1. Warts and Other
Lesions

2. Warts
• Benign neoplasms caused by keratinocytes transformed by HPV
• HPV type I, II and IV associated with plantar warts
– Type I causes verrucae plantaris lesions
– Type II causes mosaic warts
– Type IV causes seed corn lesions
– Type III causes genital warts
• Physical factors such as infectious location, weight-bearing pressure
and moisture help determine the clinical appearance of the lesion

3. Warts
• Due to immune system development, warts Note pinpoint spots
representing thrombosed
are seen more commonly in children and capillaries
less commonly in adults
• Can spread through small cuts in skin
• May disappear spontaneously, often within
2 years of appearance
• Diagnostic signs include pain with lateral
more than direct pressure and pinpoint
bleeding with sharp dèbridement of the
lesion

4. Wart Treatments
• Burning: • Tend to have the same things in
common:
– Chemical: 40% Salicylic acid,
mono, bi and tricholoroacetic – Painful
acid, cantharidin – Multiple treatments needed
– Freezing: liquid nitrogen – High rate of recurrence (40-
– Thermal: electrocautery, 60%)
pulsed-dye laser

5. Wart Treatments
• Immune system modification
• Surgical
– H2 blocker (Cimetidine) appears
– Sharp excholeation with blunt
to act by suppressing
dissection of lesion
histamine. Histamine
– Primary resection with sutured suppresses the immune system
closure by activating suppressor T-cells.
Low circulating levels of IgG
– Intentional implantation to
and IgM are associated with a
other extremity (Panacos graft)
higher incidence of verrucae
– Bleomycin treatment
(45% of immunocompromised
kidney recipients develop
warts)
– Only Tagamet seems to have
this effect
– 30mg/kg (adult) 20mg/kg
(child) TID for 6-8 wks

6. Wart Treatments
• Immune system stimulation • Others:
– Vitamin A (10K IU vit A) with – Effudex cream (5-flurouracil)
15μg of zinc BID – Retin-A
– Bleomycin injection (breaking – Denavir (Pencyclovir)
the capsule of the wart, – Aldara cream (Imiquimod)
injecting Bleomycin to arrest
• Typical use is genital warts
the growth of the virus and
• Use 3X week with 8-10 hour
allowing T cell development) application time without
occlusion
• Wash off completely
• Use for 3 months
• Dèbridement of the plantar
wart is essential as this has to
be absorbed through the
epidermis

7. Central core with no
overlying bony
Other Lesions
prominence
• Porokeratosis plantaris
discretum lesions (Steinberg’s
lesion)
•Looks like a wart
•Is a blocked eccrine
sweat gland
•Painful with direct
pressure

8. Large central core
Other Lesions
•Intractable plantar keratosis
•Caused by pressure at the
plantar metatarsal head
•Usually seen in conjunction
with contracted digits and loss
of the plantar fat pad

9. Algorithm
Lesion
is debrided
pinpoint bleeding small central core large core at
not necessarily at a weight-bearing area
weight bearing area
Wart PKP IPK
Surgery Burn Other surgical excision elevational osteotomy
(Bleomycin) (acid) (Tagamet) with chemical cautery
(Panacos) (electrocautery) (Effudex)
(resection) (cryotherapy) (Aldara)

10. What if it returns?
• Current success rate with the Bleomycin treatment is 95+%
• Those who fail the Bleomycin treatment are placed upon Aldara cream
with 1 failure so far in 12 cases
• The person who failed on the Aldara cream had primary surgical
excision with no return of lesion
• 16 current cases of the Panacos graft for mosaic warts with 2 failures,
who then responded to the Bleomycin treatment