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Wart Removal

Genital warts are caused by the genital human papillomavirus (HPV). HPV is the most common sexually transmitted disease in the U.S. Certain types of HPV cause genital warts while other types of the virus are associated with cervical, vulvar, anal, and penile cancers.

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Comprehensive testing and treatment of warts. Warts is usually caused by HPV (Human Papillomavirus). Warts can be acquired through sexual intercourse or skin to skin contact (kissing, holding hands). Some warts may look like skin cancer. Talk to us and find out effective ways of treatment.

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Warts on the external genitalia are easy to identify while warts in the vagina or on the cervix are not. Since HPV can lead to premalignant cellular abnormalities in the cervix, it’s very important that these changes be diagnosed and treated. Regular Pap smears are essential for diagnosing HPV on the cervix.

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What is a wart?

A wart of the genitalia is caused by strains of human papillomavirus (HPV) some of which are usually transmitted by sexual contact. In men and women, they may be associated with cancer of the cervix, vulva, oral, anal, and other cancers.

 

The frequency and the statistics are not known in Malaysia but it is possible that many people are shy and not forthcoming regarding their disease. Most tend to ignore warty growth until it becomes annoying or when the wart becomes too huge to hide.

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Warts need to be treated early before it becomes too complicated and numerous. When warts become complicated, then treatment time is more tedious and longer.

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What are the types of warts?

Warts can appear anywhere on the body. It can affect the skin and mucous via skin to skin contact, however, sexual transmission is still the highest way of transmission. ​

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In recent years, there are new studies showing warts related to HPV as directly transmitted through skin to skin contact, in short, a simple touch can also transmit warts. 

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Warts are caused by human papillomavirus (HPV). There are about 130 known types of human papillomaviruses. 

HPV infects the squamous epithelium, usually of the skin or genitals, but each HPV type is typically only able to infect a few specific areas on the body.

 

Many HPV types can produce a benign growth, often called a "wart" or "papilloma", in the area they infect.

 

Types of warts include:

  1. Common warts

  2. Flat warts

  3. Filiform warts

  4. Plantar warts.

  5. Mosaic warts

  6. Periungal warts

  7. Oral warts

  8. Genital warts
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Which HPV subtypes cause wart?

Human papillomavirus (HPV) is divided into Low-risk and High-risk HPV subtypes. HPV subtypes are recognized based on their number. There are bout 130 HPV subtypes and it will be impossible to call out each HPV subtypes by name, therefore we use numbers to identify HPV. 

High-risk HPV subtypes cause cancers while Low-risk HPV subtypes cause warts and certain skin growths.












Many of the more common HPV and wart types are listed below.

  • Common warts – HPV types 2 and 4 (most common); also types 1, 3, 26, 29, and 57 and others.
     

  • High-risk: 16, 18 (cause the most cervical cancer); also 31, 33, 35, 39, 45, 52, 58, 59, and others.
     

  • Plantar warts (verruca) – HPV type 1 (most common); also types 2, 3, 4, 27, 28, and 58 and others.
     

  • Anogenital warts (condylomata accuminata or venereal warts) – HPV types 6 and 11 (most common); also types 42, 44, and others.
     

  • Low-risk: 6, 11 (most common); also 13, 44, 40, 43, 42, 54, 61, 72, 81, 89, and others.
     

  • Verruca plana (flat warts) – HPV types 3, 10, and 28.
     

  • Butcher's warts – HPV type 7.
     

  • Heck's disease (focal epithelial hyperplasia) – HPV types 13 and 32.​

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How to kill HPV?

HPV virus is rather difficult to kill. They are relatively hardy and immune to many common disinfectants. Some example which can be used to kill or disinfect the HPV virus:

  1. 90% Ethanol for at least 1 minute

  2. 2% Glutaraldehyde 

  3. 30% Savlon

  4. 1% Sodium hypochlorite

  5. Silver nitrate
     

The virus is resistant to drying and heat but killed by 100 °C or in extremely low temperature (−1°C)

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Since the HPV virus is difficult to kill, therefore, certain measures need to be exercised. Not only the HPV virus is difficult to kill but is is easily transmissible via touch, which makes it spread worse for the population. 

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How to treat warts?

Warts are complicated if they are not treated early. They tend to be more complicated based on the rate they are growing and the location on which they are growing on. The faster warts grow, the more complicated it is to treat warts. Sometimes treating the fast-growing warts is a daunting task as failure of treatment is higher, due to the growth of the wart is faster than the rate of wart clearance. 

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I have also noticed that warts at the folds of the skin, folds of the penile foreskin, urethral opening, anus opening, and folds of the vagina are the most difficult to treat and requires aggressive clearance but your doctor needs to be able to gauge the intensity f the treatment because these are intimate and fragile areas. If your doctor does too little, the wart will not be cleared but if your doctor is too aggressive, then the intimate areas will be damaged. Therefore seek a doctor who has had experience in treating warts in these areas. 

