Definition
A.A wart is an elevation of the epidermal layer of the skin (skin tumor). Warts are caused by the papillomavirus.
Incidence
A.Warts occur in people of all ages, more commonly in children and those in early adulthood.
B.By adulthood, 90% of all people have positive antibodies to the virus.
C.Warts are seen more frequently in females than in males.
Pathogenesis
A.A circumscribed mass develops on the skin that is limited to the epidermal layer. The virus, papillomavirus, is located within the nucleus of the cell.
B.The virus may be transmitted by touch and is commonly seen on the hands and feet.
C.Most warts resolve without treatment within 12 to 24 months.
Predisposing Factors
A.Skin trauma.
B.Immunosuppression.
C.Exposure to public showers, pools, locker rooms, and so forth.
Common Complaints
A.Bump on the skin or specific area of the body (hands, feet, arms, and legs).
B.Usually painless unless present on the bottom of the foot.
Other Signs and Symptoms
A.Common wart (Verruca vulgaris): Flesh-colored, irregular lesion with rough surface; black dots in center of lesion occasionally seen, which is thrombosed capillaries; can occur on any body part.
B.Filiform wart (Verruca filiformis): Thin, threadlike, projected papule on face, lips, nose, or eyelids.
C.Flat wart (Verruca plana): Flat-topped, flesh-colored papule, 1 to 3 mm in diameter, with smooth surface; seen in clusters or in a line, on face and extremities.
D.Plantar wart (Verruca plantaris): Firm papule, 2 to 3 cm in diameter, indented into skin with verrucous surface; painful with ambulation, when placed on ball or heel of foot.
E.Genital warts: See the topics on sexually transmitted infections in Chapter 17.
Subjective Data
A.Determine onset, location, and duration of tumor.
B.Elicit information regarding a history of previous warts.
C.Identify with the patient what treatment has been used in the past and what the results were. Question the patient regarding length of time over-the-counter (OTC) medications were used, and how aggressive he or she was with the treatment.
Physical Examination
A.Inspect:
1.Assess skin for lesions, noting location, appearance, size, and surface texture of tumor.
2.Examine the entire body for other lesions.
Diagnostic Tests
A.None indicated.
Differential Diagnoses
A.Wart:
1.Verruca vulgaris.
2.Filiform wart.
3.Verruca plana.
4.Verruca plantaris.
B.Seborrheic keratosis.
C.Callus.
D.Molluscum contagiosum: Flesh-colored group of firm papules found on the face, trunk, and/or extremities. A white core may be expressed from lesion. Lesion may be successfully removed by curettage or cryotherapy.
Plan
A.General interventions:
1.Identify type of wart.
2.Treatment is based on the type of wart.
B. 
See Section III: Patient Teaching Guide Warts.
C.Pharmaceutical therapy:
1.Common wart:
a.After soaking and filing wart with a nail file, apply one of these:
i.Salicylic acid 17% (Compound W) gel twice daily for up to 12 weeks, if needed. Keep site covered with adhesive and bandage.
ii.Apply duct tape to site after treatment. Repeat this treatment every night for up to 12 weeks or until resolved.
b.Cryotherapy with liquid nitrogen to site. Repeat every 3 to 4 weeks until resolved. Apply adhesive tape over the site and keep covered.
2.Flat wart:
a.Retinoic acid: Apply to site twice daily for 4 to 6 weeks.
b.Aldara (imiquimod) 5% cream may be applied by the patient at home. Although labeled use is for genital warts, the patient may consider off-label use at bed-time and wash off after 6 to 8 hours every other day until resolved. Precautions should be stressed regarding caustic nature of cream to healthy skin.
3.Plantar wart: Salicylic acid 40% (Mediplast), apply over wart. Remove in 24 to 48 hours and remove dead skin with stone or by scraping or using nail file. Repeat every 24 to 48 hours until wart is removed. May take up to 6 to 8 weeks.
4.Filiform wart:
a.Cryotherapy with liquid nitrogen to site. Repeat every 3 to 4 weeks until resolved. Apply adhesive tape over the site and keep covered.
b.Dermatologist referral for surgical removal.
5.Educate patient to throw away emory board nail file after each use. If using nail file, cleanse after each use with alcohol.
Follow-Up
A.Follow the patient every 4 to 6 weeks until resolved.
Consultation/Referral
A.If diagnosis is unclear, refer the patient to a dermatologist for surgical excision and biopsy.
Individual Considerations
A.Warts occur in all ages but are less common in the elderly. Use caution if patient elects cryotherapy to treat a wart secondary to thinness of aging skin. Always assess if the patient is taking aspirin or anticoagulant therapy prior to incisional removal or cryotherapy.