wart

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Classification according to ICD-10
B07 Virus warts
Verruca simplex
Verruca vulgaris
ICD-10 online (WHO version 2019)

A wart ( Latin verruca ) is a common, possibly contagious, small, sharply demarcated and usually benign epithelium - swelling of the upper layer of the skin ( epidermis ). Most of the time, warts are slightly raised or flat. They are mostly due to an infection with one of the more than 100 different “low-risk” human papillomaviruses from the family of Papillomaviridae (non-enveloped, double-stranded DNA viruses ). Infection occurs via contact infection or smear infection via the smallest injuries to the skin and mucous membranes. There the viruses only infect the top layer of the skin cells and multiply in their cell nuclei . Weeks to months can pass from the time of infection to the formation of the warts. The particularly pronounced occurrence of warts all over the body is called generalized verrucosis in medical terminology .

A distinction must be made between the different forms of keratoderma and fibroma pendulans ( synonyms soft fibroma , fibroma molle , molluscum simplex ), which is also known as pedunculate wart or, more correctly, pedunculated fibroma, occurs particularly in the area of ​​the neck and upper eyelids and is not infectious Cause.

Occurrence

Blood vessels as dark spots after the callus is removed

Warts occur at any age and appear individually or in groups, usually as sharply demarcated, flat hemispherical or pointed outgrowths on the skin ; seldom completely flat, mostly on the hands and feet. These are growths of the epidermis . The warts usually have a thick, horny, sometimes somewhat fissured coating of squamous epithelial cells under which there is soft, easily bleeding tissue of keratinocytes . By scratching warts, they can spread to the skin, as the bleeding and the infected skin cells they contain spread the virus further on the body.

Despite their fundamentally benign character, warts can be cosmetically disruptive, particularly if they spread further on the skin, sometimes cause severe pain in certain areas and, extremely rarely, develop malignantly.

Pathogen

An infection with the wart-causing human papillomavirus , or only with molluscum with Molluscum contagiosum virus (MCV) makes no serious progress in general. There are exceptions in the case of severely damaged people, double or secondary infections (see also infection ). This shows that in the course of evolution these viruses and their reservoir host, humans, have adapted very strongly to one another.

Damage to its reservoir host is not an advantageous effect for a virus, since it depends on it for its own reproduction. The symptoms that are nevertheless triggered in the reservoir host are side effects of the infection. The state of the immune system of the person concerned is decisive for their strength .

The role of the immune system

The condition of the immune system of the affected organism also and especially in the case of infections with pathogens that are already adapted to humans as their reservoir host . The observation that with virus infections by no means all contact persons also become ill has various causes. Previous contact with this virus variant may already result in immunity , the virus dose or virulence may be too low for an outbreak of disease, or the immune system may be able to prevent symptoms of the disease despite infection ( inapparent infection or silent celebration, i.e. immunization without vaccination or disease ). If the immune system is intact and the dose of pathogen is low, warts may either not develop at all, take a less severe course, or regress on their own after a few months without any treatment.

Since children’s immune defenses are not yet fully developed, they are more likely to be affected by warts. In the first four years of life, statistically speaking, children develop up to five bacterial or viral respiratory diseases. In this phase there is also a higher risk of infection with the human papillomavirus type 1. In the case of painful warts in children, however, these should be treated particularly quickly so that the children do not adopt an evasive posture and cause permanent misalignment of the body due to the crooked position.

Even people with weakened immune systems, such as those following a serious illness or immunosuppression, are particularly at risk and smokers are also more susceptible to warts.

If the immune system has a severe disease such as a rare idiopathic CD4 lymphopenia , warts can spread all over the body ( epidermodysplasia verruciformis ). The media reported about the case of the Indonesian fisherman Dede Koswara (the "tree man"), who, after a later diagnosed HPV-2 infection, had warts all over his body, especially his hands, over the years and feet grew increasingly horny structures that looked like tree bark.

