Warts, or known as plane juvenile warts, periungual warts, subungual warts, plantar warts, verruca, verrucae planae juveniles, filiform warts and verruca vulgaris, are small growths with a rough texture that can appear anywhere on the body’s skin, caused by the human papillomavirus (HPV). Types of warts depend on the affected area, such as common warts affect fingers and hands, foot warts, flat warts, filiform warts, and genital warts.

Warts do share common symptoms such as having smooth surfaces and being painful. On the other hand, there are some specific symptoms that are linked to certain types such as white, pink or tan in color for common warts and cauliflower-like shaped bumps in genital warts.

The risk of getting infected with warts is increased in children, teenagers and immunocompromised people. Having unprotected sex puts individuals in a risk of being infected with genital warts.

 Warts could be mainly prevented by avoiding coming in contact with warts, washing anything that has direct contact with warts and keeping area infected with warts completely dry to stop it from spreading.

Warts can be diagnosed by observation with the naked eye by dermatologist and in some rare cases by performing skin biopsy to make sure it is not any other type of growth such as skin cancer.

Warts treatment involves different types of medications and procedures, such as cantharidin, cryotherapy, electrosurgery and curettage, and excision. Imiquimod, podophyllin and podofilox, trichloroacetic acid, and sinecatechins are specific medications used for genital warts.

Usually complications are related to foot and genital warts, where patients with foot warts have muscles and joints pain, while those with genital warts may encounter cancer and problems during pregnancy.

Most cases of warts are harmless growths on the skin, which resolve on their own within 2 years. Warts can recur after treatment even after disappearing. The warts found around and under nails tend to be the hardest to cure. The prevalence is greatest among children and young adults.

Warts are non-cancerous growths of the skin caused by infection with human DNA papillomavirus (HPV), where the virus infects the surface layer of the skin. Although they are non- cancerous, they have an increased risk of cancer.

There are several types of warts, which are classified based on their location and their appearance. The subtypes are:

• Common warts

Also known as vurruca vulgaris, it occurs most often on the fingers or back of the hands, where nail biting or touching spreads the infection from the hands to the face.

• Foot warts

Also known as plantar warts that are found on the soles of the feet. They can cause severe pain. They could contain black dots and usually grow in clusters, in a flat or an inwards direction.

• Flat warts

Flat warts are generally found on the face and forehead in small sizes, and numerous. They vary in their location, on children’s faces, on men’s beards, and on women’s legs.

• Filiform warts

They appear as long threads or thin fingers shape. This type of warts often grows quickly around the mouth, eyes, and nose.

• Genital warts (condyloma)

Usually, they appear on the genitals, in the pubic area, and in the area between the thighs. In men, they may occur on the tip or shaft of the penis, the scrotum, or the anus. In women, they can appear inside the vulva, the walls of the vagina, the area between the external genitals and the anus, the anal canal, and the cervix. Oral sexual contact with an infected person could lead to mouth or throat genital warts.

Warts are caused by the contagious human papillomavirus (HPV). The possibility of getting infected with (HPV) is increased if the person has a skin cut or scrape. The spread of warts from one person to another is less common than their spread from one part to another in an infected person.

Anyone is exposed to have warts, but certain groups of people are more likely to be affected:

• Children and teenagers.
• People who bite their nails.
• Immunocompromised people.
• Having unprotected sex may increase the risk of becoming infected with genital warts.

The epithelium tissue; membranous cellular tissue that covers a free surface or lines a tube or cavity of a body, becomes infected by (HPV), without the occurrence of systemic dissemination; an infection that spreads throughout the body, often affecting numerous organ systems. The differentiated epithelial cells in the upper level of the epidermis layer represent the site of the viral replication. Nevertheless, viral particles can be found in the basal layer of the epidermis.

Usually, warts have a rough, protruding surface that is round or oval shaped. The following could be in common among all types of warts:

• Lighter or darker wart spot than the rest of the skin.
• Some warts have smooth or flat surfaces.
• Some warts may be painful.

Signs and symptoms specific to certain types could be found in:

• Common warts such as:

• Small, fleshy, grainy bumps.
• Flesh-colored, white, pink or tan.
• Rough to the touch.
• Sprinkled with black pinpoints, which are small, clotted blood vessels.

• Foot warts such as:

• Appearance of small, fleshy, rough, grainy lesions on the bottom of the foot.
• Pain or tenderness during walking or standing.
•  Appearance of lesions which interrupt the normal lines and ridges in the foot’s skin.
• Presence of hard, thickened skin over a spot on the skin where a wart has grown inward.
• Having black pinpoints.

• Genital warts such as:

• Genital area becomes swollen, with the appearance of small, flesh-colored or gray bulges.  
• Cauliflower-like shaped warts.
• Feeling of itching or discomfort in the genital area.
• Bleeding that accompanies intercourse.

Genital warts, in some cases, may multiply into large clusters but could also be so small and flat that they cannot be seen with the naked eye.

Diagnosis is done by a dermatologist by looking at it and rarely requires a biopsy to exclude it from being another type of growth, such as skin cancer.

Skin biopsy is a safe and quick procedure, where the wart is removed by the doctor, to be sent to a lab for a microscope inspection.

