A 32-year-old male patient presented with a large wart on his second finger and numerous warts on his right foot. Warts are a common skin infection caused by HPV that can persist for many years. Diagnosis of warts is usually not difficult to make clinically or histologically. Treatment options for warts include cryotherapy, which the author uses to treat digital warts, CO2 laser for foot warts, salicylic acid, photodynamic therapy, lasers, and other topical treatments. While many treatments are available, evidence for their efficacy is sometimes limited.

1. S K I N / D E R M AT O L O G Y
43Aesthetic Medicine • November 2015
SPONSORED BY CASE FILESwww.aestheticmed.co.uk
Dr Patrick Treacy shares some of his most
challenging cases. This month he talks about
treating cutaneous warts
Dr Treacy’s
CASEBOOK
A
32-year-old Irish male patient presented with
a large frond-like lesion on the middle phalanx
area of his second finger. The outgrowing mass
was not painful but sometimes bothered him
when riding his speed bike and was present
for over six months. The patient said it had started off as
a smaller lesion and had got rapidly bigger recently. He
also had numerous similar lesions on his right foot. The
lesions were immediately clinically identified as warts and
histopathology was not indicated. Liquid nitrogen was used
to treat the digital warts and CO2 laser for his foot.
Warts are a common skin disease worldwide. Infection is
common in childhood, but can occur at any age. Small cohort
observational studies have suggested that five to 30% of
children and young adults have warts.1,2
HPV can spread
from one individual to another by direct contact or via the
environment. Warts can persist for years with little or no
sign of inflammation.3
HPV-associated warts are subdivided on anatomical
or morphological grounds into (i) common wart (Verruca
vulgaris); (ii) wart on the sole of the foot, plantar wart
(Verruca plantaris); (iii) flat wart or plane wart (Verruca
plana) and (iv) genital wart (Condyloma accuminatum).4
DIAGNOSIS
Diagnosis of common hand and foot warts is usually not
difficult. Warts need to be distinguished either clinically or
histologically from other keratotic lesions on the hands or
feet, such as actinic keratoses, knuckle pads or, more rarely,
squamous cell carcinoma.5
The term “plantar warts” is used
for those that occur on the soles of the feet (the “plantar”
surface). They are also known as verrucas.
Warts are one of
the most common skin
infections and can persist for
many years, but the evidence base
for treatment is sometimes weak.
Treatments should be used as advised
by the manufacturers or under
direction by appropriate qualified
personnel who are aware of
contraindications and
side-effects
MANAGEMENT
(a) No therapy
Depending on their site and size, warts may be just a
minor nuisance. There is no antiviral treatment that is
specific for HPV, but some of the available therapies
interfere with the viral life cycle.
(b) Salicylic acid
The most commonly used, over-the-counter products
are SA paints. These contain SA at concentrations
of between 10% and 26% in either a collodion or a
polyacrylic base; they are often mixed with lactic acid.
Plasters containing 40% SA and ointments containing
50% SA are also widely available.
(c) Cryotherapy
A range of devices and techniques are used to induce
targeted cold injury to warts. Liquid nitrogen, delivered
by cryospray or cotton bud, is the most commonly used
method in medical practice. Techniques differ between
practitioners, with variations in freeze times, mode

2. 44 Aesthetic Medicine • November 2015
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S K I N / D E R M AT O L O G Y
Please advise on captions
of application and intervals between treatments. Paring
before cryotherapy can improve results in plantar warts,
butnothandwarts.6
Thereportedcurerateofcryotherapy
for warts at all sites from randomized trials is highly
variable,rangingfrom0%to69%withameanof49%.7
(d) Lasers
PDL(585nm)isthelaserusedmostfrequentlyandactsby
destroyingwartvesselvasculaturethroughhaemoglobin’s
absorption peak at 585–595 nm. Direct thermal injury to
theheat-sensitiveHPVvirusmayalsoplayarole.CO2laser,
neodymium-doped yttrium aluminium garnet (Nd:YAG),
Er:YAG, infrared and potassium titanyl phosphate laser
have also been used. The author prefers a fractional CO2
setatveryhighwattage.