Types of warts

There are the following types:

Vulgar warts (barbed warts)

Verrucae vulgares

Vulgar warts (Verrucae vulgares) , also common warts or barbed warts , are the most common type of warts at 70 percent. At first there are pinhead to pea-sized, hard and bulging nodules ( papules ) that later become horny and can also multiply on the skin like beds. A starting wart is then surrounded by several small daughter warts. They occur mainly on the hands, fingers, nail edges and the soles of the feet. They are transmitted by the human papillomavirus (HPV 1, 2, 4, 7) by smear infection . 20 percent of twelve-year-olds, but only 2 to 3 percent of all adults, have a wart.

Butcher's warts

Butcher's warts are mostly benign vulgar warts that occur on the hands of butchers in particular and that are transmitted by the human papillomavirus type 7 (HPV 7) by smear infection when there is constant skin damage and contact with fresh meat.

Plantar warts

Verruca plantaris (underside of toe)

Plantar warts (verruca plantar) , and plantar warts , plantar warts or plantar warts called, are benign (benign) epithelial hyperplasia ( squamous ). They are mainly triggered by the human papilloma viruses 1, 2, 4, 60, 63 and transmitted by smear infection. The papilloma viruses 57, 65, 66 and 156 are also rarely the cause of plantar warts. After the initial infection, it can sometimes even take months for a plantar wart to develop at the point of entry of the virus. According to previous knowledge, this type of wart spreads on the sole of the foot, which is initially only simply infected, through new infections or through superficial scattering of an already existing wart. There is no evidence of internal virus spread via the bloodstream (hematogenous spread).

The term plantar warts especially for verruca plantar is so far unhappy when the soles of both (verruca vulgaris) common warts as well as the actual plantar warts (verruca plantar) can be attacked, where a distinction is basically turn two different types:

Mosaic warts

Mosaic warts only spread superficially on the soles of the feet or the ball of the toes, initially sporadically, later in larger numbers due to superficial adhesions in bed-like form. The individual wart is usually the size of the head of a pin, whitish in color and usually does not cause any pain. Even after bed-like expansion, most of those affected remain symptom-free.

Plantar warts

Verrucae plantares (sole of the foot)

Plantar warts or piercing warts are solitary, deeply growing (endophytic) plantar warts (myrmecia) . This type of warts forms on the undersides of the toes and the pressure-loaded regions of the soles of the feet, grows there considerably in depth and is often covered by a callus . The diameter of the nipple can increase considerably in depth, and it is not uncommon for it to double its size on the surface of the skin.

Especially in the heel area, very deep-seated plantar warts can take on extremely large dimensions and are therefore difficult to treat. Upon the occurrence of locomotion plantar warts can stress the body weight to the very sensitive periosteum (periosteum) encounter and then solved by a rule no later than when walking from severe pain.

Genital warts

Genital warts around the anus

Genital warts ( genital warts ) , including genital warts , genital warts or pointed warts are, as a local variant of verruca vulgaris millimeter-sized first, whitish or flesh-colored nodules on the genitals or anal area . They are transmitted by the human papillomavirus (HPV 6) and the condylomavirus (HPV 11) via contact infection or smear infection during sexual intercourse . Another variant of the human papillomavirus (HPV 16 and HPV 18) is also involved in the development of cervical cancer .

Dellar warts

Typical dellar warts

Dell warts ( molluscum contagiosum ) , also called mollusca contagiosa , epithelioma molluscum or epithelioma contagiosum , mollusks or pool warts, actually do not belong to the warts, although they look like them. They are pinhead to pea-sized nodules with a smooth and often shiny surface. They usually have a dent in the middle and appear all over the body, especially on the arms, hands, fingers and upper body. Unlike other warts, they are also caused by the molluscum contagiosum virus (MCV) from the Poxviridae family , an enveloped double-stranded DNA virus (dsDNA), via smear infection or contact infection.

Flat warts

Flat warts ( Verrucae planae ) , also called flat warts , are flat, round or polygonal growths, mostly soft, skin-colored to gray-yellow or brown with a diameter of one to five millimeters. Their surface is usually dull and finely dotted. They can appear all over the body, but mostly on the face or wrists, backs of hands and fingers, or on the outward-facing parts of the forearms. Flat warts are transmitted by the human papillomavirus type 10 (HPV 10) and mostly type 3 (HPV 3) by smear infection .

