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Monday, August 1, 2011








     HPVs (Human pappilloma virus) can infect and cause disease at any site in stratified squamous epithelium, either keratinizing (skin) or non- keratinizing (mucosa). The clinical problems encountered with such infections can be broadly divided into cutaneous warts, genital warts, oral warts and laryngeal warts.
       Warts are a very common problem in practice, particularly among children. It can affect any part of the body. In countries with highly developed medical services, referral rates of warts to dermatology clinics have greatly increased in the last four decades.

Incubation period
    Common and plantar warts: The time of acquisition of the infection can seldom the ascertained. An estimated period ranges between a few weeks and more than a year.

   Genital Warts: Incubation period of 3 weeks to 8 months, average 2.8 months. Perinatally acquired HPV infection may not manifest as genital warts for up to 2 years.

Laryngeal Warts: Only 57% of cases of laryngeal papilloma in children are diagnosed by 2 years of age.

       In genital warts infectiviy is highest early in the course of the disease. Any sexual contact of a patient with genital warts is likely also to be infected. There is no reliable information on the infectivity of common and plantar warts, but experience suggests that it is substantially less. The infectivity of maternal genital HPV as regards laryngeal papilloma in the child seems low.

Modes of Trasmission
     Warts are spread by direct or indirect contact. Impairment of the epithelial barrier function, by trauma (including mild abrasions), maceration or both, greatly predisposes to inoculation of virus, and is generally assumed to be required for infection, at least in fully keratinized skin, as in the following examples:

·         Plantar warts are commonly acquired from swimming pool or shower- room floors, whose rough surfaces abrade moistened keratin from infected feet and help to inoculate virus into the softened skin of others.
·         Common hand warts may spread widely round the nails in those who bite their nails or periungual skin, over habitually sucked fingers in young children, and to the lips and surrounding skin in both cases.
·         Shaving may spread wart infection over the beard area.
·         Occupational handlers of meat, fish and poultry have high incidences of hand warts, attributed to cutaneous injury and prolonged contact with wet flesh and water.
·          Genital warts have a high infectivity. The thinner mucosal surface is presumably more susceptible to inoculation of virus than is thicker keratinized skin, but in addition lesions were noted to be commonest in sites subject to greatest coital friction in both sexes.

          The characteristic histological feature of viral warts is vacuolation in cells in and below the granular layer, often with basophilic inclusion bodies composed of viral particles, and eosinophilic inclusions representing abnormal keratohyaline granules. This cytopathic effect may show detailed features typical of the HPV type involved and is almost always accompanied by epidermal acanthosis and often papillomatosis.

Clinical features

                                    COMMON WARTS
Common warts (excluding plantar warts) are due mainly to HPV 2. They range in size from less than 1mm to over 1cm in diameter, and by confluence can from large masses. They are characterized by firm papules with a rough, horny surface.

       Commonly situated on the backs of the hands and fingers.

        In children under 12 years of age. A single wart may persist unchanged for months or years, or large numbers may develop rapidly after an interval. New warts may from at sites of trauma, though this kobner isomorphic phenomenon is usually less marked than in plane warts. However, multiple warts around the nail folds are often seen in nail biters.
       Common warts are usually symptomless, but may be tender on the palmar aspects of the fingers, when fissured or when growing beneath the nail plate. Warts around the nail folds or beneath the nail may disturb the nail growth, and warts on the eyelids may be associated with keratitis or conjunctivitis.
       About 65% of warts disappear spontaneously within 2years and tend to do so earlier in boys. Neither the patient’s age nor the number of warts present influences the course. Regression of common warts is asymptomatic and occurs gradually over several weeks, usually without blackening. Malignant change is extremely rare.

                                PLANTAR WARTS    
     As suggested by the name, they occur mainly on the soles of the feet. Most plantar warts are beneath pressure points, the heel or the metatarsal heads. In older girls and women they occur predominantly beneath the forefoot and toes. They are sometime found on the palms of the hand.

     A plantar warts at first appears as a small shining ‘sago-grain’ papule, but soon assumes the typical appearance of a sharply defined, rounded lesion, with a rough, keratotic surface surrounded by a smooth collar of thickened horn. If the surface is gently pared with a scalpel the abrupt separation between the wart tissue and the protective horny ring becomes more obvious, as the epithelial ridges of the plantar skin are not continued over the surface of the wart. If the paring is continued, small bleeding points, the tips of the elongated dermal papillae, are evident.

