- Author: Philip D Shenefelt, MD, MS; Chief Editor: William D James, MD more...
Warts are benign proliferations of skin and mucosa caused by the human papillomavirus (HPV). Currently, more than 100 types of HPV have been identified. Certain HPV types tend to infect skin at particular anatomic sites; however, warts of any HPV type may occur at any site. The primary clinical manifestations of HPV infection include common warts, genital warts, flat warts, and deep palmoplantar warts (myrmecia). Less common manifestations of HPV infection include focal epithelial hyperplasia (Heck disease), epidermodysplasia verruciformis, and plantar cysts. Warts are transmitted by direct or indirect contact, and predisposing factors include disruption to the normal epithelial barrier.
Treatment is difficult, with frequent failures and recurrences. Many warts, however, resolve spontaneously within a few years even without treatment.
A small number of high-risk HPV subtypes are associated with the development of malignancies, including types 6, 11, 16, 18, 31, and 35. Malignant transformation most commonly is seen in patients with genital warts and in immunocompromised patients. HPV types 5, 8, 20, and 47 have oncogenic potential in patients with epidermodysplasia verruciformis.
Warts can affect any area on the skin and mucous membranes. The HPV virus infects the epithelium, and systemic dissemination of the virus does not occur. Viral replication occurs in differentiated epithelial cells in the upper level of the epidermis; however, viral particles can be found in the basal layer.
Warts are widespread in the worldwide population. Although the frequency is unknown, warts are estimated to affect approximately 7-12% of the population. In school-aged children, the prevalence is 10-20%. An increased frequency also is seen among immunosuppressed patients and meat handlers.
Although warts may affect any race, common warts appear approximately twice as frequently in whites as in blacks or Asians. Focal epithelial hyperplasia (Heck disease) is more prevalent among American Indians and Inuit.
Male-to-female ratio approaches 1:1.
Warts can occur at any age. They are unusual in infancy and early childhood, increase in incidence among school-aged children, and peak at 12-16 years.
Cohen PR, Hebert AA, Adler-Storthz K. Focal epithelial hyperplasia: Heck disease. Pediatr Dermatol. 1993 Sep. 10(3):245-51. [Medline].
Mallory SB, Baugh LS, Parker RK. Warts in blacks versus whites. Pediatr Dermatol. 1991 Mar. 8(1):91. [Medline].
Silverberg NB. Human papillomavirus infections in children. Curr Opin Pediatr. 2004 Aug. 16(4):402-9. [Medline].
Holland TT, Weber CB, James WD. Tender periungual nodules. Myrmecia (deep palmoplantar warts). Arch Dermatol. 1992 Jan. 128(1):105-6, 108-9. [Medline].
Bellew SG, Quartarolo N, Janniger CK. Childhood warts: an update. Cutis. 2004 Jun. 73(6):379-84. [Medline].
Goldfarb MT, Gupta AK, Gupta MA, Sawchuk WS. Office therapy for human papillomavirus infection in nongenital sites. Dermatol Clin. 1991 Apr. 9(2):287-96. [Medline].
[Guideline] Sterling JC, Gibbs S, Haque Hussain SS, Mohd Mustapa MF, Handfield-Jones SE. British Association of Dermatologists' guidelines for the management of cutaneous warts 2014. Br J Dermatol. 2014 Oct. 171(4):696-712. [Medline].
Kwok CS, Gibbs S, Bennett C, Holland R, Abbott R. Topical treatments for cutaneous warts. Cochrane Database Syst Rev. 2012 Sep 12. 9:CD001781. [Medline].
Cockayne S, Hewitt C, Hicks K, et al. Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae): a randomised controlled trial. BMJ. 2011 Jun 7. 342:d3271. [Medline]. [Full Text].
Mizuki D, Kaneko T, Hanada K. Successful treatment of topical photodynamic therapy using 5-aminolevulinic acid for plane warts. Br J Dermatol. 2003 Nov. 149(5):1087-8. [Medline].
Perrett CM, Harwood C, Brown V. Topical 5% imiquimod treatment for refractory cutaneous warts. J Am Acad Dermatol. 2004. 50(3):P41.
Padilla España L, Del Boz J, Fernández-Morano T, Escudero-Santos I, Arenas-Villafranca J, de Troya M. Recalcitrant warts and topical cidofovir: predictive factors of good response. J Eur Acad Dermatol Venereol. 2015 Apr 10. [Medline].
Padilla España L, Del Boz J, Fernández Morano T, Arenas-Villafranca J, de Troya M. Successful treatment of periungual warts with topical cidofovir. Dermatol Ther. 2014 Nov-Dec. 27 (6):337-42. [Medline].
Cleary A, Watson R, McMahon CJ. Successful treatment of refractory cutaneous warts using topical 3% cidofovir in a child after heart transplant. J Heart Lung Transplant. 2014 Sep. 33 (9):971-2. [Medline].
Padilla España L, Del Boz J, Fernández Morano T, Arenas Villafranca J, de Troya Martín M. Topical cidofovir for plantar warts. Dermatol Ther. 2014 Mar-Apr. 27 (2):89-93. [Medline].
Gupta M, Bayliss SJ, Berk DR. Topical cidofovir for refractory verrucae in children. Pediatr Dermatol. 2013 Jan-Feb. 30 (1):131-4. [Medline].
