eMedicine Specialties > Dermatology > Viral Infections

Warts, Nongenital

Author: Philip D Shenefelt, MD, MS, Associate Professor, Department of Dermatology and Cutaneous Surgery, University of South Florida College of Medicine; Past Chief, Section of Dermatology, James A Haley Veteran Affairs Medical Center
Contributor Information and Disclosures

Updated: May 5, 2009

Introduction

Background

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 occur 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),1 epidermodysplasia verruciformis, and plantar cysts. Warts are transmitted by direct or indirect contact, and predisposing factors include disruption to the normal epithelial barrier. Treatment can be difficult, with frequent failures and recurrences. Many warts, however, resolve spontaneously within a few years.

A small subset of HPV types is 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.

Pathophysiology

Warts can affect any area on the skin and mucous membranes. Infection is confined to the epithelium and does not result in systemic dissemination of the virus. Replication occurs in differentiated epithelial cells in the upper level of the epidermis; however, viral particles can be found in the basal layer.

Frequency

International

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.

Mortality/Morbidity

Common warts are usually asymptomatic, but they may cause cosmetic disfigurement or tenderness. Plantar warts can be painful, and extensive involvement on the sole of the foot may impair ambulation. Malignant change in nongenital warts is rare but has been reported and is termed verrucous carcinoma.2,3,4 Verrucous carcinoma is considered to be a slow-growing, locally invasive, well-differentiated squamous cell carcinoma that may be easily mistaken for a common wart. It can occur anywhere on the skin but is most common on the plantar surfaces. Although this type of cancer rarely metastasizes, it can be locally destructive.

Race

Although warts may affect any race, common warts appear approximately twice as frequently in whites as in blacks or Asians.5 Focal epithelial hyperplasia (Heck disease) is more prevalent among American Indians and Inuit.1

Sex

Male-to-female ratio approaches 1:1.

Age

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.6

Clinical

History

HPV is spread by direct or indirect contact. It can resist desiccation, freezing, and prolonged storage outside of host cells. Autoinoculation also may occur, causing local spread of lesions. The incubation period for HPV ranges from 1-6 months; however, latency periods of up to 3 years or more are suspected.

Physical

  • Common warts: Common warts also are termed verruca vulgaris. They appear as hyperkeratotic papules with a rough, irregular surface. They range from smaller than 1 mm to larger than 1 cm. They can occur on any part of the body but are seen most commonly on the hands and knees (see Media File 2).
Common wart on the hand.

Common wart on the hand.

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Common wart on the hand.

Common wart on the hand.

  • Filiform warts: Filiform warts are long slender growths, usually seen on the face around the lips, eyelids, or nares.
  • Deep palmoplantar warts (myrmecia)7 : Deep palmoplantar warts also are termed myrmecia. They begin as small shiny papules and progress to deep endophytic, sharply defined, round lesions with a rough keratotic surface, surrounded by a smooth collar of calloused skin (see Media File 1). Because they grow deep, they tend to be more painful than common warts. Myrmecia warts that occur on the plantar surface usually are found on weight-bearing areas, such as the metatarsal head and heel. When they occur on the hand, they tend to be subungual or periungual.
Plantar warts.

Plantar warts.

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Plantar warts.

Plantar warts.

  • Flat warts: Flat warts also are termed plane warts or verruca plana. They are characterized as flat or slightly elevated flesh-colored papules that may be smooth or slightly hyperkeratotic. They range from 1-5 mm or more, and numbers range from a few to hundreds of lesions that may become grouped or confluent. These warts may occur anywhere; however, the face, hands, and shins tend to be the most common areas. They may appear in a linear distribution as a result of scratching or trauma (Koebner phenomenon). Regression of these lesions may occur, which usually is heralded by inflammation.
  • Butcher's warts: Butcher's warts are seen in people who frequently handle raw meat. Their morphology is similar to common warts, with a higher prevalence of hyperproliferative cauliflowerlike lesions. They are seen most commonly on the hands.
  • Mosaic warts: A mosaic wart is a plaque of closely grouped warts. When the surface is pared, the angular outlines of tightly compressed individual warts can be seen. These usually are seen on the palms and soles.
  • Focal epithelial hyperplasia (Heck disease)1 : Focal epithelial hyperplasia, also termed Heck disease, is an HPV infection occurring in the oral cavity, usually on the lower labial mucosa. It also can be seen on the buccal or gingival mucosa and rarely, on the tongue. The lesions appear as multiple flat-topped or dome-shaped pink-white papules. They usually are 1-5 mm, with some lesions coalescing into plaques. They are seen most frequently in children of American Indian or Inuit descent.
  • Cystic warts (plantar epidermoid cysts): A cystic wart appears as a nodule on the weight-bearing surface of the sole. The nodule usually is smooth with visible rete ridges but may become hyperkeratotic. If the lesion is incised, cheesy material may be expressed. The etiology of these lesions is uncertain. One theory is that a cyst forms, originating from the eccrine duct, and secondary HPV infection occurs. Another theory is that the epidermis infected with HPV becomes implanted into the dermis, forming an epidermal inclusion cyst.

Causes

Warts are caused by HPV, which is a double-stranded, circular, supercoiled DNA virus enclosed in an icosahedral capsid and comprising 72 capsomers. More than 100 types of HPV have been identified.

  • Common warts - HPV types 2 and 4 (most common), followed by types 1, 3, 27, 29, and 57
  • Deep palmoplantar warts (myrmecia) - HPV type 1 (most common), followed by types 2, 3, 4, 27, 29, and 57
  • Flat warts - HPV types 3, 10, and 28
  • Butcher's warts - HPV type 7
  • Focal epithelial hyperplasia (Heck disease) - HPV types 13 and 32
  • Cystic warts - HPV type 60

More on Warts, Nongenital

Overview: Warts, Nongenital
Differential Diagnoses & Workup: Warts, Nongenital
Treatment & Medication: Warts, Nongenital
Follow-up: Warts, Nongenital
Multimedia: Warts, Nongenital
References
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References

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Further Reading

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Keywords

nongenital warts, human papilloma viruses, HPV, common warts, verruca vulgaris, flat warts, palmoplantar warts, myrmecia, focal epithelial hyperplasia, Heck disease, plantar cysts, epidermodysplasia verruciformis, verrucous carcinoma, filiform warts, Koebner phenomenon, butcher's warts, hyperproliferative cauliflowerlike lesions, mosaic wart, cystic warts, plantar epidermoid cysts, epidermal inclusion cyst

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Contributor Information and Disclosures

Author

Philip D Shenefelt, MD, MS, Associate Professor, Department of Dermatology and Cutaneous Surgery, University of South Florida College of Medicine; Past Chief, Section of Dermatology, James A Haley Veteran Affairs Medical Center
Philip D Shenefelt, MD, MS is a member of the following medical societies: American Academy of Dermatology, American College of Physician Executives, American Contact Dermatitis Society, American Medical Association, American Society of Clinical Hypnosis, Florida Medical Association, Noah Worcester Dermatological Society, and Society for Clinical and Experimental Hypnosis
Disclosure: Nothing to disclose.

Medical Editor

Mark W Cobb, MD, Consulting Staff, WNC Dermatological Associates
Mark W Cobb, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and American Society of Dermatopathology
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory
Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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