Warts are benign growths of the top layer of skin cells which are caused by a family of viruses called Human Papilloma Virus (HPV).  Another name for common warts is Verruca Vulgaris.  There are several different types of warts which are caused by different viruses designated by “HPV” followed by a number which represents the genetic type, for example, HPV-1.

Common warts are mostly found on the hands, fingers, and around the nails, but they may be found anywhere else on the body.  They are usually firm, flesh-colored papules with a rough surface which sometimes includes black dots.

Flat warts are smooth, slightly elevated flesh-colored papules, usually small measuring only a few millimeters and frequently found on the face, neck, and legs. They may occur in any other location, but the locations listed are more prone to spreading because of shaving.

Mosaic warts also known as “seed warts,” are found only on the palms and soles, usually in groups of many small warts forming large plaques that are extremely resistant to therapy.

Plantar warts refer specifically to warts on the bottom of the sole of the foot. These warts may be single or multiple.  Because of their location on weight-bearing areas, they may cause pain on walking and tend to grow downward into the skin due to the effect of the pressure. This feature also renders them extremely difficult to eradicate without causing a deeper wound and some scarring.

GENITAL AND CERVICAL WARTS

Warts on the external genitalia are relatively easy to diagnose due to their pink or flesh-colored appearance and outward growth patterns resembling skin tags or cauliflower when they are very large.  However, a skin biopsy or a pap smear can confirm the diagnosis if there is any doubt, ruling out the possibility of cancer and also confirming the presence of viral particles using special stains that are specific for detecting HPV.

TREATMENT OF WARTS

It is well known that warts are resistant to therapy and that they frequently recur after treatment has been completed. Therefore, it should be understood by patients that it sometimes takes many weeks of treatments in order to eradicate warts, and sometimes these treatments are only partially effective.  Even if the treatment appears to be totally effective, that may only be temporary should the wart virus remain dormant in the skin or the mucous membrane for some period of time before recurring.

The most common treatment for warts are the over-the-counter acids containing salicylic acid and lactic acid in a solution, gel, or collodion. These medicines are usually applied directly to the wart and gradually cause a peeling effect on the excess layers of skin that are caused to grow by the virus.  The chemicals do not kill the virus but rather they cause exfoliation of the skin cells which are infected by the virus. If these over-the-counter treatments fail, then it is recommended that the patient consult a doctor for more aggressive or specific therapy.

In the dermatology office, liquid nitrogen cryosurgery is probably the most common treatment applied.  Liquid nitrogen is a super cold gas which is non-toxic but which can freeze the top layer of skin cells with greater depth than the acids thereby killing these infected cells.  The treatment is somewhat painful and may result in blister formation. In some occasions the blister fluid may contain blood. It is often necessary to perform multiple applications of cryosurgery over several visits in order to eradicate warts.  Cryosurgery is generally used without giving any anesthesia.

The next line of therapy for resistant warts may be electrosurgery or electrofulguration. This is done using local anesthesia in the area containing the wart including some skin surrounding and below the wart.The wart is then destroyed with an electrical current and scraped away with a sharp instrument. While this treatment is often effective with one visit, there is a risk of scarring in the treated area as well as a risk of warts recurring in the scar tissue.

When the above more common treatments fail, some innovative treatments may be attempted by your physician. For some warts, Vitamin A acid creams or gels such as Retin-A may be applied repeatedly to the warts causing exfoliation.  This type of treatment may be combined with the acid exfoliation and liquid nitrogen treatments. Another innovative therapy is the use of a topical chemotherapy cream called 5-Fluorouracil such as Efudex cream. This is a treatment that is also used for precancerous growths of the skin caused by sun damage and would only be used on adults with especially recalcitrant warts and would likely be combined with some of the other therapies mentioned. There are also certain types of laser beams that can be used on warts. These are probably as successful as electrosurgery but also require multiple visits including the risk of discomfort as well as recurrence and treatment failure.