     Mosaic wart is so described from the appearance presented by a plaque of closely grouped warts on the sole with a polygonal outline and a rough surface.

     Pain is a common but variable symptom. It may be severe and disabling but may be absent, and many warts are discovered only on routine inspection. Mosaic warts are often painless.

    The duration of plantar warts is very variable. Spontaneous regression occurs sooner in children than in adults and is delayed if hyperhidrosis or orthopaedic defects are present.

    The number of warts present does not influence the prognosis, but mosaic warts tend to be persistent. Regression is occasionally clinically inflammatory, and often culminates in blackening from thrombosed blood before the lesion separates, but in many cases simply takes the from of apparent drying and gradual separation.

Differential Diagnosis
  • Plantar warts are often confused with callosities or corns, with which they may indeed be associated.
  • Callosities have a uniformly smooth surface across which the epidermal ridges continue without interruption. In cases of doubt the horny layer should be gently pared.
  • Corns occur on pressure points on the toes, soles or interdigital skin. When the surface is scraped it shows the absence of papillomatous surface typical of plantar warts. Corns are most painful when pressed from top as compared to the wart in which the pain is felt on pressure from the top as well as the sides.


                                         PLANE WARTS
     The face and the backs of the hands and the shines are the sites of predilection. Children are most commonly affected.

     They are smooth, flat or slightly elevated and are usually skin- coloured or grayish- yellow, but may be pigmented. They are round or polygonal in shape and very in size from 1 to 5 mm or more in diameter. Contiguous warts may coalesce and a linear arrangement in scratch marks is a characteristic feature.
      Regression of plane warts is usually heralded by inflammation in the lesions, causing itch, erythema and swelling, such that preciously unnoticed warts may become evident. Depigmented haloes may appear around the lesions. Resolution is usually complete within a month.

Differential Diagnosis 
         In differential diagnosis, lichen planus causes most difficulty. It is relatively less common in children, favours the flexor aspects of the forearms, is unusual on the face and is often itchy. The mucous membranes may be involved. The flat, polygonal papules are lilac-pink and smooth and may show wickham’s striae. In contrast, the surface of plane warts has a stippled appearance under the hand lens. The lesions in molluscum contagiosum are pearly in colour, look like solid vesicles, and when squeezed, cheese like material is demonstrated.

                         FILIFORM AND DIGITATE WARTS  
      Commonly seen in males, on the face and neck, irregularly distributed, and often clustered. Digitate warts, often in small groups, also occur on the scalp in both sexes, where they are occasionally confused with epidermal naevi. Isolated warts on the limbs often assume filiform shape.

      The lesions are flesh coloured or somewhat darker, rounded or oval papules or nodules. The size of these varies from lentil seeds to split peas (somewhat bigger). Their verrucous surface is very typical; once seen it is seldom missed. On the scalp the wart may have a cauliflower like appearance. The warts do not itch but the subungal warts may be painful. Koebner’s phenomenon represented by linear group of warts following inoculation of virus into the scratch may be seen. In the beard region, they may take the form of finger like processes: filiform warts.  

Differential Diagnosis
     A single common wart should be distinguished from Butcher’s or postmortem wart (tuberculosis cutis verrucosus), which is marked by induration around the periphery of the lesions. Verruca vulagaris should be distinguished from seborrheic warts, which are multiple, circumscribed, flat elevations covered with dark, greasy scales. They occur mainly on the trunk, forehead and temples.

                                          ANOGENITAL WARTS
      The term condyloma acuminatum (condyloma= knuckle; acuminatum= pointed), pl. condylomata acuminate, was originally used to emphasize the difference between ano- genital warts, which are usually protuberant, and the flatter syphilitic lesions, condylomata lata. It became an accepted term, mostly in the American literature, for viral anogenital warts.
      With recent developments in the understanding of HPV disease, it is clear that the term is used variously to denote (i) the classical protuberant type of anogenital wart only; (ii) all clinically identifiable HPV disease of the anogenital region including flat warts on the external genitalia and cervical ‘flat condylomas’; (iii) all clinical lesions due to the HPV types usually associated with genital warts, including those in extragenital sites, for example the mouth.

