8.6 - Warts And Drugs For Warts

Front 1

Common Warts
- what causes them
- different types of warts

Back 1

Human papilloma virus
1. cutaneous: common, flat, mosaic, plantar (= verruca--> mosaic), palmar, planar/plane
2. anogenital: vulva, vagina, cervix, penis, scrotum, anus, urethra, rectum
3. extracutaneous warts: oral and laryngeal

Front 2

Molluscum contagiosum
- what causes that
- what does it look like: age group, location, wart appearance?

Back 2

- A pox virus
- usually in patients under 5 - resolves as patient immumity improves
- usually on face and neck but trunk can be involved
- smooth, round, pearly papules with a central dimple --> pop, red halo --> resolve (if red doesn't resolve could be infected)

Front 3

Molluscum contagiosum
- how is it treated?

Back 3

- refer if groin in case of sexual transmission
- Otherwise, it is self limiting (each wart usually resolves in 2-3/12) but if treatment is desired, refer to a GP:
(b) imiquamod 5% (aldara) diluted 20x to 0.1% cream - apply this 3 times per week or up to 3 times per day (RCH will compound for community)
(c) cryotherapy

Front 4

What is a verruca?

Back 4

- ingrowing warts, and are found on weight bearing areas
- often painful
- often have tiny black dots
- may coalesce to form a "mosaic wart"

Front 5

What is a corn (heloma) & a callus

Back 5

Corn - pressure and friction against a bony prominence causing hyperkeratosis - causes increased pressure against soft tissue and bone. Sometimes between the toe & softer, due to one toe rubbing against the other
Callus - as above but can be beneficial or occassionally painful, eg. against big toe

Front 6

How do you tell the difference of a corn from a verucca (easy to differentiate from a wart)?

Back 6

1. patient diagnosis is often accurate
2. location: top/between toes = corn
3. Pain: pain of a verucca will be felt regardless of whether pressure applied (e.g. shoes, walking) or not!! cf. corn which is relieved by relieving pressure
4. corns and calluses are white or yellow, veruccas are dotted black
5. corns, calluses have a history of ill fitting shoes

Front 7

What is a bunion?
Treatment?

Back 7

Bunion - inflammation of bursa, first joint of big toe due to ill fitting shoes

Treatment - refer to a podiatrist, sometimes removed through operations

Front 8

How do you treat corns and calluses?

Back 8

1. Remove pressure and friction:
(a) shoe change, eg. to sandles
(b) padding, such as moleskin placed around the corn, or shoe insert for heal calluses
2. Keratolytics if neccessary (but avoid if possible) - exactly the same as for wart treatments

Front 9

Common warts - what do they look like?

Back 9

Front 10

What does a plane/planar wart look like?

Back 10

- Small clusters on face or back of hand
- Can be spread by areas of irritation

Front 11

Filiform warts - what do them look like?

Back 11

Raised up, hair like
Frequently on face, lips and tongue

Front 12

When do you refer warts?

Back 12

1. when there is a chance of malignancy:
(A) first time wart and over 50
(B) itchy
(C) bleeding without provocation
(D) has developed color (a reddish hue) or have changed color
2. Diabetes & PVD & poor wound healing - use Ac.Sal with caution
3. Many or on the face
4. Molluscum contagiousum and desire treatment, or on the groin and a child

Front 13

What if the patient is immunocompromised and has a wart?

Back 13

More likely to get warts.
It is more desirable to treat the wart because these may develop into squamous cell carcinomas.

Front 14

What treatments are available for common warts? (& what other treatment advice)

Back 14

1. Salicyclic acid is choice
2. Ac. Sal. with lactic acid or tricholoroacetic acid (Upton's paste) - combo with L.A. has no extra evidence
3. Glutaraldehyde (Diswart) - reserved for plantar warts, rarely used
4. Podophyllum resin (Posafilin)
5. Silver nitrate, nitric acid
6. cryotherapy (painful, scaring, dyspigmentation)
7. blunt dissection - avoid for plantar warts

** Avoid transmission: avoid towels and skin maceration

Front 15

What treatments are available for anogenital warts? (& what other treatment advice)

Back 15

1. imiquimod (Aldara)
2. Podophyllotoxin (Wartec, Condyline Paint) - treatment of choice

1. use condoms - there is a degree of infectivity even in the absence of lesions
2. women should have regular pap smear, although visable wart types are rarely associated with cervical cancers

Front 16

Salicyclic Acid - scheduling, including in combos with other ingredients

Back 16

S3: >40% salicylic acid for dermal use

Duofilm Gel is 27% Sal Acid - however, its base is made of ether in collodion which is S2 as conc is >10%

Lactic acid is unscheduled

Podophyllum resin is S2 when not for anogenital warts and <10%, S3 when <20% and not for anogenital warts

