Common warts are caused by human papillomavirus infection; clinical lesions develop after a latent period of weeks to several months. They have a peak incidence in late childhood and adolescence and then the occurrence sharply declines. They may, however, be found in all age groups. Usually patients will recall a single lesion, which is often interpreted at first as a splinter or thorn.
The clinical course is variable. Some will develop only a few lesions over years, while others will be covered within a few months. Conventional wisdom is that given time all verrucae (VV) will spontaneously involute. Unfortunately this is not a universal occurrence and in children, uncontrolled spread can lead to social disfigurement and infection of playmates and other family members. In one longitudinal study of the natural history of common warts, only 40% of patients were clear 2 years later.
Evolution of Skin Lesions
The initial lesion may be indolent for years but most often expands in size while satellite lesions emerge.
1. Natural sunlight or ultraviolet light in the UVA and UVB spectra.
2. VV is spread by close physical contact and fomites and is especially common in some occupations such as butchering, where chronic cuts and abrasions afford a portal of entry. Warts occur frequently on the soles of persons who go without footwear in locker rooms and public bath facilities.
3. In immunosuppressed patients, pregnancy, and persons in active stages of HIV disease, warts tend to be more aggressive and more refractory to treatment.
Multiple proprietary wart medications are available at any pharmacy. The marginal efficacy of these products can be measured by the number that are on the shelf. On occasion, patients will have some success but in general most of these products are variations of keratolytics that have been in use since the early part of the last century. Self-treatment is a problem mainly when delay leads to widespread lesions or when applied to lesions that have been inappropriately diagnosed.
In unusually widespread or therapeutically refractory lesions, obtain history for possible sources of immunosuppression. Warts in the genital and perianal areas of small children have been reported in the literature as an indication of sexual abuse. In clinical studies where this has been investigated, the relationship to abuse has been unreliable. The practitioner should, however, be wary and look for other corroborating history or physical findings.
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