    The area of frenulum, corona and glans I men, and the posterior fourchette in women, correspond to the likely sites of greatest coital friction.

     They are often asymptomatic, but may cause discomfort, discharge or bleeding. The typical anogenital wart is soft, pink, elongated and sometimes filiform or pedunculated. The lesions are usually multiple especially on moist surfaces, and their growth can be enhanced during pregnancy, or in the presence of other local infections. Large malodorous masses may form on vulvar and perianal skin. This classical ‘acuminate’ (sometimes called papillomatous, or hyperplastic) form constitutes about two- thirds of anogenital warts.
     Patients with genital warts frequently have other genital infections. These are mainly minor conditions such as candidiasis, trichomoniasis and non- specific genital infection. The duration of anogenital warts varies from a few weeks to many years. Recurrences can be expected in about 25% of cases, the interval varying from 2 months to 23 years.

Differential Diagnosis
     Differentiation is from condylomata. In long standing cases, gaint condyloma accuminatum of Buschke and squamous cell carcinoma must be excluded by microscopic examination. Genital warts are often acquired along with other venereal infections and as such testes for syphilis and gonorrhea should be carried out.

   Invasion of viral warts in genetically predisposed persons, manifested by profuse coalescent eruptions of verruca plana type lesions, usually on the limbs.


    Warts are something very peculiar. Some, specially, if they are numerous, sometime heal very rapidly, whereas others isolated warts, sometime bid defiance to all treatment. This is one of the important manifestations of sycotic miasm.
    The following points should be noted very carefully during case taking:

  • After gonorrhea: Thuja.
  • After having consumed too much salt: Nitri spiritus dulcis.
  • After abuse of mercury: sarsaparilla.
  • After syphilitic infection: aurum met.
  • After injury: Bellis perennis.

Previous Treatment
       It is essential to know whether patient has attempted to cauterize with the help of the following:
·         Acetic acid.
·         Caustic potash.
·         Fluoric acid.
·         Silver nitrate.
·         Burning with the help of Agarbatti (a perfume stick used in India).

If it is so then it should be antidoted as follows:
  • Aliments after cauterization: Caust, Nit-ac, Thuj.
  • Use of Acetic acid, Caustic Potash and Fluoric acid preferably in high potencies.
  • For bad effects of Silver nitrate – Use Natrium mur. In high potencies. 
  • When Agarbatti is used, then to neutralize its ill effects, use Carbolicum acidum  or Causticum.
  • When electric cautery is used for cauterization, it should be antidoted with drugs like Carbolicum acidum, Causticum, Radium bromatum and X-ray.

·         Face
·         Fingers
·         Palms, etc.

·         Flat
·         Fleshy
·         Hard
·         Horny
·         Pedunculated
·         Smooth, etc.

Whether warts are associated:
·         With or without inflammation.
·         With or without itching.
·         With or without bleeding.
·         With or without suppuration.
·         With or without ulceration.
·         Tender or non- tender.

Important Characteristic Sensations
            You should always enquire about e.g.:

  • Burning.
  • Pulsating.
  • Stinging.
  • Stitching.
This is very important when the wart is isolated.
     The colour of the warts
Sometimes the colour of the wart also helps us to select remedy indirectly:
·         Red: Calc Carb, Thuja. 
·         Brown: sepia, Thuja.
·         Grayish brown: Conium.
      It is strongly advised not to recommended to the patient any local application for the treatment of warts, e.g. application of lime, homeopathic mother tinctures or remedies like Salicylic acid, Fluoric acid, for the following reasons:

·         It is against the basic principle of homeopathic.
·         Recurrence rate is very high.
·         Since the cause lies within, it is futile to cure disease externally.

some of cured cases

                  Treatment Review
·        I have observed that majority of cases get cured, where only, constitutional remedies were prescribed and occasionally those remedies, which do not produce warts in its proving, have frequently cured the cases at the beginning should be on a constitutional background.
·        Falling to respond to the above method a drug should be selected taking into account the local signs and symptoms. If this also fails then only one should take help of empirical or specific medicine.
·        It is always wise to restudy the case at least three times before seeking these specific medicines.
·        Ficus carica, Calcarea ovi testae and Calcarea calcinata are three good homeopathic remedies that I have found useful in my practice.

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