Verruca Vulgaris (Common Warts)
Medically reviewed by The Dermatologists and written by Dr. Alexander Börve
More than 3 million US cases per year
- Self-diagnosable (self assessment)
- Symptoms: slightly raised bumps with rough surface, smaller blisters, black dots
- Color: Typically lighter or darker than surrounding skin
- Location: On the hands, feet and knees
- Treatment: Topical agents (Salicylic Acid), Liquid nitrogen cryotherapy, Intralesional injections, Systemic agents, Cryotherapy, Laser, Electrodessication and surgical excision
Verruca vulgaris (common warts) is a benign growth caused by viral infection. Warts are very common among children of school age, but anyone can be infected. It is one of the most common complaints encountered by dermatologists in routine practice.3 They are contagious through skin contact and by damp towels or wet floors in showers and changing rooms
The infection is localized and is with one of the many types of human papillomavirus (HPV). HPV-2 and HPV-4 are the most common type to cause verruca vulgaris; other subtypes that may cause the warts include HPV-1, HPV-3, HPV-27 and HPV-57.
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Verruca vulgaris has a rough surface and usually appears on the hands or feet. They can occur on the back of fingers or toes and on the knees. The warts are small blisters that appear usually on the hands or under the feet (so called verrucas). You may see them in groups or a linear pattern. Warts are likely to appear in large numbers and bigger sizes during pregnancy and in immune suppressed patients.
They are often slightly raised, excessively keratinized, have hard edges and softer centers. They may be either lighter or darker than the surrounding skin. There may be small black dots in the warts as well. Warts on the hands are usually more visible and larger in size. They may look like tiny cauliflowers.
According to the place where the warts appear, they are given distinctive names. Warts in the soles of feet are called plantar warts. Those that appear on mucus membranes such as tongue are tongue warts, and they do not get keratinized so remain soft. Warts near the genital area are called condyloma (genital warts). If they appear near nail beds, it can be hard to identify as a wart, so the diagnosis should be made very carefully.
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Common warts are the result of human papillomavirus infection. There are several ways you can catch this virus. Most common is, coming to direct skin to skin contact with an infected person.
Also, there is evidence to believe in sexual transmission and direct mother to fetus transmission.5 There is no significant difference between mother to fetus transmission in vaginal and caesarean deliveries. Both are shown to have 27.66% probability.5
You can get the virus during some treatment methods as well. Especially high temperature evaporation treatment methods like CO2 laser treatment produce a vapor that contains HPV from the destroyed skin lesion, which has the ability to give you new warts in the surrounding skin or on a totally different body part.
A medical professional will be able to say if it is really a wart from history and several physical signs. The first important thing is the natural skin lines. If it is a wart, it will obscure the normal skin lines. Furthermore, your doctor might shave off the keratinized layer on top of the wart with a surgical blade to expose the characteristic black dots, which are blocked vessels due to small clots. This will reveal a uniform surface mosaic pattern, that will help confirm the diagnosis.4
However, to be one hundred percent sure, especially in the case of a wart with atypical features, a histopathological study should be done. This should be performed if the skin lesion is suspected to be cancerous or precancerous, which means having the potential to turn into a cancerous growth. For this a small sample will be extracted from the wart, and genotyping would be done for human papillomavirus.
What can I do?
For warts under the sole of the foot, which often become hard because of the pressure, there are also relieving patches available in pharmacies.
To speed up the healing process, you can soften the wart in water and then file it down as much as possible without bleeding. Then, you may put on topical cream. You should treat the wart as such every day for at least 5 to 10 sessions.
You can also get a spray at the pharmacy to freeze the wart. However, you should not use the spray on children under the age of four, if you have diabetes or if you are pregnant or breastfeeding.
Should I seek medical care?
Medical care is generally recommended if you have extensive, spreading or symptomatic warts. The same applies if you have had the warts for more than 2 years. And of course, if the wart is simply annoying you because of the cosmetic inconvenience, painful or avulsed partially, you can consider treatment options.
It is difficult to avoid the wart virus. Warts are not dangerous in any way, and they usually disappear after a few months or years. There are several methods to get rid of warts. Some methods are rapid, and others may take months to years. However, the faster methods usually cause more pain than slower ones. Despite the recent developments in modern dermatology, treating and fully curing warts with no relapses or recurrent episodes still remains a challenge. Most of the current treatment options do not focus on eradicating the virus that causes the disease; the human papillomavirus.
If you still wish to have the warts removed, there is a number of remedies and medications to buy over the counter, such as salicylic acid.
Salicylic acid is a keratolytic agent that works by breaking down the protein that makes up the wart. It can be found in various forms such as gels, solutions, pads, and plasters, and can be applied directly to the affected area. However, it’s important to note that salicylic acid can cause skin irritation and inflammation, leading to soreness and discomfort.