There are two topical chemicals which have been approved for the treatment of genital warts, and these may also be used on resistant skin warts. The oldest one is called Podophyllin.  This is a plant derived chemical that inhibits the rapid cell division of infected cells.  It can be applied either in the doctor’s office or at home by the patient in prescription gels or solutions. The newer treatment is a cream called Imiquimod (Aldara) which stimulates the patient’s own local immune system to generate chemicals such as interferon which help to destroy the virus.

Almost all common warts are caused by HPV that do not have any cancer causing potential. Therefore, patients may be reassured that they are not at risk for developing skin cancer from these common lesions. Warts are extremely common in childhood and most of these will resolve spontaneously without treatment.  Spontaneous clearing in adults is much less likely to occur.

Some genital warts are caused by carcinogenic strains of HPV. Therefore, a special test has been devised that may be used on the cells taken from a pap smear of the cervix and vagina that can identify these HPV types. Cervical warts are usually treated by gynecologists using either standard cold-steel surgical measures or laser treatments.  Because the HPV virus can be spread by sexual contact, it is necessary for the patient’s sexual partners to be examined for the presence of warts and the virus. There is now a vaccine available which can prevent the most common carcinogenic HPV types. It is recommended that young girls receive this vaccine before they become sexually active.

ECZEMA  (DERMATITIS)

Eczema represents superficial inflammation of the skin and may also be called Dermatitis. It is the most common reaction pattern of the skin seen by Dermatologists.  The clinical appearance and biopsy findings are virtually the same for all the different forms of eczema. The causes which are not always identifiable are different.  The clinical changes include redness and swelling of the skin. In the more acute stages, there may be blisters or weeping of clear fluid from the skin.  If the lesions persist over time, the weeping ceases and more crusting or scaling develops on the surface.  Because eczema is nearly always itchy which leads to chronic rubbing and scratching, the skin becomes thickened and develops changes in pigmentation, especially if the rash remains active for several weeks or months.

Atopic Eczema or Dermatitis is probably the most common type of eczema seen by dermatologists.  Atopic Dermatitis runs in families. About 70 percent of patients have a family history of an atopic tendency which includes the dermatitis, seasonal allergies, and asthma. These patients tend to have an exaggerated response to extremes of heat, cold, and humidity. Intermittent flare ups of atopic eczema occur during their lifetime in the majority of patients when they are under physical or emotional stress. About one-third of relapses are related to bacterial infections. Several abnormalities of the immune system have been associated with atopic eczema including elevated IgE antibodies in the blood, an increased number of allergy cells in the blood called eosinophils, and a reduced immune response to certain viral infections which cause warts, molluscum, and herpes.  The following clinical features are commonly seen in patient with atopic eczema, especially in children but also in adults: extremely dry skin of the arms and legs, increased skin markings of the palms, and extra folds of the lower eyelids, and a vexing but harmless condition on the upper arms and legs called keratosis pilaris.  Keratosis pilaris is a mild form of eczema around the hair follicles resulting in small red and sometimes spiny bumps that resemble and feel like goose skin.

Contact Dermatitis results from the application to the skin of chemicals in the environment that are either irritant or allergenic. Irritant Contact Dermatitis accounts for about 80 percent of the cases. The most common contact irritants are probably soap and water which causes dermatitis when the hands are washed frequently such as in the following occupations: Healthcare, childcare, food service, and hair styling. Other common irritants besides detergents include organic solvents such as alcohol and acetone, oils, acids or alkaline chemicals, fiberglass, and wood dust.