Juvenile flat warts

Juvenile flat warts ( Verrucae planae juvenilis ) are those flat warts that occur in children and adolescents before, during and also after puberty , mostly on the face, less often on the back of the hand and shin.

Brush warts

Verrucae filiformes

Brush warts ( Verrucae filiformes ) are thread-like skin growths, especially on the face. Preferred regions where they like to settle are the eyelids, chin, neck region and near the lips. They are usually white to pink, often with a brown tip. They are transmitted by the human papillomavirus by smear infection.

Age warts

Age warts ( Verrucae seborrhoicae ) , also called senile warts , are round or oval, light brown to brown-black, lenticular to bean-sized, mostly occurring in large numbers on the skin surface in adults, predominantly from the age of 50. They are mostly harmless, sometimes a bit itchy, and extremely rarely malignant degeneration is possible. The person or persons responsible for these warts are not known.

treatment

Warts can regress on their own after a few months without any treatment if the body's immune system succeeds in killing the virus that is causing them. The warts will then dry up and the horn cover will wear off. After healing, however, the recurrence rate ( recurrence rate ) of warts is generally high. On the other hand, they can also persist for years from the start or even multiply through self- infection. In this case, the warts are usually difficult to treat.

Surgical removal

Right: relapse after surgical removal

If the warts reach deep into the tissue (plantar warts), they may be scraped off with a so-called sharp spoon under local anesthesia. Depending on the size and depth, there is subsequent wound pain, a correspondingly long healing time and possibly scarring . Since relapses are always possible, less intrusive ( invasive ) forms of treatment are first tried . It is mainly warts that have returned after unsuccessful surgical removal (recurrent warts) that are characterized by extreme pain and resistance to therapy .

Removal of warts by electrocoagulation
The removal of warts by electrocoagulation takes place either independently or directly after a surgical removal. After local anesthesia, the skin is charred concentrically down to the basal layer of the epidermis . This kills all infected cells and 70 percent of the time, relapses are excluded. However, painful scarring on the soles of the feet must be expected with this method.
Laser wart removal
There are two variants of laser wart removal: the wart is cut out with a CO 2 laser scalpel ; the laser replaces the sharp spoon mentioned above. Here, too, there are possible disadvantages of severe after-pain and scarring, especially on the soles of the feet. A newer method uses intense pulses from a dye laser to coagulate the blood vessels of the wart growths and gradually dry them out. This method is tedious and requires three to fifteen or more sessions two weeks apart, depending on the size of the wart or areola. In addition, this treatment is usually uncomfortable to painful, as the laser pulses are perceived as a burn stimulus. The advantage is the non-intrusive (non-invasive) type of treatment and, according to previous experience, a very low risk of relapse. However, this method has not proven effective for deep plantar warts on the soles of the feet.

Cryotherapy (icing)

Icing bubble

With cryotherapy , the wart is locally cooled (frozen) to a very low temperature within a short time . Cooling can be done by spraying liquid nitrogen (temperature −196 ° C) directly from a device for several seconds . However, it can also be carried out by placing an applicator (object with which something is applied or carried out) directly onto the wart. The applicator is cooled to less than −50 ° C within seconds using an evaporating, pressurized coolant ( dimethyl ether-propane mixture ). The duration of this application is usually between 15 and 25 seconds, depending on the size of the wart.

The strong cooling of the skin causes local frostbite, which cuts off the blood supply to the affected upper skin cells, so that the skin cells infected by the virus die. The frozen skin initially turns white during the treatment; there is a slight pulling pain to feel from the frostbite. After the end of the treatment, the treated skin area slowly thaws again and becomes red. This can result in several hours of pain that can be severe. This treatment usually creates a fluid-filled blister under the dead skin cells in the area of ​​the local frostbite; it must not be pricked so that no pathogens can penetrate the treated area. The fluid in the bladder is reabsorbed over time. New skin forms under the dead skin layers, so that dead skin falls off after a while. If all skin cells infected by the virus have been killed, a single treatment is sufficient, otherwise the treatment can be repeated several times.

