Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Warts, Common and Plantar
Benign intra-epidermal tumors of the skin.
I. Etiology: Human papillomavirus (HPV), a papovavirus that grows within the nucleus of the epithelial cells causing hyperplasia
II. Incidence
A. Worldwide in occurrence
B. Plantar and common warts are most frequently seen in children from 12 to 16 years of age. Both are more common in females.
III. Incubation period
A. Varies from 1 to 12 months after inoculation
B. Averages 2 to 3 months
IV. Communicability
A. Transmitted through hetero or autoinoculation.
B. Transmission through fomites and clothing may occur.
C. Virus concentration is greatest in warts of 6–12 months duration.
V. Subjective data
A. Common warts: Verruca vulgaris
1. Complaints of warts that started as small papules and grew over a period of weeks or months
2. There may be no presenting complaints, but warts may be found on physical examination.
3. Complaint is generally prompted by cosmetic appearance; however, some large warts in certain areas may be irritated by pressure (e.g., use of a pencil may cause pain in wart on finger).
B. Plantar warts: Verruca plantaris
1. Pain on the sole of the foot on weight bearing or walking
2. Corn or callus on the sole of the foot
3. Complaint of plantar wart
4. May be history of trauma
VI. Objective data
A. Common warts
1. Lesions begin as tiny, translucent papules and progress to sharply circumscribed, circinate, firm lesions. Surface is roughened and pitted with papillary protuberances. Black pinpoint spots are often seen on the surface (thrombosed capillaries). Color of lesions ranges from skin-colored to gray-brown.
2. Found most often in multiple distribution on the hands, but may occur anywhere on epidermis, usually on sites subjected to trauma
B. Plantar warts
1. Lesions are flat (because of weight bearing) or slightly elevated.
2. Resemble a callus with pinpoint depressions on the surface
3. Capillary dots may be seen.
4. Interrupt natural skin lines (calluses do not)
5. May be a single wart or a multiple distribution
VII. Assessment
A. Diagnosis is made by appearance.
B. Differential diagnosis
1. Molluscum contagiosum: Umbilicated waxy papules; molluscum body can be expressed
2. Foreign body reaction: By history and surrounding erythema
3. Callus: Does not interrupt skin lines as does a plantar wart
VIII. Plan
A. Many treatments are available for warts, including benign neglect.
B. Vigorous treatment, which may cause pain and scarring, is not generally recommended.
C. Treatment is not always successful; rate of recurrence is high.
D. Many times the warts resolve spontaneously (66% within two years).
E. Treatment modality selected must be individualized according to the child and the location of the wart.
F. Therapies can be combined, e.g., occlusive and imiquod.
G. Common warts
1. Occlusive therapy: Periungual and subungual warts, which tend to be painful, may respond well to this therapy.
a. Completely occlude wart with adhesive tape.
b. Leave tape undisturbed for 1 week.
c. After 1 week, soak wart thoroughly in warm water.
d. Scrape surface of wart with emery board or fingernail.
e. Reapply adhesive tape, and repeat process.
f. May take several weeks for wart to disappear
2. Duofilm or Occlusal (salicylic and lactic acid in collodion)
a. Soak wart for 10 minutes.
b. Scrape surface with emery board.
c. Apply medication to wart only, using a toothpick.
d. Allow to dry.
e. Repeat every 24 hours.
f. If pain or inflammation occurs, discontinue treatment until symptoms subside, then resume.
3. Trans-Ver-Sal patch (salicylic acid 15%), 6-mm or 12-mm size
a. Cut patch to size of wart.
b. Clean skin and smooth wart surface with emery file.
c. Moisten wart with drop of water.
d. Apply patch and secure with tape.
e. Apply at bed time and remove in morning, about 8 hours later.
f. Use nightly until wart is gone.
4. Retin-A gel, 0.01%. Use once daily.
5. Cryosurgery (Histofreezer or Verruca Freeze)
a. Office procedure
b. Follow directions with product.
c. Treatment intervals—every 2 weeks
6. Heat therapy: Use in conjunction with other therapies.
a. Local heat at 50C for 30 to 60 seconds, 1 to 4 times or
b. Immersion in water bath at 45C for 30 minutes, 3 times a week
c. Use extreme caution to avoid burns.
7. Imiquod
a. Apply 1–2 times a day with or without occlusion
b. Use for up to 16 weeks.
G. Plantar warts
1. Duofilm or Occlusal
a. Soak foot in warm water for 10 minutes.
b. Scrape surface of wart with emery board.
c. Apply Duofilm to wart with a toothpick; allow to dry and apply more if necessary to cover wart.
d. Apply adhesive tape to wart once Duofilm is dry, and leave on for 24 hours.
e. Repeat process daily.
2. Trans-Plantar patch (salicylic acid 21%), 20-mm size: Follow directions as for Trans-Ver-Sal patch.
3. Hyperthermia
a. Hot water (45C) immersion 30 to 45 minutes 2 to 3 times a week for 10 treatments
b. Wart virus is thermolabile.
4. Podofilax (Condylox)
a. Apply small amount at night.
b. Cover with adhesive tape.
c. Leave on for 12 to 48 hours.
d. Scrape wart.
e. Repeat procedure.
5. Cryosurgery (Histofreezer or Verruca Freeze)
a. Office procedure
b. Follow directions with product.
IX. Education
A. Warts are caused by a virus.
B. Warts generally occur following trauma to the skin.
C. Warts are transmitted by direct contact, but plantar warts can be transmitted by fomites and floors.
D. Virus concentration is greatest in warts of 6 to 12 months’ duration.
E. Most warts eventually disappear without treatment. Approximately 66% resolve spontaneously within 6 months, 50% in one year, and 66% in two years.
F. Recurrences occur in 20% to 30% of all cases.
G. Duofilm/occlusal
1. Do not use applicator with medication; drops are large and apt to get on surrounding skin.
2. Do not apply to surrounding skin; causes desquamation and tissue destruction.
3. Keep Duofilm bottle tightly closed.
4. With erythema or tenderness, discontinue treatment until inflammation subsides.
5. Do not use on infected or recently treated areas.
6. Overtreatment will cause scarring.
H. Trans-Plantar or Trans-Ver-Sal
1. Do not apply to surrounding skin.
2. Do not use on any other lesions. Use only on warts that have been diagnosed as such.
3. Patient directions and emery file are included in package.
I. Wear correctly fitting shoes to avoid pressure and trauma to the feet with plantar warts.
J. Treatment of warts may require several weeks.
K. With occlusive therapy, if skin is sensitive to tape, use Micropore or Dermicel.
L. Visible clinical improvement should be noted in 2 to 4 weeks. Complete resolution may take 6 to 12 weeks.
X. Follow-up
A. Return in 1 week if using Duofilm.
B. Telephone in 2 weeks with occlusive therapy.
C. Recheck periungual or subungual warts treated with occlusive therapy every 10 to 14 days.
D. Retreat within 3 weeks if using cryotherapy.
XI. Complications
A. Secondary infection
B. Trauma to surrounding skin
XII. Consultation/referral
A. For more vigorous treatment: Electrodesiccation for common warts or laser surgery for plantar warts
B. Diabetics
C. Venereal warts (condyloma acuminatum): Soft, friable, vegetative clusters on the foreskin, penis, labia, vaginal mucosa, or perianal area