View source for Plantar wart

'''For patient information click [[Plantar wart (patient information)|here]]'''
{{DiseaseDisorder infobox |
  Name        = Plantar wart |
  ICD10       = B07 |
  ICD9        = {{ICD9|078.19}} |
  Image       = Veruca_right_foot_detail.jpg |
  Caption     = A plantar wart. Striae (fingerprints) go around the lesion. |
}}
{{Plantar wart}}
{{CMG}}

==Overview==
A '''plantar wart''' (''verruca plantaris'', ''VP''; also commonly called a '''verruca''') is a [[wart]] caused by the [[human papillomavirus|human papilloma virus]] (HPV). It is a small lesion that appears on the sole of the foot (hence the name, from [[Latin]] ''planta pedis'', the sole of the foot) and typically resembles a cauliflower. A plantar wart may have small black specks within it that ooze blood when the surface is shaved; these are abnormal capillaries. Though the name ''plantar wart'' describes specifically HPV infection on the sole of the foot, infection by the virus is possible anywhere on the body and common especially on the palm of the hand, where the appearance of the wart is often exactly as described above for plantar warts. Because of pressure on the sole of the foot, a layer of hard skin forms over the wart. A plantar wart may or may not be painful. It can be spread in communal showers, around swimming pools, by sharing shoes, etc.

==Epidemiology and Demographics==
It is estimated that 7-10% of the US population is infected. Infection typically occurs on moist walking surfaces such as showers, swimming pools, or shoes. The virus can survive many months without a host, making it highly contagious.<ref name="emed_plantar" /><ref name="emed_hpv">{{cite web |url=http://www.emedicine.com/MED/topic1037.htm |title=Human Papillomavirus |accessdate=2008-02-27 |author=Peter A Gearhart |date=January 19, 2007 |publisher=eMedicine}}</ref>

==Pathophysiology==
Plantar warts are benign [[epithelial]] [[tumors]] caused by infection by human papilloma virus types 1, 2, 4, or 63. These types are classified as clinical (visible symptoms). The virus attacks the skin through direct contact, entering through possibly tiny cuts and abrasions in the [[stratum corneum]] (outermost layer of skin). After infection, warts may not become visible for several weeks or months. Because of pressure on the sole of the foot, the wart is pushed inward and a layer of hard skin may form over the wart. A plantar wart may be painful.<ref name="emed_plantar" /><ref name="hipusa">{{cite web |url= http://www.hipusa.com/webmd/encyclopedia/plantarwart/index.html |title=Understanding Plantar Warts |accessdate=2007-12-07 |publisher=Health Plan of New York }}</ref>

Warts may spread through [[autoinoculation]], by infecting nearby skin or by infecting walking surfaces. They may fuse or develop into clusters called mosaic warts.<ref name="emed_hpv" />

==Diagnosis==

[[Image:Wart-IMG 1676.JPG|thumb|left|Young plantar warts]]
Plantar warts, can often be differentiated from [[Callus|helomata]], corns, by close observation of skin striations. Feet, like hands, are covered in skin striae, which are more commonly called ''[[fingerprint]]s''. With plantar warts, the skin striae go around the lesion; if the lesion is not a plantar wart, the cells' [[DNA]] is not altered and the striations continue across the top layer of the skin. Plantar warts tend to be painful on application of pressure from eithe side of the lesion rather than direct pressure. Helomata tend to be painful on direct pressure rather than pressure from either side.

The difference between plantar warts and warts elsewhere on the body is that warts are generally outgrowth lesions, but on the bottom of the foot, they are pushed inward by the pressure of walking. Since the skin on the bottom of the foot tends to be thicker than elsewhere, the treatment of plantar warts is more difficult.

==Treatment==
No treatment in common use is 100% effective.  The most comprehensive medical review{{ref|cochrane2006}} found that no treatment method was more than 73% effective and using a [[placebo]] had a 27% average success rate.  The [[American Family Physician]] recommends:{{ref|afp2005}}
<center>
{| class="wikitable" cellpadding=5
| First-line therapy  || over the counter [[salicylic acid]]
|- 
| Second-line therapy || [[Cryosurgery]], intralesional [[immunotherapy]], or pulsed dye laser therapy
|- 
| Third-line therapy  || [[Bleomycin]], surgical excision
|}
</center>
 
[[Podiatrist]]s and [[Dermatology|dermatologists]] are considered specialists in the treatment of plantar warts, though most warts are treated by [[primary care physician]]s.

===Vaccination===
Although immunization is available for the HPV and strains causing [[cervical cancer]] and [[venereal warts]], there is currently no vaccination treatment for plantar warts.

