You may not catch a prince by kissing a toad, but you also won't get warts! Despite this classic misconception laying blame upon the lowly toad for causing warts, they are strictly a viral infection that afflicts us humans.

Warts are the result of a viral infection (human papilloma virus) of the skin that cause unsightly, sometimes painful growths. Warts can be flat or raised, soft or crusty.

The warts most people think of are hard and crusty and can be located on most any body surface. Most of the time they will be raised, especially as they age. The misconception that warts have "seeds" stems from the appearance of pinpoint black flecks within a wart. These are actually the blood vessels that feed the wart viewed head on. Think of looking at the end of a pipe, and this is how you are visualizing the blood vessel. The black color is due to small clots within the vessel. Warts DO NOT have roots! I don't know how that idea arose, but it seems to be a common misconception. Warts never grow deeper than the thickeness of the epidermis.

Warts are an infection. I think that a major reason they infect certain individuals and not every one is that certain people's immune systems simply don't recognize the existence of the wart on the surface of the skin. This doesn't mean that the person has a major immune deficiency, it simply means that certain families have genetic predispositions to this. Think of people who always have sinus infections or strep throat or fungal infections. This is the same thing. I do know that families with atopic dermatitis as well as red haired individuals seem to be more predisposed to chronic reinfections with warts. Women who are pregnant naturally have a reduced immune system and often pick up warts more easily and typically have a more difficult time getting rid of them during the time of the pregnancy.

Warts are technically categorized by families. There are individual wart groups within a family, and typically this shouldn't make any difference unless you're a researcher. There is no clinical way to identify which group of wart you're looking at, only the general family category. And it honestly doesn't matter when it comes to clinical practice when dealing with garden variety warts.

Here are a few of the groups of warts within this most common family:

Plantar Warts

Plantar warts are a form of wart everyone has heard of. However, what most people don't realize is that they are no different from any other wart in that family. It's simply that they are on the "Plantar" surface (bottom) of the foot. Nor do they have roots that grow up into the foot. They just seem deeper because the skin on the bottom of the foot is thicker.

Periungual Warts

Periungual warts are a terribly difficult form of wart that affects the skin surrounding the nail. The wart virus can get under the skin fold, or even the nail plate and sometimes the nail will become deformed. If caught early enough before damage can occur to the area of the nail fold where the actual nail is made, it usually resolves with time. I have also seen several patients develop yeast or fungal infections of the involved nail due to breaks in the nail created by the upward motion of the wart's growth. Periungual warts often make for prolonged treatment.

Flat Warts

Flat warts are tiny, smooth warts, often only a few millimeters in diameter. Many people are familiar with them on areas that get shaved through, such as the beard area and legs. Although I happen to like treating these very gently with liquid nitrogen, I have found that topical Retin A or a chemotherapy cream called Efudex can help in stubborn cases. Retin A type medications should only be applied once a day. Efudex may be prescribed once or twice daily depending upon what your doctor feels appropriate for your situation. Whatever you use, make certain to keep them away from the eyes (do NOT apply any of these to warts on the eyelids) and pay attention to what your skin is telling you. Back off or stop their use altogether if too much irritation develops or you see sores. Too much of a good thing here is not a good thing.

Molluscum

Molluscum, also known as soft warts, are a different family of warts. They are very common in children, often spreading to adults. Molluscum are highly contagious. These lesions are usually flesh colored or almost clear and often have a central depression like a belly button. Growths are usually rather small, just a few millimeters in size. There are several ways to treat these warts ranging from liquid nitrogen to physically removing by curettage. These treatments are done in the dermatologist's office. Currettage is a simple method and relatively painless (I didn't say pain free). The doctor utilizes an instrument that resembles a bobby pin and literally pops them out of the skin. Molluscum are self contained, so that they come off basically in 1 piece, sort of like scooping them out of a shell. They may ooze and Drysol is often applied to the base to help stop the small amount of bleeding.

In cases where children won't cooperate with treatment, medications such as podophyllin can be applied to the lesions in the doctor's office to kill the lesion. Routine OTC wart medications won't help these warts.

Due to molluscum's high rate of contagion, do not share towels within the family, this is a great way to spread them throughout the household. Also, you will likely continue seeing new molluscum form for up to 6 months after they are intially treated. This is the time frame it takes for the invisibly infected skin cells to form these new lesions that were not apparent. Keep up with them a few at a time. It is much easier and less traumatizing this way to your children. It also helps cut down on the risk of infecting other areas of the skin.

Genital warts are another family of wart, which I will address in a separate article.

Wart, Wart, Go Away...

There are hundreds of old wive's tales about eradicating warts. One of my favorites is the idea of rubbing the wart with a raw piece of potato, and then burying it at night under a full moon on the east side of the house! This continues to be a great story, but so far has never gotten rid of a wart! When you really want serious treatment, consider these facts.

