Warts

Diagnosis/Definition

• Warts are benign tumors of the skin and other epithelial tissues.
• They appear as discrete keratotic papules or plaques and can be classified by their location (plantar, genital, periungual, etc.).
• They are most common in children and young adults.
• The etiologic agents for these infections are a class of double-stranded DNA viruses called papillomaviruses.

Initial Diagnosis and Management

• The initial diagnosis is generally clinical based on physical exam.  Location, duration and extent should be noted.  If there are lesions near a mucous membrane, these should be examined as well.  If the diagnosis is not obvious a biopsy may be indicated.
• Treatment options include:
  • Acids - Salicylic acid preparations on formulary are Occlusal (17%) and Mediplast (40%); with some instructional assistance, patients can use these at home.  Similar Over-The-Counter (OTC) preparations are readily available.
  • Cryotherapy - Liquid Nitrogen applied as spray or cotton applicator, with frost lasting for 20-30 seconds.  Goal is to treat visible wart plus a millimeter "halo".  After thawing, a second treatment may be applied.
  • Caustics (Podophyllin) - For genital warts (condyloma acuminata), in-office podophyllin may be used, with or without light cryotherapy.  Avoid use in occlusive (under foreskin, ventral penis, etc.) environment.  Condylox is on the formulary and patient applies gel twice a day for 3 consecutive days a week, repeating up to 4 weeks for external genital warts only.
  • Immune modulator (Imiquimod 5% [Aldara] cream) - Is on the formulary and may be selected for patients who fail cryotherapy and podophyllin therapy options (mention in "comments" section of CHCS when ordering).  Apply once at bedtime, wash off after 6-10 hours 3x/week every other day; treat for 16 weeks maximum.
  • Duct tape—Shown to actually work.  Apply duct tape cut to the size of the wart and leave in place for 5 days.  Replace it if it comes off.  Remove on the 5th day and let it air out over night.  Repeat for another 5 days until the wart resolves.

Ongoing Management and Objectives

• Patients may be followed up at 2-4 week intervals.  Again, it should be emphasized that although they are often refractory to therapy, most warts eventually resolve with persistent treatment.
• Self-treatment between visits is important to increase the rate of success.

Indications for Specialty Care Referral

• Periungal Warts, if large or refractory to the conservative management noted above.
• Markedly extensive warts (may indicate underlying immunodeficiency or disease).
• Large or numerous warts that are resistant to therapy for 6 months.
• All Retiree's, VA and dependents with foot conditions 30, 31, 01, 02, 03, 04 etc.. Respectfully need to be routed to Schofield Barracks Podiatry or net worked out for treatment. Tripler Podiatry unfortunately does not provide orthotics or inserts for dependents, VA or Retiree's.

Criteria for Return to Primary Care

Warts have resolved and/or a suitable treatment plan has been established.