This method is recommended for superficial warts. The last Cochrane review from 2006 came to the conclusion that surprisingly there is a lack of evidence of efficacy : " Evidence for the absolute efficacy of cryotherapy was surprisingly lacking ". In a recent Dutch study with 240 patients, cryotherapy for warts on the hands was found to be superior to cautery with salicylic acid.

Plantar wart after treatment with salicylic acid

cauterization

During cauterization , tissue is destroyed by heating it with an electric current . In a broader sense, this also includes keratolysis with various etching agents.

Keratolytics

By applying salicylic acid - or trichloroacetic acid -containing solutions - or once a week monochloroacetic acid - the surface layer of the common wart is softened and can be peeled off. Salicylic acid-containing plasters can be left on for several days. Also formic acid can be used for treatment. Another drug for chemical burns is the Höllenstein pen, which is based on silver nitrate to be moistened .

Corrosive substances must not be used on the face or genital area. The healthy skin in the area should not be treated at the same time, but especially in the case of acetic acids, it should be protected by applying a well-adhering, fatty cream , ointment or paste (e.g. vaseline , zinc paste ) beforehand. During treatment there is a risk that the skin will tear and bleeding will occur, which can lead to a new infection.

In molluscum also comes potassium hydroxide used.

Cytostatics

Active ingredients such as 5-fluorouracil (5-FU) or podophyllin can be used as cytostatic agents . The principle of treatment with a cytostatic is to prevent the skin cells infected by the wart virus from dividing further, which means that the viruses die and the wart disappears.

Diluted 5-fluorouracil is applied to the wart as an aqueous solution in combination with salicylic acid to facilitate the removal of the upper layers of the skin, or it is injected directly into the wart. Due to the poisonous effect of 5-FU, this treatment may only be carried out under medical supervision and is particularly suitable for warts that do not respond to other forms of treatment or respond only weakly.

Podophyllin is a hygroscopic powder that is extracted from the root of the May apple (Podophyllum peltatum) . It contains lignan , podophyllotoxin and other, partly cytostatic substances. It was used as an ointment, varnish, or alcoholic tincture . Because of the undefined mixture with poisonous admixtures and the relatively weak effect, it has now largely been replaced by the pure substance podophyllotoxin and is only used to combat genital warts ( Condylomata acuminata ).

Antivirals

On various cream formulations of were cidofovir tentatively to combat HPV inserted infections. In vitro , cidofovir caused apoptosis of HPV-positive keratinocytes . In various studies with a few patients, the local application of a one percent cream or gel to the condylomata acuminata led to a reduction or complete healing in over 50 percent of the treated patients. For therapy-resistant multiple verrucae vulgares or plantar warts, cure rates of 90 to 100 percent have been reported in individual reports and in a small study with one or three percent cidofovir cream. Systemic side effects of cidofovir were not observed, but local irritation was common . In one lung transplant patient , intravenous administration of cidofovir could lead to acute kidney failure ; in other patients, oral administration resulted in nephrological impairment.

Stimulation of the immune system

The locally acting immunomodulator imiquimod is supposed to strengthen the immune system in the affected area in order to destroy the viruses. It is mainly used against genital warts , but can also be used against cutaneous warts. A therapy with the as in Germany cignolin designated dithranol appear promising. Here the induction of local inflammation is used to stimulate the immune system.

suggestion

The treatment methods also include the so-called “ discussion ” or “turning” of warts, which is practiced in folk medicine , as is still offered today by alternative practitioners and alternative medicine practitioners .

Home remedies

Treatment with adhesive tape was investigated in a small prospective study in 2002 and found to be more effective than the insufficiently investigated cryotherapy (complete healing of the treated warts: 85% versus 60%). In 2006, a six-week study by the University of Maastricht found adhesive tape hardly more effective than placebo and skin irritation occurred in 15 percent of the school children treated. Long-term studies with better adhesive tape would be necessary.

A traditional home remedy for warts is garlic . The effect is controversial. A cell-killing (cytotoxic) and cancer risk-lowering (anti-carcinogenic) effect of allicin , which results from the breakdown of the garlic ingredient alliin , has so far been shown in in vitro studies (cell cultures). There is also evidence of therapeutic success when using aqueous and oily garlic extract.