(e) Photodynamic therapy. Studies show there was a
significant difference in wart clearance after 14 weeks
in 45 patients with palmar and plantar lesions treated
with 20% aminolaevulinic acid photodynamic therapy
(ALA-PDT).8
(f) Formaldehyde soaks have been used to treat verrucas,
and they were reported to give a cure rate of 80% in an
open study of 646 children.9
(g) Podophyllotoxin can inhibit cell division by interfering
with the mitotic spindle, and will affect normal skin as
well as warts. It can have dangerous systemic effects if
used in high concentrations or over large areas, and its
use is contraindicated in pregnancy.
(h) Topical 5-FU has been used with effect to treat both
plane warts and common warts on the hands and feet.
5-FU blocks DNA synthesis and damages dividing basal
layer cells. When used topically or intralesionally, it
produces inflammation and occasionally erosions.
(i) Bleomycin is a cytotoxic agent used in systemic
chemotherapy, but it has been recognized and applied
as a therapy for warts for 40 years (10).
(j) Imiquimod is a well-established treatment for genital
and perianal warts. It stimulates a proinflammatory
response through the induction, synthesis and release
of interferon (IFN)-a, tumour necrosis factor-a and
interleukin (IL)-12, as well as promoting natural killer
(NK) cell activation.
DrPatrickTreacy is CEO Ailesbury Clinics, chairman of the Irish Association of Cosmetic Doctors and Irish
regional representative of the British College of Aesthetic Medicine (BCAM). He is also president of
the World Trichology Association. Dr Treacy has won a number of awards for his contributions to facial
aesthetics and hair transplants including the AMEC Award in Paris in 2014. Dr Treacy also sits on the
editorial boards of three international journals and features regularly on international television and
radio programmes. He is scientific committee for AMWC Monaco 2015, AMWC Eastern Europe 2015,
AMWC Latin America 2015, RSM ICG7 (London) and Faculty IMCAS Paris 2015 and IMCAS China 2015.
REFERENCES
1. van Haalen FM, Bruggink SC, Gussekloo J et al. Warts in primary schoolchildren:
prevalence and relation with environmental factors. Br J Dermatol 2009;
161:148–52.
2. Kyriakis K, Pagana G, Michailides C et al. Lifetime prevalence fluctuations of
common and plane viral warts. J Eur Acad Dermatol Venereol 2007; 21:260–2.
3. Kilkenny M, Merlin K, Young R, Marks R. The prevalence of common skin
conditions in Australian school students: 1. Common, plane and plantar viral
warts. Br J Dermatol 1998; 138:840– 5.
4. Am Fam Physician. 2010 Nov 15;82(10):1209-13. Human papillomavirus: clinical
manifestations and prevention. Juckett G, Hartman-Adams H.
5. Guidelines for Management of Cutaneous Warts (JC Sterling, S Handfield-
Jones, PM Hudson). BJD, Vol. 144, No.1, January 2001 (p4) – British Association
of Dermatologists
6. Berth-Jones J, Hutchinson PE. Modern treatment of warts: cure rates at
3 and 6 months. Br J Dermatol 1992; 127:262–5.
7. Kwok CS, Holland R, Gibbs S. Efficacy of topical treatments for cutaneous
warts: a meta-analysis and pooled analysis of randomized controlled trials.
Br J Dermatol 2011; 165:233–46.
8. Stender IM, Na R, Fogh H et al. Photodynamic therapy with 5-aminolaevulinic
acid or placebo for recalcitrant foot and hand warts: randomised double-blind
trial. Lancet 2000; 355:963–6.
9. Vickers CF. Treatment of plantar warts in children. BMJ 1961; 2:743–5.
10. Lewis TG, Nydorf ED. Intralesional bleomycin for warts: a review. J Drugs
Dermatol 2006; 5:499–504.
DISCUSSION
Warts are one of the most common skin infections and can
persist for many years, but the evidence base for treatment
is sometimes weak. Treatments should be used as advised
by the manufacturers or under direction by appropriate
qualified personnel who are aware of contraindications and
side-effects. The author gets good results with cryotherapy
and CO2 lasers and feels combination of cryotherapy with
laserorpossiblyatopicalagentcanimproveclearancerates.
Plantar warts are caught by contact with virally-infected
skin scales; these are usually encountered on such surfaces
as the floors of public locker rooms, shower cubicles and the
tiledareasaroundswimmingpools.However,thevirusisnot
highly contagious, and it is unclear why some people catch
plantar warts while others do not. The virus enters the skin
through tiny breaks in the skin surface, and moistness and
maceration of the skin on the feet probably make infection
with the wart virus easier. AM