• Common warts  and foot warts diagnosis

• Examining the wart.
• The removal of the top layer by scraping to check for common signs of warts such as dark pinpoint dots that are clotted blood vessels.
• Shave biopsy that includes removing a part of the wart to be analyzed at the lab for excluding other types of growths.

Genital warts diagnosis

• Pap tests

The doctor collects a small sample of cells from the cervix using a long-handled tool called a speculum. The cells are examined under the microscope to check for any abnormalities.

HPV test

Regular pelvic exams, which are physical assessment of the internal pelvic organs, along with the Pap test are able to reveal vaginal and cervical changes that result from genital warts or detect early signs of cervical cancer which maybe a complication of genital (HPV) infection.

Warts in general resolve on their own and despite the fact that they are considered harmless, treatment by dermatologists is done. There are many treatments and procedures associated with wart removal including:

• General wart treatment

• Cantharidin

Cantharidin; a medication that is a combination of green blister beetle secretions and salicylic acid , is sprayed on the wart, at the clinic. After a week, the patient should return to get the dead wart removed.

• Cryotherapy

Cryotherapy or freezing therapy, is the most common treatment for warts. This type of treatment is performed in the doctor’s clinic, by applying liquid nitrogen to the wart. This leads to blister formation, which causes shedding of the dead wart within a week or more, as the skin begins to heal.  Stimulation of the immune system to fight viral warts is possible with this treatment. In general, repeated treatments may be required. Method can also stimulate the immune system to fight viral warts. The patient may need to repeat treatments.

• Electrosurgery and curettage

Electrosurgery involves burning, and curettage; a surgical scraping or cleaning using a surgical tool, of the wart with a sharp knife or small, spoon-shaped tool that could be used collectively.. Electrosurgery is a good treatment for common warts filiform warts, and foot warts. The dermatologist may remove the wart by scraping it off before or after electrosurgery.

• Excision

The doctor uses special tools for excising the wart. General or local anesthesia should be used.

• Hard-treated warts require the following treatments:

• Laser treatment

When warts fail to respond to other treatments, laser is used. After the wart is numbed with an anesthetic injection, this treatment works on burning the tiny blood vessels using pulsed-dye laser; an organic dye mixed in a solvent as the lasing medium.

• Chemical peels

Flat warts exist in high numbers which requires peeling. Applying peeling medicines such as salicylic acid is done on a daily basis at home. 2

• Bleomycin

The warts will be injected with bleomycin, which is an anti-cancer medicine and is painful.  Nail loss could occur, if given in the fingers. 2 

• Immunotherapy

When other treatments fail, stimulation of the patient’s immune system to fight the warts is used.

Diphencyprone (DCP) is a chemical involved in immunotherapy, where it is applied to the warts. Another example is shots of interferon that enhance the body’s immune system.

• Genital warts treatment

This uses direct application of medication onto the skin:

• Imiquimod

This cream is used to stimulate the immune system’s ability to fight genital warts. Sexual contact should be avoided during the use of this medication since it weakens condoms and has a possibility of irritating the partner’s skin.

• Podophyllin and podofilox

Podophyllin and podofilox contain the same active compound that destroys genital wart tissue. Podofilox shouldn’t be used during pregnancy.

• Trichloroacetic acid (TCA)

This chemical treatment is used for internal warts, it acts on burning genital warts and could be used on internal warts.

• Sinecatechins

This cream is used for treatment of external genital warts and warts in or around the anal canal.

Foot warts patients suffer from pain and altered posture or gait which may lead to muscle or joint discomfort.

Genital wart complications include:

• Cancer

Cancers in the vulva, anus, penis, mouth and throat are closely related with certain types of HPV. Cervical cancer is strongly associated to genital HPV infection. Regular Pap tests, particularly when previous infection with higher risk types of HPV, are recommended for women even though HPV may not always lead to cancer.

• Problems during pregnancy

Enlargement of warts causes urination difficulties. Vaginal tissues have a reduced ability of stretching during childbirth due to the   warts growth on the vaginal wall. Furthermore, during delivery large warts on the vulva or in the vagina can bleed when stretched.

Rare cases require surgery for the baby’s airway for a baby born to a mother with genital warts, since such cases may have warts in the throat.

Preventing the spread of warts is accomplished via:

• Avoiding contact with other people’s warts and if it happens hands should be carefully washed.
• Avoiding picking or scratching the warts.
• Wearing socks or shoes in public showers, locker rooms, and pool areas to prevent getting plantar warts.
• Keeping foot warts dry moisture renders the spread of warts.
• When filing or cutting nails do not use the same utensil on the infected nail and the healthy nails or wash it carefully.
• Ask about vaccines that can prevent some types or strains of viruses that cause genital warts.

The majority of wart cases are harmless and fade away within 2 years. Warts around and under the nails are considered the most difficult to heal. Even with treatment, warts could recur after fading away. After wart removal, minor scars can form.

Viral warts prevalence is highly variable with different populations, age groups, and periods of time. According to two large population-based studies in an American journal, American family physician, the prevalence rates viral warts are 0.84 % in the United States and 12.9 % in Russia. Prevalence is greatest among children and young adults. Two other studies in school populations have shown prevalence rates of 24 % in 16- to 18-year-olds in Australia, and 12 % in four- to six-year-olds in the United Kingdom.