===Pharmacologic Rx===
; [[Keratolytic|Keratolytic Chemicals]]: The [[treatment of warts by keratolysis]] involves the peeling away of dead surface skin cells with [[trichloroacetic acid]] or [[salicylic acid]]. 
; [[Immunotherapy]]: Intralesional injection of antigens ([[mumps]], candida or trichophytin antigens USP) is a new wart treatment which may trigger a host immune response to the wart virus, resulting in wart resolution. Distant, non-injected warts may also disappear.
; [[Chemotherapy]]: Topical application of dilute [[glutaraldehyde]] (a virucidal chemical, used for cold sterilization of surgical instruments) is an older effective wart treatment.  More modern chemotherapy agents, like 5-fluoro-uracil, are also effective topically or injected intralesionally. [[Retinoid]]s, systemically (eg. [[isotretinoin]]) or topically ([[tretinoin]] cream) may be effective.

:As warts are contagious, precautions should be taken to avoid spreading.

===Surgical===
* Liquid nitrogen : [[Cryosurgery]] with [[liquid nitrogen]]. A common treatment that works by producing a blister under the wart.  It is painful but usually nonscarring.
* Electrodesiccation and surgical excision produce scarring. If the wart recurs, the patient has a permanent scar along with the wart.
* Lasers may be effective, especially the 585nm pulsed dye laser which the most effective treatment of all, and does not leave scars, but is generally a last resort treatment as it is expensive and painful, and multiple laser treatments are required (generally 4-6 treatments repeated once a month until the wart disappears).

===Other===
* X-ray is an old method that is seldom recommended due to the long term adverse side effects of irradiation. 
* [[Duct tape occlusion therapy]]: The wart is kept covered with duct tape for six days, then soaked and debrided with a pumice stone. The process is repeated for 6 to 8 weeks.{{ref|ducttape}} 
* [[Watchful waiting]] may be appropriate since many warts will eventually resolve due to the patient's own immune system.  In many cases, the body will become naturally immune to the wart and verrucæ will turn black and effectively fall off, although it can be two years before this takes place

==Relative effectiveness of treatments==

A 2006 study assessed the effects of different local treatments for cutaneous, non-genital warts in healthy people.{{ref|cochrane2006}} The study reviewed 60 randomized clinical trials dating up to March 2005.  The main findings were:
* overall there is a lack of evidence (many trials were excluded because of poor methodology and reporting).
* the average cure rate using a placebo was 27% after an average period of 15 weeks.
* the best treatments are those containing salicylic acid.  They are clearly better than placebo.
* there is surprisingly little evidence for the absolute efficacy of cryotherapy.
* two trials comparing salicylic acid and cryotherapy showed no significant difference in efficacy.
* one trial comparing salicylic acid and duct tape occlusion therapy showed no significant difference in efficacy.
* evidence for the efficacy of the remaining treatments was limited.

==Complications==
Warts may spread, develop into clusters or fuse to become a mosaic wart. Plantar warts can be painful making it difficult to walk and run. Over-aggressive treatment may lead to scarring. Others may be infected.

If a wart is being treated professionally and does not seem to improve in a reasonable period of time, the growth should be excised and biopsied.

==Prevention==
* Avoid walking barefoot in public areas such as showers, communal changing rooms.  (Covering with an adhesive bandage is not a safe method as it will not last for long at all, especially while showering or swimming)
* Change shoes and socks daily.
* Avoid sharing shoes and socks.
* Avoid direct contact with warts on other parts of body.
* Avoid direct contact with warts on other persons.

==References==
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# {{Note|cochrane2003}} Cochrane Database Syst Rev. 2003;(3):CD001781. PMID 12917913
# {{Note|cochrane2006}} Cochrane Database Syst Rev. 2006;(3):CD001781. PMID 16855978 [http://www.cochrane.org/reviews/en/ab001781.html]
# {{Note|Gibbs2002}} BMJ. 2002 Aug 31;325(7362):461. PMID 12202325
# {{Note|ducttape}} Plantar Warts, Treatment [http://www.mayoclinic.com/health/plantar-warts/DS00509/DSECTION=8] (Mayo Clinic) 
# {{Note|banana}} Warszauer-Szwarc L.Treatment of plantar warts with banana skin. Plast.Reconstr.Surg 1981. 68; 975-6. PMID 7301999
# {{Note|afp2005}} Cutaneous Warts: An Evidence-Based Approach to Therapy.  American Family Physician 2005;72(4):647-52. PMID 16127954

==External links==
# [http://www.mayoclinic.com/health/plantar-warts/DS00509 Mayo Clinic]
# Advice from [http://www.feetforlife.org/cgi-bin/item.cgi?id=61 UK Society of Chiropodists and Podiatrists]
# [http://www.merck.com/pubs/mmanual/section10/chapter115/115b.htm Warts, The Merck Manual]
# [http://www.dermnet.com/thumbnailIndex.cfm?moduleID=21&moduleGroupID=634&groupIndex=0&numcols=0 Plantar Wart photo library at Dermnet]
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[[Category:Dermatology]]
[[Category:Viruses]]
[[Category:Foot diseases]]
[[Category:Mature chapter]]

[[fr:Verrue plantaire]]
[[ru:Бородавки]]

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