If you are considering using salicylic acid to treat your common warts, it’s best to consult with a healthcare professional to determine the appropriate strength and application method for your specific situation. They can also provide guidance on how long to use the medication and what to do if there is no improvement after several weeks of treatment.
While salicylic acid is generally considered safe and effective, it may not be suitable for everyone. For example, individuals with diabetes, poor circulation, or weakened immune systems should avoid using salicylic acid to treat their warts. Additionally, salicylic acid should not be used on genital warts or on moles, birthmarks, or unusual skin growths.
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Liquid nitrogen cryotherapy
If you seek medical care, liquid nitrogen cryotherapy is the most common treatment for common warts. It is also the most rapid and most painful one. And it may leave a scar, or a patch of skin that is darker (hyperpigmentation) or lighter (hypopigmentation) than your natural skin color.5 In this method, first the keratin layer that is deposited on the wart is surgically removed using a scalpel blade. Then using a cotton tipped applicator, liquid nitrogen is applied on the area to create 1 mm to 2 mm frozen tissue zone for about 5 seconds. Then it is allowed to defrost. Repeating the process two to three times in the same treatment session will increase the probability of total cure. It is very important to use proper analgesics because this method will generate severe pain that can last for minutes to hours. Also, an experienced medical professional should perform the procedure, so it is a strictly ‘do not try at home’ type of option.
Other treatment methods include topical agents, intralesional injections, systemic agents, cryotherapy, laser, electrodessication and surgical excision. CO2 laser treatment is shown to have a 90% success rate.4 And for the warts that do not go away with other treatments, an immunomodulation drug called imiquimod 5% cream is applied topically, in combination with keratolytic agents.
To treat multiple common warts in people with low pain tolerance, thermotherapy is used.5 A temperature of 440 C is maintained over the wart for about 30 minutes. This has to be repeated several times. And some adverse reactions are not uncommon, which include burning sensation, blisters induced by heat and darker skin on the area following inflammation, known as post inflammatory hyperpigmentation.
And strangely enough, there is evidence to believe that suggestive therapy also works as a method of treatment for warts in children under the age of ten.4 Suggestive therapy is a type of psychotherapy, where symptoms can be reduced or eliminated by direct suggestions or reassurance. The theory behind this method is, rather than actually treating the wart, you are manipulating the patient’s mind, which may or may not increase the speed of the natural healing process of the wart. For example, applying a banana peel, a penny or a potato eye to the skin and covering it up with tape has worked for young children.4 This method obviously takes time, but it is not painful at all.
These traditional methods of treatments were invented in the past due to lack of access to proper medical care. However, nowadays these methods are becoming more and more popular amongst the western population because people tend to believe these methods help to cure them in a healthier and more natural way.
Bottomline, common warts are usually benign skin lesions that cause no harm. There is a very slight chance the skin lesion might be cancerous or pre-cancerous, so it is better to get it checked by a dermatologist if your wart shows one or more atypical features mentioned here.
The information provided in this article is for educational purposes only and is not intended to be used as medical advice or diagnosis. The article does not replace the advice of a licensed medical professional. Always consult your doctor or dermatologist for medical advice and treatment of any skin condition.
- MedicineNet, Inc. Viral Skin Diseases – Picture of Verruca Vulgaris. Disponible en: http://www.medicinenet.com/image-collection/verruca_vulgaris_picture/picture.htm
- Wart (Plantar, Verruca Vulgaris, Verrucae). Ahmad M, et al. https://www.ncbi.nlm.nih.gov/books/NBK431047/
- Muršić I, Včev A, Kotrulja L, Kuric I, Milavić T, Šustić N, Tolušić Levak M. TREATMENT OF VERRUCA VULGARIS IN TRADITIONAL MEDICINE. Acta Clin Croat. 2020 Dec;59(4):745-750. doi: 10.20471/acc.2020.59.04.22. PMID: 34285446; PMCID: PMC8253083.
- Philip Buttaravoli, M. F. (2007). Minor Emergencies. Splinters to Fractures (2nd ed., Vol. 1). Mosby, Inc. an affiliate of Elsevier Inc.
- Zhu, P., Qi, R. Q., Yang, Y., Huo, W., Zhang, Y., He, L., Wang, G., Xu, J., Zhang, F., Yang, R., Tu, P., Ma, L., Liu, Q., Li, Y., Gu, H., Cheng, B., Chen, X., Chen, A., Xiao, S., … Gao, X. H. (2022). Clinical guideline for the diagnosis and treatment of cutaneous warts (2022). Journal of Evidence-Based Medicine, 15(3), 284. https://doi.org/10.1111/JEBM.12494
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The Specialist doctor from the University Hospital in Gothenburg, alumnus UC Berkeley. My doctoral dissertation is about Digital Health and I have published 5 scientific articles in teledermatology and artificial intelligence and others.