Viral Warts treatment

Introduction

Viral warts are benign proliferative lesions of the skin and mucous membranes caused by infection with the Human Papillomavirus (HPV). They are among the most common dermatological conditions encountered in primary care and affect individuals of all ages, particularly children, adolescents, and young adults.

Different HPV types produce distinct clinical manifestations. Common forms include common warts (verruca vulgaris), plane (flat) warts (verruca plana), plantar warts (verruca plantaris), and oral warts. Most lesions are self-limiting, but persistent, symptomatic, or cosmetically significant lesions may require treatment.

Predisposing factors include:

• Direct skin-to-skin contact with infected individuals

• Contact with contaminated surfaces (e.g., communal showers, swimming pools)

• Minor skin trauma

• Nail biting or shaving over affected areas

• Immunosuppression

• Atopic dermatitis

Pathophysiology:

HPV infects the basal layer of the epidermis through microscopic breaks in the skin or mucosa. Viral replication stimulates proliferation of keratinocytes, resulting in localized hyperkeratotic papules with a verrucous surface.

Signs & Symptoms

• Verrucous papules or plaques

• Rough, hyperkeratotic surface

• Solitary or multiple lesions

• Skin-coloured, grey, or brown lesions

• Black punctate dots (thrombosed capillaries) may be visible after paring

Clinical types:

Common warts (Verruca vulgaris)

• Rough papules on fingers, hands, elbows, knees, and periungual areas

Plane (flat) warts

• Small, smooth, flat-topped papules

• Common on the face, forehead, hands, and shins

Plantar warts

• Hyperkeratotic lesions on the soles of the feet

• Painful on applying pressure or walking

Oral warts

• Papillary lesions affecting the oral mucosa, lips, tongue, or palate

Diagnostic Criteria

• Characteristic verrucous papules on the skin or mucous membranes

• Pain on direct pressure in plantar warts

• Typical distribution according to wart type

• Diagnosis is primarily clinical

Investigation

Routine laboratory investigations are not usually required.

Investigations may be considered in atypical cases:

• Dermoscopy

• Skin biopsy where diagnosis is uncertain

• Histopathological examination for suspicious lesions

Consider differential diagnosis:

• Corns (clavus)

• Calluses

• Molluscum contagiosum

• Seborrhoeic keratosis

• Actinic keratosis

• Squamous cell carcinoma

• Condyloma lata

• Cutaneous horn

Treatment

Non-Pharmacological Treatment

• Reassure patients that many warts resolve spontaneously.

• Avoid picking or scratching lesions to prevent autoinoculation.

• Keep affected skin clean and dry.

• Avoid sharing towels, footwear, nail clippers, or personal items.

• Wear footwear in communal showers and swimming pool areas.

Pharmacological Treatment

• Silver nitrate pencil: apply 3 times per week for 4 weeks for plantar and common warts.

OR

• Tretinoin cream (topical) 2.5%: apply every 12 hours for 4 weeks for plane warts.

Note:

• For treatment of genital warts, refer to the Sexually Transmitted Infections chapter.

Surgical Treatment

• Cryotherapy.

• Curettage.

• Excision of large warts.

Prevention

• Avoid direct contact with existing warts.

• Do not share personal items such as towels, razors, socks, or footwear.

• Wear protective footwear in communal bathing areas.

• Avoid scratching or shaving over warts.

• Maintain good hand hygiene.

Follow-up

• Review patients after completion of treatment to assess response.

• Repeat treatment if clinically indicated.

• Refer persistent, recurrent, atypical, or extensive lesions for specialist assessment.

• Consider evaluation for immunodeficiency in patients with numerous, recurrent, or treatment-resistant warts.

Complications

• Pain, particularly with plantar warts

• Cosmetic concerns

• Secondary bacterial infection

• Autoinoculation leading to additional lesions

• Recurrence following treatment

Prognosis

The prognosis is excellent. Many viral warts resolve spontaneously within 1–2 years due to cell-mediated immune clearance. Persistent lesions are more common in immunocompromised individuals and may require repeated treatment or surgical intervention. Early treatment can reduce symptoms, prevent spread, and improve cosmetic outcomes.