Cutaneous Warts
🦠 Cutaneous warts are benign epidermal proliferations caused by infection with the human papillomavirus (HPV).
They commonly affect areas exposed to trauma such as the hands and feet.
👶 Frequently seen in children and young adults, warts may appear as rough, raised papules or flat lesions.
Most are self-limiting, but persistence or discomfort often leads to treatment.
🧩 Clinical Presentation
- Common warts (verruca vulgaris): Rough, raised papules, often on hands, knees, or periungual areas.
- Plantar warts: Found on soles; can be painful when walking due to pressure, sometimes form “mosaic” clusters.
- Flat warts (verruca plana): Small, smooth, flat-topped papules, usually on face, neck, or hands.
- Filiform warts: Finger-like projections, typically around the mouth, nose, or eyelids.
🔍 Clinical Tests
- Visual examination: Diagnosis is usually clinical. Key clue = rough/scaly surface with interruption of skin lines.
- Dermatoscopy: Helpful for atypical lesions. Shows thrombosed capillaries (“black dots”), distinguishing warts from seborrhoeic keratoses or squamous cell carcinoma.
💊 Management
- First-line:
- Topical salicylic acid (paint, gel, or plaster) – applied daily for several weeks; gradually removes keratinised layers.
- Cryotherapy with liquid nitrogen every 2–3 weeks; effective for common and plantar warts, but may need multiple sessions.
- Second-line:
- Topical imiquimod or 5-fluorouracil for resistant warts.
- Laser therapy (e.g. pulsed dye, CO₂) targets the wart’s blood supply in refractory cases.
⚙️ Other Management Options
- Duct tape occlusion therapy: Occlusive treatment; evidence mixed but low risk.
- Surgical curettage or cautery: Reserved for resistant or symptomatic lesions; higher risk of scarring and recurrence.
- Patient education: Warts are contagious. Advise against sharing towels and recommend footwear in communal areas (e.g. swimming pools, gyms).
- Natural history: Many warts resolve spontaneously within 1–2 years, especially in children. Reassurance is often appropriate.
💡 Clinical Pearl: Treatment choice should balance efficacy, side effects, and patient preference.
In the UK, topical salicylic acid is usually first-line in primary care, with referral for cryotherapy or specialist management if refractory.
