Warts and Other Lesions

Warts• Benign neoplasms caused by keratinocytes transformed by HPV• HPV type I, II and IV associated with plantar warts

– Type I causes verrucae plantaris lesions– Type II causes mosaic warts– Type IV causes seed corn lesions– Type III causes genital warts

• Physical factors such as infectious location, weight-bearing pressure

and moisture help determine the clinical appearance of the lesion

Warts• Due to immune system development, warts

are seen more commonly in children and less commonly in adults

• Can spread through small cuts in skin• May disappear spontaneously, often within

2 years of appearance• Diagnostic signs include pain with lateral

more than direct pressure and pinpoint bleeding with sharp dèbridement of the lesion

Note pinpoint spots representing thrombosed capillaries

Wart Treatments• Burning:

– Chemical: 40% Salicylic acid, mono, bi and tricholoroacetic acid, cantharidin

– Freezing: liquid nitrogen– Thermal: electrocautery,

pulsed-dye laser

• Tend to have the same things in common:– Painful– Multiple treatments needed– High rate of recurrence (40-

60%)

Wart Treatments• Surgical

– Sharp excholeation with blunt dissection of lesion

– Primary resection with sutured closure

– Intentional implantation to other extremity (Panacos graft)

– Bleomycin treatment

• Immune system modification– H2 blocker (Cimetidine) appears

to act by suppressing histamine. Histamine suppresses the immune system by activating suppressor T-cells. Low circulating levels of IgG and IgM are associated with a higher incidence of verrucae (45% of immunocompromised kidney recipients develop warts)

– Only Tagamet seems to have this effect

– 30mg/kg (adult) 20mg/kg (child) TID for 6-8 wks

Wart Treatments• Immune system stimulation

– Vitamin A (10K IU vit A) with 15μg of zinc BID

– Bleomycin injection (breaking the capsule of the wart, injecting Bleomycin to arrest the growth of the virus and allowing T cell development)

• Others:– Effudex cream (5-flurouracil)– Retin-A– Denavir (Pencyclovir)– Aldara cream (Imiquimod)

• Typical use is genital warts• Use 3X week with 8-10 hour

application time without occlusion

• Wash off completely• Use for 3 months• Dèbridement of the plantar

wart is essential as this has to be absorbed through the epidermis

Other Lesions• Porokeratosis plantaris discretum lesions (Steinberg’s lesion)

•Looks like a wart

•Is a blocked eccrine sweat gland

•Painful with direct pressure

Central core with no overlying bony prominence

Other Lesions•Intractable plantar keratosis

•Caused by pressure at the plantar metatarsal head

•Usually seen in conjunction with contracted digits and loss of the plantar fat pad

Large central core

Algorithm

Surgery(Bleomycin)(Panacos)(resection)

Burn(acid)

(electrocautery)(cryotherapy)

Other(Tagamet)(Effudex)(Aldara)

Wart

pinpoint bleeding

surgical excisionwith chemical cautery

PKP

small central corenot necessarily at aweight bearing area

elevational osteotomy

IPK

large core atweight-bearing area

Lesionis debrided

What if it returns?• Current success rate with the Bleomycin treatment is 95+%• Those who fail the Bleomycin treatment are placed upon Aldara cream

with 1 failure so far in 12 cases• The person who failed on the Aldara cream had primary surgical

excision with no return of lesion• 16 current cases of the Panacos graft for mosaic warts with 2 failures,

who then responded to the Bleomycin treatment