Allergic Contact Dermatitis is a delayed type hypersensitivity reaction to a specific chemical.  Poison Ivy or Oak Dermatitis represents the most familiar example of the mechanism of Allergic Contact Dermatitis. After the first exposure to the skin of the resin from the poison ivy plant, it takes 2-3 weeks for the immune system to become sensitized.  Upon the next exposure to the plant resin, the reaction in the skin may be elicited within 48 hours. Besides poison ivy, there are many common allergens in every day use at home and in occupations that can cause sensitization followed by Allergic Contact Dermatitis, for example nickel, fragrances, preservatives, hair dye, rubber, leather, and formaldehyde.  There are even some common over-the-counter topical cream medicines that can cause Allergic Contact Dermatitis including Neomycin, Bacitracin, and Benzocaine.  Because of their increased use in practice, allergy to natural rubber latex in gloves has become an occupational hazard for doctors, dentists, and their assistants.  About 10 percent of healthcare workers have become sensitized to latex, and 1-2 percent of these show evidence of Dermatitis.

Nummular Eczema is a form of Dermatitis which begins on the legs or trunk of adults. The initial lesions are coin-shaped, about 1-5cm in diameter with a tendency to clearing in the center. They are red and scaly and sometimes blistery, weeping, or crusted. They are nearly always extremely itchy and may become secondarily infected from scratching.  The cause is not known, but occasionally there is a history of atopy or a preceding serious emotional stressor.  Nummular Eczema has a reputation for being treatment resistant. It tends to be chronic and recurs in the original locations.

Dyshidrotic Eczema may be associated with increased sweating of the palms and soles, however, about half of the patients have a history of atopy. The rash is distinctive: Many 0.1- 0.5cm superficial clear blisters resembling tapioca develop on the sides of the fingers, palms and soles.  The lesions are usually associated with itching. When the blisters dry up, there is superficial peeling of the skin.  Flare ups may be associated with stress such as in a student preparing for final examinations.

The Treatment of Eczema may be complicated because there are several different types of eczema and they may be short-lived or chronic long standing cases.  However, some general principles may be applied.  If the eczema is in an acute weeping stage, then treatment with an astringent and aseptic compress such as Burow’s solution applied 2-3 times daily will help dry up the lesions. Following the compress, a medium to high potency corticosteroid cream should be applied for a couple of weeks followed by the application of bland emollient creams. For itching, antihistamines of the sedating type may be helpful in the early stages such as Diphenhydramine (Benadryl), Zyrtec, or Hydroxyzine by prescription.  Secondary infection is a common problem seen with eczema because of the scratching that follows the itching.  We usually prescribe Mupirocin ointment for localized lesions or oral broad spectrum antibiotics that have good anti-staph and anti-strep coverage if the rash is more generalized on the body.

For acute  severe flare ups of either Allergic Contact Dermatitis or Atopic Eczema, a burst of systemic steroids in the form of Prednisone, Medrol Dosepak, or Intramuscular Kenalog is very helpful in rapidly reducing the inflammation and associated itching and making the patient comfortable. It may also be necessary to apply medium to high potency topical steroid creams or ointments. For the maintenance of chronic Atopic Eczema, a newer class of medicines called topical immunomodulators has been developed (Elidel or Protopic).  Both of these are safe for use on facial dermatitis and for rash in the body fold areas such as the elbow and knee creases.  For the more severe, resistant to therapy, or generalized cases of eczema, we frequently recommend Narrow Band Ultraviolet B Light  for the entire body skin on a ongoing basis.  For the patients with chronic dyshidrotic eczema we utilize a treatment called Bath PUVA which consists of a 15 minute soak in a chemical which makes the palms and soles more sensitive to the light followed by exposure to long wave ultraviolet A light .

DRY SKIN

Dry skin is a problem which all of us have encountered at one time or another.  The medical term for dry skin is Xerosis. Simply put, dry skin is caused by the loss of water from the skin. It is necessary for skin to be hydrated in order for it to have a smooth supple texture. Factors that lead to dehydration or dryness of the skin include excessive bathing or showering, detergents and solvents applied to the skin, cold temperatures, and low humidity.

