Warts (verrucae) are small, benign, usually painless, and sometimes self-limiting growths on the skin caused by human papillomaviruses (HPV).

• Common warts (Verruca vulgare)
• Flat warts (Verruca plana)
• Genital warts (Condyloma acuminatum)
• Plantar warts (Verruca plantaris)

Although prevalence is highest in children and lowest in the elderly, warts affect all age groups. Genital warts are contagious; common, flat, and plantar warts generally are not. All warts can spread from one part of the body to another. Warts can disappear without treatment, and reappear.

Human papillomaviruses (HPV)

• Contact with affected persons or shed skin with HPV (particularly for genital warts)
• Trauma
• Immunosuppressive diseases (e.g., AIDS) and drugs
• Atopic dermatitis
• Communal facilities (locker rooms)

General characteristics:

• Appear singularly, clustered
• Sometimes painful

Common warts:

• Round and asymmetric
• Can grow from tiny (1 mm), smooth, flesh-tone papules to large (5 to 10 mm), thick, rough plaques
• May form mosaics (1 to 3 cm in diameter)
• Found anywhere, but generally on the hands

Flat warts:

• Small (1 to 3 mm) papules with flat tops
• Usually flesh-tone or pink
• Sometimes itchy
• Generally found on the face and back of hands

Genital warts (venereal warts):

• Tiny flat papules that grow to resemble common warts
• Generally found on external genitalia, pubic, and perineal regions
• May be found intravaginally and in the anal canal

Plantar warts:

• Rough, thickened, scarcely elevated papules
• Sometimes exhibiting black dots, indicating thrombosed capillaries
• Often quite tender, possible leg/back pain from disrupted posture
• Found on the sole of the foot, sometimes completely covering the heel or plantar region

• Corns or clavi Scar tissue
• Skin tags Molluscum contagiosum
• Moles Condyloma latum
• Calluses Seborrheic keratoses
• Skin cancer

General clinical characteristics of warts include:

• Disturbed skin lines
• Tiny black dots (thrombosed capillaries)
• Previous trauma to sites (e.g., fingers, nails, knees, face, scalp)

• Warts usually can be diagnosed by location, appearance, and, if necessary, paring or debridement.
• Genital warts: Check intravaginally and in the anal canal.
• Plantar warts: To confirm diagnosis (vs. corns or clavi), pare lesion and look for characteristic black dots (thrombosed capillaries).
• Electron microscopy
• Immunohistochemistry
• Nucleic acid hybridization

Although asymptomatic warts can be ignored (with some risk of spreading), treatment may be desirable because warts can be embarrassing and disfiguring.

A number of treatments are available, including drug therapy (usually the initial therapy), cryosurgery (minimal scarring), electrosurgery, laser vaporization, curette and desiccation (scarring possible), and excision (scarring possible). Actual treatment depends on the location, type, and severity of warts. Because warts are benign, avoid treatments that could be harmful or could result in scarring.

Advise patients not to self-treat warts on mucous membranes or genitals and to be aware of scarring when treating warts on the face. Also, advise patients to keep warts covered during treatment.

Common, flat, and plantar warts: 12% to 40% salicylic acid, sometimes paired with lactic acid, qid (OTC). To optimize treatment, review guidelines with patients:

• Soak wart in warm water or bathe before treatment.
• Dry wart area.
• Apply medication per manufacturer's instructions.
• Keep area dry during treatment.

Some practitioners advise filing (pumice stone) before application.

Less common drugs include trichloroacetic acid or cantharidin (common warts), tretinoin (retinoic acid, Retin-A) (flat warts, notably on the face), benzoyl peroxide, bleomycin (intradermal injection), and cimetidine.

Genital warts: physician-applied podophyllin 25% in tincture of benzoin weekly or patient-applied podofilox 0.5 bid three days/rest four days, repeat up to four cycles. U.S. FDA-approved intralesional interferon alfa-n3 can be effective for persistent and recurring external genital warts. Covering warts for a week at a time with waterproof tape can cure warts by preventing viral growth. Plantar warts sometimes respond to hot-water soaks, 113°F water for 30 to 45 minutes, two to three times/week for six to eight weeks.

Nutritional and herbal support may enhance immune function and minimize recurrence of HPV. Some cases of HPV may respond to alternative therapies alone.

• Eliminate caffeine, alcohol, refined foods, and sugar.
• Avoid saturated fats, which increase inflammation (animal protein and dairy products).
• Increase whole grains, fresh vegetables, fruits, legumes, and essential fatty acids (nuts, seeds, and cold-water fish).
• Vitamin C (1,000 to 1,500 mg tid), beta-carotene (100,000 IU/day), vitamin E (400 IU/day), and zinc (15 to 30 mg/day) support immune function. Vitamin E may also be used topically to treat warts.
• B complex (50 to 100 mg/day) helps to reduce the effects of stress, which can weaken the immune system. Folic acid (800 mcg/day) is especially recommended for cervical HPV.
• Selenium (200 mcg/day) has antioxidant activity and supports immune function.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. of herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Antiviral herbs that support the immune system. Combine tinctures of 1 part of goldenseal (Hydrastis canadensis) with 2 parts each of the following: lomatium (Lomatium dissectum), licorice root (Glycyrrhiza glabra), coneflower (Echinacea purpurea), osha (Ligusticum porteri), thuja leaf (Thuja occidentalis). Take 30 drops bid.

Topical applications are most effective for eradicating warts. Discontinue any topical application if irritation should develop in the surrounding skin.

For plantar, flat, and common warts use one or more of the following applications. The application may need to be repeated nightly for up to three weeks. Wart will turn black as it begins to die.

• Peel patch. Cut a piece of banana peel and place over wart before going to bed. Tape in place.
• Raw garlic patch. Cover wart and surrounding skin with a thin layer of castor or olive oil. Apply a thin slice of fresh garlic; tape in place.

To maximize benefit, place 2 to 4 drops of tincture of thuja or greater celandine (Chelidonium majus) on the wart before application.

For genital HPV, paint the warts with vitamin A or beta-carotene once or twice daily. Add 3 to 4 drops each of thuja, echinacea, and lomatium for best results. Cervical involvement may need to be treated under the supervision of a physician. A retention douche with 1 tsp. each of thuja, echinacea, and lomatium in 2 cups of water may be helpful in resolving superficial warts.

Thuja is the classic remedy for warts, although by no means the only remedy that expresses warts. For the greatest benefit, an experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency.

May be helpful in stimulating immune system.

Monitor patients with diabetes or poor circulation for infections.

• Avoid contact with warts, particularly genital warts.
• Cover warts during treatment and avoid wound fluid.
• Use footwear in public areas.
• Do not scratch, pick, or bite warts.
• Do not share towels and washcloths with affected persons.

All warts: auto inoculation, scars

Common warts: nail deformity

Plantar warts: chronic pain from plantar wart removal

Genital warts: intraepithelial neoplasms

Although some warts will disappear without treatment, usually within 6 to 24 months, resolution without remission cannot be guaranteed.

With treatment, resolution for common, flat, and plantar warts can be six weeks or more; for genital warts, 20 weeks or more. If treatments are unsuccessful, first consider cryosurgery (multiple treatments may be needed) and then consider electrosurgery, laser vaporization, curette and desiccation, or excision.

High doses of vitamins and herbs are contraindicated in pregnancy. Topical applications are safe. Pregnant women should not use podophyllin.

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