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Treatment options:

  1. CONSERVATIVE TREATMENT

    • Tape compression
      Using silicon or cellophane tape applied tightly on the wart. This works very well on flat warts of the hand and legs but less effective for the private areas like the penis, vulva, and anus. 
       

    • Imiquimod 
      Imiquimod is an immunomodulator cream to increase the skin's immunity and suppresses wart expansion. This cream is considered a 3rd line therapy and is usually not the treatment of choice unless in specific cases where cryosurgery, cautery, or salicylic acid treatment is not available.
      The side effects of Imiquimod vary from one person to another. Some may experience skin itching, redness, flaking and skin peeling after a few applications of Imiquimod.
       

    • Spot on acid
      Certain acids have better penetration through the skin while other acids only scratch the surface of the wart and are not effective enough to treat large warts.
      According to guidelines for treating wart; salicylate acid is the golden standard. I believe that the effectiveness of salicylate acid may depend on the percentage of the acid and the method of application.

      Usually, the commercial concentration of salicylic acid is about 12% to 15% and a higher concentration of salicylic acid in clinics can range from 20% to 30%.
      A higher concentration of salicylate acid can clear warts faster but requires expert medical supervision. Some intimate places like the vulva, penis, and anus may suffer burns to the private parts if the concentration of salicylate acid is too high. For more intimate areas, I personally will prefer Cryosurgery with liquid nitrogen, because it is easier to control the intensity of the treatment as compared to acid. 

      Newer studies have seen treatments with Phenols have an efficacy of 80% against warts. Phenols can be damaging to the liver if used in high concentrations and also prolonged use because phenols are chemical compounds that can be absorbed through the skin, enter the blood circulation, and damages the liver.
      You will need a doctor trained in treating with acids and he will decide the best option for you. Do not perform any of these procedures on yourself!
       

    • Silver nitrate
      Silver nitrate can be used to treat certain warts but in my experience, it is a long process to achieve clearance as silver kills the HPV virus hence prevents the progression of the wart.
       

    • Topical fluorouracil
      Fluorouracil is a cytostatic drug that can be used to kill wart cells therefore reducing the growth of the wart and ultimately leads to clearance of the wart.
       

    • CO2 laser
      Lasers can be used to burn away warts. The laser is an effective machine to remove warts but is an expensive alternative to as opposed to cautery surgery, which is equally effective and cheaper. Currently, we are unsure about the efficacy of lasers versus cryosurgery. These trials are still ongoing and require more time to compare lasers vs cryosurgery.
       

    • There are other medications available but it is not approved for use in Malaysia as of now:

      • Podophyllin

      • Dinitrochlorobenzene

      • Cantharidin
         

  2. SURGICAL TREATMENT

    • Cryotherapy
      Liquid nitrogen is considered as the 1st line of treatment for warts. It is effective due to precision in the area of treatment. You can easily isolate the wart and use the liquid nitrogen to treat it. Some warts are in very difficult to reach areas and it is not feasible to use acids or creams to apply to the affected areas.

      The use of liquid nitrogen can exactly pin-point the wart and freeze the wart. Warts are usually difficult to treat and they are recurrent in most cases. The temperature of liquid nitrogen can determine the effectiveness of treatment. HPV virus which causes warts is difficult to be killed. They usually require high temperature or extremely low temperature to be killed, therefore most over-the-counter cryotherapy products freeze the tissue to −94°F (−70°C), whereas liquid nitrogen used by primary care physicians, and it can freeze the tissue to a temperature of −321°F (−196°C). 

      Is there a difference of efficacy in using over the counter cryotherapy versus primary care physician liquid nitrogen?
      Yes. The duration and temperature can influence the effectiveness of the treatment course. A longer duration of application of cryotherapy can promise a better effect for wart clearance as the skin cells are frozen into the deeper layers where the HPV virus is hiding. A much lower temperature can freeze the affected skin cells more and reach deeper into the skin. 

      Cryotherapy needs to be performed at about 2 weeks interval to achieve good results. However, the location and number of warts may cause variability of the interval time and frequency of cryotherapy.

       

    • Cautery-surgery
      Cautery surgery is using electricity to convert into heat. This machine is called diathermy and is used to cut through the wart and the skin. It is fast and effective but may not totally clear the virus hiding deeper under the skin. This method is the best option if the wart is big. Cutting off large warts is the fastest option as compared to cryotherapy because cryotherapy may not be able to penetrate well on larger warts.

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CONCLUSION:

There is no sure way to treat warts but each modality needs to be personalized based on the expectation and affordability of the patient. Each method has it pros and cons which may not be suitable in different situations.

Differential diagnosis of warts?

Warts are complicated if they are not treated early, they tend to grow faster and faster.  They are many cases people mistake warts for other things and they can look the same.

What is the possible diagnosis of warts?

  1. Pearly penile papules

  2. Vulvar vestibular papillae

  3. Contagious mollusks

  4. Condyloma lata

  5. Horny keratosis

  6. External anal tact

  7. Skin tact

  8. Basal cell carcinoma

  9. Squamous cell carcinoma

  10. Melanoma

  11. Nervi

  12. neurofibromatosis

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