While dry skin can affect any part of the body, the most commonly involved areas are the  lower legs, backs of the arms and hands, back, flanks, abdomen, and waist. Areas that have more sweat and oil glands such as the scalp, face, underarms and groins are usually moist and spared from having dry skin.

Dry or xerotic skin in the affected areas appears to have an irregular surface with small flakes or scales and possibly fine cracks or fissures on the surface of the skin. Because dry skin is usually itchy skin, scratching and rubbing ensues which produces inflammation and more itching.  Thus, a vicious cycle develops. In persons who are prone to eczema, the dry itchy skin may lead to a full blown flare up of eczema requiring more aggressive treatment than just the moisturization of skin.

Dry skin is also a very common problem for the elderly.  That is because older skin loses sweat glands and oil glands and is more prone to water loss through the epidermis. In other words, the barrier function of the outer lipid layer of skin is gradually lost with aging. Moreover, elderly persons may have other medical conditions or treatments which predispose to dry skin including atopic eczema, kidney disease, malnutrition, decreased thyroid function, high blood pressure treated with diuretics (water pills) which may produce dehydration unless the patients replace water loss by drinking fluids.

Treatment and prevention of dry skin have to be discussed together.

1. Frequent use of soap and water can have the effect of making the skin even drier. In addition, hot water also dries out the skin more. Therefore, whenever possible, we recommend using soap less often and using a milder soap that is fragrance-free. Here are some examples of soaps we recommend in either their liquid or bar forms in alphabetical order:  Aquanil, Basis, Cerave, Cetaphil, Dove white unscented, Oilatum, Oil of Olay, and Vanicream.
2. When showering, reduce the heat of the water to a tepid temperature and try not to stay in the shower longer than five minutes. The hotter the water and the longer the exposure, the more difficult it will be to prevent dryness of the skin.
3. After showering, especially dry skin patients may benefit from applying an oil such as Keri or Johnson’s baby to a wet washcloth and rubbing it over your damp skin followed by gently patting your skin dry with a towel. Please do not rub the skin vigorously with a towel as the friction of the towel will remove more skin cells from the surface than is necessary and may aggravate dryness.  We do not recommend adding oil to the bath because of the danger of slipping in the tub when getting out.
4. As soon as possible after drying off your skin, apply the moisturizer of choice as quickly as possible to the entire body.  It is important to do this before the skin dries, within 3 minutes of bathing or showering. Moisturizers come in many different shapes, sizes, brands, and vehicles.  Here are some tips for you to decide which vehicle to choose. Ointments are the greasiest, creams are intermediate and lotions are the most watery. Ointments are the least easy to spread and the least elegant preparation but penetrate best and give the most moisture to the skin. Creams are a little easier to apply and more elegant and more substantial than lotions. Lotions are the most watery and therefore the easiest and quickest to spread but have the least durability. While it may be necessary to reapply all of these preparations during the day both at home and at work in order to keep the skin moist, lotions will have to be applied most often. Here are some examples of ointments we recommend to our patients in alphabetical order: Aquaphor, Crisco (original), and Vaseline petroleum jelly. Examples of products that are available in both cream and lotion forms in alphabetical order are: Aveeno, Cerave, Cetaphil, Eucerin, Oil of Olay, Purpose, and Vanicream.
5. In more temperate or Northern climates, the forced air heating dries out the skin rapidly, but in our subtropical climate, constant exposure to conditioned cool air also dries out the skin. Therefore, it is necessary to have a humidifier in the home in both situations.

Here is another pearl  for persons who complain of excessive dryness on their back.  It may be that those individuals allow the suds from their shampoos to run down their backs when washing their hair. I recommend that after the scalp is lathered that the person lean forward and allow the soapy water and residue wash forward and not run down the shoulders and back but rather run off the top of the head past the face and onto the shower floor.  This is because the chemicals in the shampoo are detergents which remove the oils from the scalp and while passing over the back skin may do the same there and aggravate  the dryness problem.