Types of warts

Types of warts:
Warts are grossly classified as cutaneous wart and ano-genital warts.

A) Cutaneous warts:
They are the benign lesion caused secondary to the invasion of Human papilloma virus into the keratinocytes, visible as well defined hyperkeratotic verrucous lesion.

1. Common warts (verruca vulgaris):
Common warts is very frustrating problem and cause of social concerns as it affects the social lifestyle and day to day activities of the patients. HPV types 1, 2, 4, 27, 57 and 63 cause common warts. It’s usually asymptomatic but sometimes it bleeds and painful when fissured; Filiform wart of eyelids may lead to conjunctivitis and keratitis.
It presents as a solitary papule of variable size from 1mm to 5 cm with average size of 5 mm. They grow over the period of months to year to form multiple round elevated, yellowish grayish color papules with a rough surface which lead to characteristic appearance so called verrucous appearance. In some cases, a single large wart (mother wart) grow slowly over the years and then suddenly multiple new lesion appears in the vicinity of the mother wart. (Andrews).

They are most commonly present at dorsum of hands and feet, sometimes on the knee join especially in children but can occur anywhere on the body. In nail bitters, warts can occur over the lips and tongue, usually in the middle half of the lips and rarely in the commissures. Filiform or digitate warts can present as single or multiple spikes stuck on appearance on the face and scalp. Koebner like isomorphic phenomenon is commonly seen in common wart, but less frequently in plane warts.
2. Planter warts
Human papillomaviruses types 1, 2, 27, and 57 cause plantar warts. It generally appear on the ball of the foot, heel and metatarsal head. A plantar wart first starts as a multiple small shinning ‘sago grain’ like papules which fuses to form a single plaque known as a mosaic wart.(stulberg) Typical plantar wart appear as a sharply defined round lesion with soft, pulpy central core surrounded by thick smooth hyperkeratotic border. If the surface of wart is parred with scalpel, the protective ring becomes more obvious, as plantar epithelial ridges are not continued on the wart surface. If further parring is continued, then multiple pin point bleeding spot appear which corresponds to the dilated capillary loops within the elongated dermal papillae. Plantar warts are often confused with corns or callus which can be differentiated on parring. Warts shows pinpoint bleeding spot, while corns or callus lacks such features.

The myrmecia verruca, a variant of plantar wart is caused by HPV-1.(yesudian) It is smooth surfaced, deep, Inflamed and tender papules or plaque present mostly on the palms or soles. They are more bulky than they appear on surface.

The Ridged warts, a variant of plantar wart caused by HPV -60. It preserves dermatoglyphics over the lesion, occur over the non-weight bearing areas and lack typical features of plantar warts.

HPV-60 also causes plantar verrucous cyst, 1.5-2cm size over the weight bearing areas of the plantar surface. HPV infected epidermis form the cyst wall.

Spontaneous resolution of wart is more common in children than in adults, it will be further delayed if patient had hyperhidrosis or any orthopaedics defects. The number of warts does not affect the prognosis but mosaic tends to remain for longer duration.

3. Plane warts (Flat warts)
Human papillomavirus types 3, 10, 28, and 41 are most common cause of flat warts. They primarily affect the children and young adults. Sun exposure is known risk factor for plan warts. They present as multiple flat topped to slightly elevated, skin colored to slightly erythematous, and may be pigmented, round to polygonal papules. The site of predilection for plane warts is the face, neck, dorsa of hands, wrists, elbows, or knees. There number ranges from two to three to many hundreds. Plane warts tends to present with Koebner phenomenon as multiple linear papules in scratched area. Men who shave the beard and women who shave the legs are more prone to develop plane wart because of Koebner phenomenon.

Erythematous plane wart of the face need to be differentiated from acne vulgaris. Plaque like plane warts are often confused with lichen planus and verrucous nevus. Hyperpigmented plane wart may be confused with lentigens or ephelides. Among all warts, plane warts have highest self-resolution rate.

4. Periungual warts
Periungual warts commonly occur around the nail folds or beneath the nail plate. It disturb the nail plate growth. Nail bitter are more prone to develop periungual warts. (tosti)
Variants:
5. Filiform and digitate wart
It occur commonly on the face, neck and scalp area in male. On the scalp is often confused with epidermal nevus.

6. Huge hyperkeratotic warts.

They are extremely hyperkeratotic lesion with horny projection and extensive in distribution. Immunocompromised status predispose to such huge warts.

7. Butchers’ warts
Butchers who are constantly in contact with moist animal flesh are more exposed Human papilloma virus. HPV-2 is frequently associated with butcher’s warts but HPV-7 is present in near about half of the cases. Among 1480 workers of New York meat trade, 23% of those directly handling meat had warts, compared with 10% of those employed in some other work. 43 rooks These lesion are larger than common wart, affect the hands and have high recurrence rate even after successful treatment.

8. Pigmented warts
HPV types 65, 4 and 60 known to causes pigmented wart over the palms and soles in Japanese population. (53 rooks)
B) Anogenital Warts:
It is also known as a condyloma acuminate. There is light male preponderance with male to female ratio of 1:07. They are mostly sexually acquire but can also spread through direct contact from perianal warts following coitus. It can be benign lesions, most commonly caused by low risk HPV type 6 and 11 or malignant lesion in form of cervical or penile carcinoma, caused by high risk HPV types 16 and 18.
The typical condyloma present as multiple soft, pink, elongated or sometime filiform or pedunculated lesion of variable size from 2-5mm. In women, lesions appear over the mucosal surface of the cervix or vulva, on the perineum while in men, lesions appear on the frenulum, corona and glans penis. They are often asymptomatic, but can cause pain, bleeding and discharge. Sometime large cauliflower like growth present on the moist areas like perianal skin, vulva and inguinal folds, which result in accumulation of purulent discharge producing malodorous masses. There can be sudden eruption of numerous lesions during the pregnancy.

When perianal warts are present, history of receptive anal intercourse must be taken so as to rule out intra-anal warts and need for anoscopy. Routine anal PAP smear should be done in immunocompromised patient and those with history of high risk HPV type wart elsewhere in the body to rule out any malignant changes.

1. Yesudian PD, Parslew RA. Treatment of recalcitrant plantar warts with imiquimod. J Dermatolog Treat 2002;13:31–33
2. Stulberg DL, Hutchinson AG. Molluscum contagiosum and warts. Am Fam Physician 2003;67:1233–1240.

3. Tosti A, Piraccini BM. Nail disorders. In: Bolognia, J, Jorizzo J, Rapini R, eds. Dermatology. 1st ed. London: Mosby; 2003:1061–1078.