash hands with soap and water more frequently.
   • Use an alcohol-based hand rub if washing is not possible.
   • Keep draining or open wounds clean.
   • Cover wounds and injuries with dressings until they heal.
   • Avoid hot tubs, swimming pools, and other water bodies such as lakes, rivers, and oceans until the wound heals completely.
4. Maintain hand hygiene
   Washing your hands more often is always advisable, especially after coughing and sneezing. Hand hygiene should also be maintained before preparing food and during eating.
5. Keep the skin moisturized
   HPV quickly infects dry and cracked skin, increasing the chances of warts. It is advisable to apply moisturizer within 5 minutes of bathing or whenever the skin feels dry.
6. Maintain skin barrier
   The skin barrier should be maintained through timely management of skin conditions such as atopic dermatitis and eczema. Any allergen or irritant to the skin should be avoided.
7. Avoid nail biting and cuticle chewing
   Excessive nail and cuticle biting causes sores and tears in the skin, which makes it easier for HPV to enter. Avoiding this habit minimizes the risk of warts.
8. Get treated for excessive sweating
   Excessive sweating increases the chances of developing warts as the virus thrives in damp skin. Managing and treating this condition can help prevent warts.
9. Go for regular skin examination
   Individuals with diabetes or obesity should undergo regular skin screening. Early management can help prevent infection. Diabetics should also check their feet daily for signs of injury or infection.

No treatment for warts can permanently cure the condition. Recurrences are very common. Various treatment options include:

1. Topical agents
   • Salicylic acid is the first-line agent for most common warts.
   • Tretinoin is used in treating flat warts.
   • Dibutyl squaric acid, also known as squaric acid dibutyl ester (SADBE), and diphenylcyclopropenone (DCP) are contact sensitizers that activate the immune system, providing symptomatic relief.
   • Imiquimod targets the body's immune system and helps fight viruses. It is available in gel form and effectively manages genital and common warts.
   • 5-Fluorouracil is an anticancer medication that has been reported to be effective in treating warts.
   • Cidofovir, an antiviral agent, has proven beneficial for unresponsive warts.
2. Intralesional injections
   • Skin test antigen involves injecting a viral and fungal extract that acts as an antigen, stimulating the immune system to produce antibodies that eradicate the virus.
   • Bleomycin, an anticancer agent, is used to inhibit the growth of the wart virus.
   • Interferon-alfa is an immunomodulator with antiviral, antibacterial, and anticancer properties. It is used in warts that do not respond to standard treatments.
3. In-clinic treatments
   • Cantharidin is a fatty substance secreted by the beetle that removes the outer layer of skin containing warts.
   • Trichloroacetic acid causes immediate death of the superficial tissue.
   • Cryosurgery involves the application of liquid nitrogen using a cotton bud applicator around the wart. The procedure is repeated every 1-4 weeks for approximately three months.
   • Curettage involves scraping off the wart using a knife.
   • Excision involves cutting out the wart.
   • Photodynamic therapy uses light and photosensitizing agents to treat warts. The procedure involves injecting the agent and exposing it to light for a specific duration, which kills the cells containing warts.
   • Laser treatment directs laser light towards the affected area and is usually used for large and severe warts.

Some home remedies for warts can be tried. However, it is essential to consult your healthcare provider before initiating any of these:

1. Garlic (Lehsun): Garlic is used to treat several skin conditions. Its antimicrobial properties also help treat warts.
   How to use it? A garlic extract can be prepared by crushing a clove and mixing it with water. It must be applied daily for three to four weeks.
2. Orange peel: Orange peels are known to remove warts.
   How to use it? Rubbing an orange peel on the wart daily helps it fall off.
3. Pineapple: The active ingredient bromelain helps remove dead and damaged cells, including warts.
   How to use it? Pineapple juice can be applied to the warts.
4. Honey (Sehad): It is a potent antibacterial and antiviral agent.
   How to use it? Apply a small quantity of honey over the wart and let it sit for 15-20 minutes.
5. Green Papaya: Papaya contains an enzyme that helps peel away dead skin and remove warts.
   How to use it? Cut a green papaya in half and collect the white sap that runs out from the skin. Mix that with a teaspoonful of the papaya pulp mash and water to make a smooth paste. Apply this paste to the warts twice daily and leave it on for 15-20 minutes. This mixture helps graze the dead tissue and gradually makes the wart disappear.
6. Aloe vera: It has numerous skin benefits, including wart removal. It acts as a natural antioxidant and anti-infective.
   How to use it? Apply the Aloe vera gel to the warts and let it stay for 30-45 minutes before washing it off.
7. Apple cider vinegar: It can help peel off the affected skin, removing the warts.
   How to use it? A cotton ball dipped in diluted apple cider vinegar can be used to apply it to the wart.

Approximately two-thirds of warts resolve on their own over several years. However, some warts can lead to scarring as a result of topical treatment.

Certain strains of HPV have been associated with the development of:

• Cervical cancer
• Vulvar cancer
• Anal cancer
• Rarely, cancer of the penis

This is usually seen in genital warts. Occasionally, the occurrence of warts on the vaginal wall may pose a challenge to the vaginal elasticity required for childbirth. In these instances, a cesarean delivery may be advised.

Some alternative therapies might be effective in treating warts. Do consult your doctor before initiating any of these:

• Podophyllin resin: This extract is derived from the roots of the May apple plant. The topical application of this extract is known to treat genital and plantar warts. It works by inhibiting the growth and multiplication of viruses. Podofilox is another less irritating form of podophyllin available in the market.
• Duct tape therapy: In this method, duct tape is applied to the wart, creating an environment that aids in the detachment of warts.
• Hypnosis: This technique involves controlling the brain through various activities and is used to treat unresponsive warts. Hypnosis can be induced through methods such as the application of an imaginary freezing agent to the wart. The success rate is reported to be between 27-55% in children.
• Hyperthermia: This treatment involves immersing the affected area in hot water for 30-45 minutes, performed 2-3 times per week.

Living with warts can be bothersome due to their chronic nature. It is essential to understand that most warts resolve on their own. The following measures help in faster recovery and reduce transmission.

Measures for Recovery

• Keep the warts covered: Keeping warts covered helps prevent the transmission of warts to other body parts and other people.
• Wash your hands after touching the wart: Maintaining good personal hygiene is crucial. Every time you handle a wart, whether for dressing or any other reason, wash your hands thoroughly.
• Avoid shaving over a wart: Shaving over a wart can create microtears, increasing the spread of warts. Refrain from shaving over a wart to better manage and prevent its spread.

Preventing Transmission

The virus of warts spreads rapidly from one person to another. Significant complications can develop due to the intra-transfer of the virus from one body part to another. These transmissions can be minimized through a more conscious approach. The following measures may help prevent transmission:

• Avoid touching the wart.
• Use a waterproof plaster to cover the warts while swimming.
• Avoid sharing towels, shoes, gloves, and socks.
• Wash your hands frequently, especially after touching the wart.
• Avoid scratching or picking at warts.
• Wear flip-flops or pool shoes in public showers, locker rooms, and pool areas.