The treatment of routine warts for the most part still involves physical or chemical destruction. There are no topical antiviral agents that kill the wart on contact, nor are there any oral medications to give a patient the way antibiotics are used. One thing is constant, they are contagious and should be treated before you develop further lesions. One of my pet peeves is the patient who presents with 20, 30, 40 or more warts because their primary care physician told them treatment was unnecessary ("they go away on their own, you know"). Although this occasionally may be true, it's much far more likely they increase in number.

Liquid nitrogen sprayed onto the wart (or applied with a cotton swab), is still one of the most effective and easiest of wart therapies. It usually takes 3 treatments to kill the average wart. For warts that are huge it could take much longer. I usually do a treatment every 2 weeks. This allows the treated area to heal for the next round. An area treated with liquid nitrogen is usually pink and puffy for a day or so, and the discomfort is typically minimal. However, Liquid nitrogen can cause a blister, blood blister or a superficial sore as it is basically controlled frostbite.

Compound W Freeze Off Wart Removal System is a home version cryotherapy spray for the treatment of warts. Follow directions carefully. The wart is literally frozen to minus 55 degrees Celsius! Like physician applied cryotherapy, the wart may blister, often scabs up and falls off in about 2 weeks. Be careful, though. The goal is success eradication, not a cold-induced injury.

Following liquid nitrogen treatment, I also often have patients use an OTC wart medication on a non-blistered site, as this helps denude some of the infected tissue. It's important not to apply the these medications to an open wound; and if you're trying home cryotherapy, skip this step altogether until the area has healed from the freezing.

My favorites contain 17% salicylic acid as the active ingredient. Occlusal-HP and Duofilm fall into this category. Wart medications are now over the counter, they were originally available by prescription only. The best way for these medications to be effective is to make sure the area is moist, and then lightly rough up the surface with either a pumice stone such as Tweezerman Callus Stone, an emery board, or even a piece of fine-grade sand paper. The viral particles will remain on your pumice stone or embry board, so don't use them elsewhere. A good way to deal with this would be to use a metal buffer such as Diamancel Diamond File for Foot Calluses #20 and disinfect it so you can use it elsewhere.

Remember, regardless of which instrument you select, you're just roughing up the surface to enhance absorption of the medication, not trying to rub off the wart. These OTC meds aren't to be used on the face or by diabetics unless under direction and supervision by a physician. Usually 2 coats of the medication are applied to the treated area. These medications will make the wart soft, white and moist over time as it's being treated.

Physical destruction with other methods such as electrodessication and curettage (ED&C) or by CO2 laser, have also been used on warts. Statistics have shown that ED&C for wart removal is about as effective as liquid nitrogen. It tends to be a somewhat messy procedure and there is more discomfort and healing time involved, so I tend to hold off on this therapy if at all possible. There's no question that destruction by CO2 laser which simply evaporates the wart tissue, or by Tunable Dye Laser, which kills the blood vessels that feed the wart are effective, cost can be an issue. Lasers are expensive to purchase, and medical insurance only pays for the category of "destruction of warts" regardless of how they were destroyed. This may not be enough to cover the laser costs by some practitioners. Be sure to inquire before therapy.

Periodically I have used an injectable chemotherapy agent, Bleomycin for recalitrant warts. This therapy is not appropriate for warts present on fingers or toes because it can potentially cause diminished blood flow to these areas. The injections can be rather painful, and is a costly therapy. Usually more than one treatment will be required. Bleomycin kills the blood vessels that support the wart's growth, and the lesion turns black within a day or two. For troublesome resistant warts this therapy has been helpful for my patients.

Topical application of a liquid known as DNCB is a non-FDA approved yet long time recognized method of treating various dermatologic conditions including recalicitrant warts. The chemical solution is initially applied to the forearm to elicit a reaction similar to poison ivy. DNCB was found to cause a contact dermatitis on all people who come in contact with it. The theory goes that if you stimulate the body to recognize the DNCB and then apply it to a recalcitrant wart, the body, (which is oblivious to the wart) will destroy the treated area, wart and all. This has proven a nice method when all else has failed on a wart.

Oral medications have long been rumored to help fight warts. I have tried stimulating patient's immune systems with oral vitamins C and A. To be honest, I have been unimpressed with this treatment for warts. An ulcer medication, Tagamet, in combination with another medication known as Levamisole, seems to have an effect on some warts. A report in the Australian Journal of Dermatology reports more than a 70% reduction in the size and/or number of warts with this therapy.

An Ounce Of Prevention

What can you do about warts? For one thing, I recommend that you protect your feet at pools and areas such as locker rooms by wearing foot wear. Public areas like these are common places to pick up the infection. It's much better to be proactive and prevent infection in the first place! Second, don't wait for lots of warts to develop or for your wart to be the size of a quarter before you seek medical attention. This will only make your treatment that much more difficult. Third, by all means if you know you have a "regular" wart, you can go ahead and start treating it with an OTC wart medication such as Occlusal-HP while you're waiting to see the dermatologist.

Thank you for taking the time to read my newsletter. I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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