The juice of the celandine is a long-known home remedy for warts. The plant is therefore popularly known as wart herb.

prevention

The first HPV vaccine against genital warts pathogens has been approved since 2006 . In clinical studies, it offered complete protection against disease with the tested pathogens in women. There is neither a vaccination nor any other general protection against the other types of warts , as the pathogens occur everywhere and particularly frequently on floors or in towels. However, compliance with the simplest hygienic rules can reduce the risk of infection. In particular, walking barefoot in swimming pools, saunas or sports halls should be avoided.

Individual evidence

  1. ↑ Warts and the child's immune system. Retrieved November 9, 2018 .
  2. ↑ a b KM consultation hour: treatment of warts. In: KM-online. Archived from the original on June 16, 2012 ; Retrieved July 5, 2015 .
  3. ↑ B. Alisjahbana et al. a .: Disfiguring generalized verrucosis in an indonesian man with idiopathic CD4 lymphopenia . In: Archives of Dermatology . tape 146 , no. 1 , 2010, p. 69-73 , PMID 20083696 .
  4. ^ The man who looks like a tree. In: Metro. November 22, 2007, archived from the original on September 24, 2008 ; Retrieved July 5, 2015 .
  5. ↑ Photo gallery - The tree man in Indonesia. In: sueddeutsche.de. Archived from the original on September 11, 2012 ; Retrieved July 5, 2015 .
  6. ↑ MSD Sharp, Dohme GmbH (Ed.): The MSD Manual for Diagnostics and Therapy . 7th edition. Urban & Fischer, Munich 2007, ISBN 978-3-437-21761-6 , pp. 1206 .
  7. ↑ a b c d Carl Joachim Wirth (ed.), Jürgen Arnold: Fuß. Thieme, Stuttgart 2002, ISBN 3-13-126241-9 ( Orthopedics and orthopedic surgery. Section 18.2 Plantar warts).
  8. ↑ Human Papillomaviruses Compendium. Retrieved September 20, 2015 .
  9. ^ Franz Sitzmann: Hygiene. A textbook for healthcare professionals . Springer, Heidelberg 1998, ISBN 3-540-64642-6 , pp. 56 .
  10. ^ Mary H. Bunney: Viral Warts. Their Biology and Their Treatment . Oxford University Press, Oxford 1982, ISBN 0-19-261335-9 .
  11. ↑ Fritz Bittig: Picture Atlas of podiatry. 2nd Edition. Thieme, Stuttgart 2002, ISBN 3-8304-5204-7 , p. 112.
  12. ↑ a b Fritz Bittig: picture atlas of medical foot care. 2nd Edition. Thieme, Stuttgart 2002, ISBN 3-8304-5204-7 , p. 29.
  13. ↑ James A. Dickson: Surgical treatment of intractable plantar warts. ( Memento from December 25, 2010 in the Internet Archive ) In: The Journal of Bone & Joint Surgery . 30, No. 3, 1948, p. 757.
  14. ↑ Sam Gibbs, Ian Harvey: Topical treatments for cutaneous warts. In: Cochrane Database of Systematic Reviews. No. 3, 2006, doi: 10.1002 / 14651858.CD001781.pub2 .
  15. ^ Sjoerd C. Bruggink, Jacobijn Gussekloo, Marjolein Y. Berger et al .: Cryotherapy with liquid nitrogen versus topical salicylic acid application for cutaneous warts in primary care: randomized controlled trial. In: Canadian Medical Association Journal. (Can Med Assoc J) October 19, 2010, Vol. 182, No. 15, pp. 1624-1630, doi: 10.1503 / cmaj.092194 , ( full text ).
  16. ↑ Gita Faghihi, Anahita Vali, Mohammadreza Radan et al .: A double-blind, randomized trial of local formic acid puncture technique in the treatment of common warts. In: Skinmed. 2010, Vol. 8, No. 2, pp. 70–71, PMID 20527136 (e-pub p. 70; full text as PDF file ( Memento of November 12, 2015 in the Internet Archive )).
