If you’ve ever been struck with a pesky wart over your palms or soles at least once in your life, you’ve probably been left wondering what caused it. Nope, it is no longer just a childhood infection, adults are increasingly attending my clinic with concerns about stubborn warts that don’t go away and are plain annoying. In this article, I share my experience with the common concerns of those of you who are troubled by viral warts.
1. What exactly are warts?
Warts, also known as verruca, are growths of the skin due to human papillomavirus (HPV) infection. Several subtypes are known, and they all look different. The initial infection occurs in the top layers of the skin, it reprogrammes the skin to cause excessive growth of the keratinocytes (skin cells), leading to thickening of the skin where the viral wart has started. The most common subtypes of HPV are types 2, 3, 4, 27, 29, and 57. Warts appear first like an area of hardened skin, and when one looks carefully, one may find tiny black dots centrally, which is due to thrombosed(or clotted) tiny blood vessels.
2. Who gets viral warts?
Warts are traditionally more commonly found in school-going children and teenagers but can affect people of any age group. People suffering from eczema, whereby their skin barrier is genetically defective, are also prone to getting viral wart infections from areas of broken skin. Those who are immune suppressed are at high risk of getting larger, persistent and multiple warts. These include patients who are pregnant, on medications such as azathioprine or ciclosporin, or with human immunodeficiency virus (HIV) infection. Nevertheless, it’s perfectly normal to have a healthy young adult to suffer from viral warts as well, especially in areas of friction and contact, such as the palms and soles. The palms and soles of feet are subject to small cuts and wounds due to contact on a day to day basis. HPV virus, which is present on surfaces, then has the potential to infect the skin.
3. Is your gym giving you warts?
Moving on to the causes of viral warts. HPV is contagious and is most commonly spread by direct skin-to-skin contact. Another way it occurs is via scratching or picking warts, whereby the virus may be spread to other areas of uninfected skin. Common places where people pick up the wart virus are at public areas such as pools, bathrooms and gyms. Sharing footwear, slippers and shoes, walking barefoot and handling shared gym equipment that has not been properly disinfected. So yes, a good proportion of adults who visit dermatologists for treatment of their viral warts actually get it from shared gym equipment, especially when small cuts are present.
4. Do I need to see a dermatologist to diagnose viral warts?
Warts are common and have a typical appearance, with painful areas of hard skin, almost like a callus, and black dots centrally. While tests are usually not required to diagnosis viral warts, there are some cases whereby the appearance or the location of the wart is unusual, leading to a missed diagnosis of a potential skin cancer. In such cases, dermatologists usually would perform either a dermatoscopic examination or may recommend a skin biopsy to distinguish viral warts from other growths such as seborrhoeic keratosis and skin cancer. It may be necessary sometimes to perform a skin biopsy for diagnosis, especially to rule out rare infections( in people who are immunosuppressed) and also skin cancers.
5. When to get your wart treated by a dermatologist
Small warts which otherwise don’t hurt or bother in any way can sometimes be left alone. However, once you suspect you may have a wart, do get it checked out by a dermatologist rather than using DIY methods. I have seen several patients who have used corn plasters or DIY freeze kits bought online over their wart, which all became worse after their self-treatment. I do not recommend corn plasters as these typically contain salicylic acid which is a keratolytic, essentially dissolving the thicker layers of skin overlying the wart, often causing irritation and blistering, but does not actually treat the underlying viral wart. Many end up with complications of skin infection. DIY freeze kits or not permitted legally in Singapore, however, I have had patients who purchased such kits online or overseas and ended up having severe blistering and infections, some even requiring drainage after that. The reason is that these freeze kits contain liquid nitrogen, which is meant to kill off the virus-infected skin cells and should be applied by a trained healthcare professional upon the direction and assessment of a dermatologist. Importantly, there are variations of the appearance of viral warts as well, which may lead to misdiagnosis or delayed diagnosis. I have seen cases of squamous cell carcinoma, a potentially lethal form of skin cancer, for example, which had been undiagnosed because of an assumption that it was just a stubborn wart that would not go away.
6. How does wart treatment work?
The truth is, once you get a viral wart infection, the virus affects your skin’s DNA where it has infected, causing all new skin cells to be produced with the HPV virus. What that means is the treatment of viral warts is not like that of a skin growth or cyst, whereby cutting it out fully results in removal and a cure. Viral warts are persistent because they are alive, and in order to eliminate the wart virus one has to rely on stimulating the body’s own immune system to overcome the wart virus. Hence, surgeries whereby the wart is excised does not work because the HPV virus replicates and would grow the wart again.
The location of the wart, the morphology as well as the underlying health status of the patient affects the type of treatment chosen as well. There are subcategories of warts as follows which your dermatologist will diagnose you with:
Common warts and plantar warts are those commonly appearing over the palms and soles, with characteristic pinpoint black dots centrally due to clotted blood vessels, a result of the HPV virus infection. Plane warts as the name suggests, have a plane or a flat surface and are found over areas of the knuckles, the knees and the elbows. Another type known as filiform warts are protuberant with a thread-like elongated stalk and are common in areas such as the face. Mucosal warts affect areas such as the lips, inside the mouth and also the anal/genital region.
7. What treatments are available for viral warts?
First of all, make sure the growth you are dealing with is indeed a viral wart. From there, depending on the type of viral wart, your dermatologist will suggest one or a combination of the following.
Use of topical treatment alone in the treatment of viral warts is uncommon and is usually used in combination with topical treatment i.e. creams, ointments and lotions formulated for wart treatment usually contain active ingredients such as salicylic acid. Salicylic acid is a keratolytic, which means it works by dissolving dead skin cells. Another anti-viral ingredient used is podophyllin, which destroys skin cells i.e. cytotoxic, but is prohibited in pregnancy.
Cryotherapy is the use of liquid nitrogen to freeze areas of infected skin. It is performed every one to two weeks. It is a safe and effective treatment except that it requires multiple sessions, with a success rate of about 60–70% for 3 months of regular treatments. It causes blistering and may subsequently leave a scar after treatment.
Electrosurgery and Laser Vaporisation
Electrosurgery and laser vaporisation would be used for larger or stubborn warts. Surgical paring is performed under local anaesthesia and the base of the wart is burned, destroying both healthy tissues together with the bulk of virus infected tissue. Wound healing is expected within two weeks generally. However, about 20%- 30% of warts do recur within a few months, although the rate of recurrence decreases with proper monitoring by a dermatologist.
© 2017. Dr. Teo Wan Lin. All rights reserved.
Meet with Dr. Teo Wan Lin, founder and Specialist Consultant Dermatologist of TWL Specialist Skin & Laser Centre, an accredited dermatologist specialising in medical and aesthetic dermatology. She integrates her artistic sensibility with her research background and specialist dermatologist training, by means of customised, evidence-based aesthetic treatments using state-of the-art machines, injectables (fillers and toxins) which work synergistically with her proprietary line of specialist dermatologist grade cosmeceuticals Dr.TWL Dermaceuticals.