Front 17

Salicylic Acid - preparations for warts

Back 17

1. Duofilm Gel - 27%
2. Duofilm Liquid - 16.7% plus lactic acid 16.7%
3. DermaTech Wart Treatment (solution) - 17% salicylic
acid and lactic acid
4. Posafilin oint 25% and liquid 10% salicylic acid with 20% podaphyllum resin
5. extemp products up to 70% - upton's paste is 60% with 10% TCA and glycerol

Front 18

Duofilm / DermaTech:
- CIs, cautions
- preg/BF

Back 18

CI on anogenital warts, moles and birthmarks, inflammed skin, infected skin, and intertrigenous areas
Avoid in - diabetics, PVD, the elderly
Do not use in neonates, children more easily irritated by treatment
Preg - safe on small areas only
BF - safe on small areas

Front 19

DermaTech
- Side effects

Back 19

Infrequent: skin irritation
Rare: ulceration, salicylate intoxication

Front 20

What is in Wartner and Freeze Verruca & Wart remover?
How do you use them?
What scheduling?

Back 20

Dimethyl ether and propane

Apply for 20 seconds or less; repeat after 2 weeks if neccessary. Don't treat multiple warts on same digit at the same time.
Unscheduled

Front 21

DermaTech/Duofilm
- How to use

Back 21

- Apply 1-2 times daily for warts, corns and calluses (if daily, do at night to prevent washing or rubbing off)
- Before application, soak wart in warm water for 5 minutes & remove loose tissue with a pumice stone/emery board/rough towel (do not share this towel)
- protect the surrounding skin with soft paraffin, nail polish, or a plaster with a hole in it
- cover
- treatment takes weeks or months
- higher concentrations do not neccessarily give better treatment rates

Front 22

What if the patient is pregnant?

Back 22

Podophyllotoxin and podophyllum resin are contraindicated because they are teratogenic

Imiquamod (anogenital warts) is B1, not preferred, but should be safe due to minimal BA

Salicylic acid IS safe to use on small areas but should be avoided on large areas due to good BA.

Front 23

glutaraldehyde
- product
- indications
- contraindications
- pregnancy
- A/Es
- dosage

Back 23

- antiviral action
- especially for plantar warts(verrucas)
- CI: face, anogenital use, broken skin, NEONATES (children ok)
- Safe to use in pregnancy and BF
- brown staining of skin, infrequent irritation
- Apply bd for up to 3 months (prepare for application as for salicylic acid)

Front 24

Imiquimod product

Back 24

Aldara
6 or 12 x 250mg sachets (5% imiquimod)

Front 25

Aldara
- NO CIs
- considerations
- pregnancy, BF
- A/Es

Back 25

- reduced efficacy in immunosuppression
- B1: ltd data but low BA, "should be safe"
- BF: "should be safe"
- Common: local skin irritation

Front 26

Aldara
- dosage

Back 26

- Warts: three times per week until total clearance, up to 16 weeks (avg 10 weeks)
- BCC: 5 consecutive days of week to BCC and 1cm surrounding skin
- Actinic keratoses: apply to contiguous area 3 alternate days of week for up to 16 weeks (not >25cm2)

Front 27

Aldara
- how to apply

Back 27

1. Apply at night to clean dry area, and leave on for 6-10 hours
2. wash hands before and after
3. remove cream before sex - they may also weaken condoms, diaphragms
4. protect treated areas for sunlight. Avoid contact with lips, eyes, nostrils

Front 28

Aldara
- what if there is severe discomfort?

Back 28

take a rest period of several days - it is not neccessary to make up missed doses or prolong treatment

Front 29

Podophyllotoxin
- product
- MOA
- indication
- CI/Caution/Preg
- A/Es
- Application

Back 29

WARTEC 0.15% cream, 0.3% paint
CONDYLINE PAINT 0.3% paint
- antimitotic
- anogenital warts
- CI: pregnancy, avoid use in BF
- Common: local irritation
- Apply bd for 3 consecutive days, break for 4 days, treat for up to 4 weeks
- prescribers should apply the first treatment
- NO NEED TO WASH OFF

Front 30

Podophyllum resin
- product
- MOA
- indications
- CIs, preg, bf
- adverse effects

Back 30

Posafilin - 20% as a liquid with 10% Sal. Ac. or as an ointment with 25% Sal Ac
- antimitotic, for skin warts
- CI in pregnancy, damaged skin (increased systemic BA), anogenital use, infant use
- common: irritation, staining
- more toxic systemically than Wartec, rarely causing serious SEs such as blood dyscrasias, hallucinations

Front 31

Posafilin
- how to use
- scheduling

Back 31

- schedule 3
- Apply liquid daily, apply ointment on plantar or stubborn warts 2-3 times a week
- Treat only a small number at a time; don't use vaseline for protection - use varnish or plaster
- rest as for normal sal ac treatment