  17. ↑ RM Bhat, K. Vidya, G. Kamath: Topical formic acid puncture technique for the treatment of common warts. In: International Journal of Dermatology. 2001, Vol. 40, No. 6, pp. 415-419, PMID 11589750 .
  18. ↑ G. Coremans et al. a .: Topical cidofovir (HPMPC) is an effective adjuvant to surgical treatment of anogenital condylomata acuminata. In: Diseases of the Colon and Rectum . 46, No. 8, 2003, pp. 1103-1108, PMID 12907906 .
  19. ↑ K. Zedtwitz-Liebenstein a. a .: Acute renal failure in a lung transplant patient after therapy with cidofovir. In: Transplant International . Vol. 14, No. 6, 2001, pp. 445-446, PMID 11793044 .
  20. ↑ Jürgen Steinert: Wart remedies . In: Öko-Test . April 2003, ISSN  0948-2644 ( oekotest.de ). [http://www.oekotest.de/cgi/index.cgi?artnr=31086 oekotest.de] (link not available)
  21. ↑ Ulrich R. Hengge: Special dermatological treatment options with Imiqimod, p. 22 ff. Thieme, Stuttgart 2008, ISBN 978-3-13-145861-2 . Online: limited preview in Google Book search
  22. ↑ Hamid Emminger, Thomas Kia: Exaplan: the compendium of clinical medicine, Volume 2, p. 2019 . Elsevier / Urban & Fischer, 2010, ISBN 978-3-437-42463-2 ( limited preview in Google book search).
  23. ↑ Yael Adler: Do warts go away on their own? In: Frankfurter Allgemeine. January 16, 2017, accessed May 24, 2019 .
  24. ↑ Dermatology: Warts - As They Come As They Go. In: Deutsche Apotheker Zeitung. February 23, 2003, p. 40 , accessed May 24, 2019 .
  25. ^ Regina Philip: Big sayings, little warts. About discussing and chatting away simple warts - or whatever helps against the viral disease. In: The Standard. June 12, 2009, accessed May 24, 2019 .
  26. ↑ DR Focht, C. Spicer, M. P. Fairchok: The Efficacy of Duct Tape vs Cryotherapy in the Treatment of Verruca Vulgaris (the Common Wart) . In: Archives of Pediatrics & Adolescent Medicine . tape 156 , no. 10 , 2002, p. 971-974 , PMID 12361440 . Presentation by: Arznei-Telegramm 11/2002: Warts treatment with adhesive tape? ( Memento of April 30, 2012 in the Internet Archive ) In: arznei-telegram. 33, No. 11, 2002.
  27. ↑ Marloes de Haen et al. a .: Efficacy of Duct Tape vs Placebo in the Treatment of Verruca Vulgaris (Warts) in Primary School Children . In: Archives of Pediatrics & Adolescent Medicine . tape 160 , no. 11 , 2006, p. 1121-1125 , PMID 17088514 .
  28. ↑ Michelle M. Lipke: An Armamentarium of Wart Treatments . In: Clinical Medicine & Research . tape 4 , no. 4 , 2006, p. 273-293 , PMID 17210977 , PMC 1764803 (free full text).
  29. ↑ Suby Oommen et al. a .: Allicin (from garlic) induces caspase-mediated apoptosis in cancer cells . In: European Journal of Pharmacology . tape 485 , no. 1–3 , 2004, pp. 97-103 , PMID 14757128 .
  30. ↑ K. Hirsch et al. a .: Effect of purified allicin, the major ingredient of freshly crushed garlic, on cancer cell proliferation . In: Nutrition and Cancer . tape 38 , no. 2 , 2000, pp. 245-254 , PMID 11525603 .
  31. ↑ Farzaneh Dehghani et al. a .: Healing effect of garlic extract on warts and corns . In: International Journal of Dermatology . tape 44 , no. 7 , 2005, p. 612-615 , PMID 15985039 .
  32. ↑ European Medicines Agency recommends continued vaccination with Gardasil. European Medicines Agency, February 19, 2009, accessed July 5, 2015 (Press release on the European Public Assessment Report (EPAR) for Gardasil).

Web links

Commons : Warts  - Collection of pictures, videos and audio files