Gladsjo JA, Alio Saenz AB, Bergman J, Krikorian G, Cunninghan BB. 5% 5-fluorouracil cream for treatment of verruca vulgaris in children. Pediat Dermatol. 2009. 26:279-285.
Horn TD, Johnson SM, Helm RM, Roberson PK. Intralesional immunotherapy of warts with mumps, Candida, and Trichophyton skin test antigens: a single-blinded, randomized, and controlled trial. Arch Dermatol. 2005 May. 141(5):589-94. [Medline].
James MP, Collier PM, Aherne W, et al. Histologic, pharmacologic, and immunocytochemical effects of injection of bleomycin into viral warts. J Am Acad Dermatol. 1993 Jun. 28(6):933-7. [Medline].
Munn SE, Higgins E, Marshall M, Clement M. A new method of intralesional bleomycin therapy in the treatment of recalcitrant warts. Br J Dermatol. 1996 Dec. 135(6):969-71. [Medline].
Ohtsuki A, Hasegawa T, Hirasawa Y, Tsuchihashi H, Ikeda S. Photodynamic therapy using light-emitting diodes for the treatment of viral warts. J Dermatol. 2009. 36:525-528.
Yilmaz E, Alpsoy E, Basaran E. Cimetidine therapy for warts: a placebo-controlled, double-blind study. J Am Acad Dermatol. 1996 Jun. 34(6):1005-7. [Medline].
Kottke MD, Parker SR. Intravenous cidofovir-induced resolution of disfiguring cutaneous human papillomavirus infection. J Am Acad Dermatol. 2006 Sep. 55(3):533-6. [Medline].
McAleer MA, Bourke J. Intravenous cidofovir for resistant cutaneous warts in a patient with psoriasis treated with monoclonal antibodies. Clin Exp Dermatol. 2011 Aug. 36 (6):638-40. [Medline].
Cusack C, Fitzgerald D, Clayton TM, Irvine AD. Successful treatment of florid cutaneous warts with intravenous cidofovir in an 11-year-old girl. Pediatr Dermatol. 2008 May-Jun. 25 (3):387-9. [Medline].
Potthoff A, Wieland U, Kreuter A. Failure of intravenous cidofovir for generalized verrucosis in a patient with severe combined immunodeficiency. Arch Dermatol. 2012 May. 148 (5):659-60. [Medline].
Focht DR 3rd, Spicer C, Fairchok MP. The efficacy of duct tape vs cryotherapy in the treatment of verruca vulgaris (the common wart). Arch Pediatr Adolesc Med. 2002 Oct. 156(10):971-4. [Medline].
Wenner R, Askari SK, Cham PM, Kedrowski DA, Liu A, Warshaw EM. Duct tape for the treatment of common warts in adults: a double-blind randomized controlled trial. Arch Dermatol. 2007 Mar. 143(3):309-13. [Medline].
Ewin DM. Hypnotherapy for warts (verruca vulgaris): 41 consecutive cases with 33 cures. Am J Clin Hypn. 1992 Jul. 35(1):1-10. [Medline].
Zedan H, Hofney ERM, Ismail SA. Propolis as an alternative treatment for cutaneous warts. Internat J Dermatol. 2009. 48:1246-1249.
Silverberg NB. Garlic cloves for verruca vulgaris. Pediatr Dermatol. 2002 Mar-Apr. 19(2):183. [Medline].
Millar BC, Moore JE. Successful topical treatment of hand warts in a paediatric patient with tea tree oil (Melaleuca alternifolia). Complement Ther Clin Pract. 2008 Nov. 14(4):225-7. [Medline].
Bourke JF, Berth-Jones J, Hutchinson PE. Cryotherapy of common viral warts at intervals of 1, 2 and 3 weeks. Br J Dermatol. 1995 Mar. 132(3):433-6. [Medline].
Berth-Jones J, Hutchinson PE. Modern treatment of warts: cure rates at 3 and 6 months. Br J Dermatol. 1992 Sep. 127(3):262-5. [Medline].
Gloster HM Jr, Roenigk RK. Risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts. J Am Acad Dermatol. 1995 Mar. 32(3):436-41. [Medline].
Sloan K, Haberman H, Lynde CW. Carbon dioxide laser-treatment of resistant verrucae vulgaris: retrospective analysis. J Cutan Med Surg. 1998 Jan. 2(3):142-5. [Medline].
Hughes PS, Hughes AP. Absence of human papillomavirus DNA in the plume of erbium:YAG laser-treated warts. J Am Acad Dermatol. 1998 Mar. 38(3):426-8. [Medline].
Rivera A, Tyring SK. Therapy of cutaneous human Papillomavirus infections. Dermatol Ther. 2004. 17(6):441-8. [Medline].
Guadara J, Sergi A, Labruna V, Welch M, Gazivoda PL. Transformation of plantar verruca into squamous cell carcinoma. J Foot Surg. 1992 Nov-Dec. 31(6):611-4. [Medline].
Kolker AR, Wolfort FG, Upton J, Tahan SR, Hein KD, Zewert TE. Plantar verrucous carcinoma following transmetatarsal amputation and renal transplantation. Ann Plast Surg. 1998 May. 40(5):515-9. [Medline].
Noel JC, Detremmerie O, Peny MO, et al. Transformation of common warts into squamous cell carcinoma on sun-exposed areas in an immunosuppressed patient. Dermatology. 1994. 189(3):308-11. [Medline].