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Viral warts are benign proliferations of the skin and mucosa caused by infection with Human Papilloma Virus (HPV); more than 150 subtypes of the DNA virus are known. Common warts (verruca vulgaris, HPV types 2 and 4): hard papule with dry surface most often on hands and knees. Plane or flat warts (HPV types 3 and 10): smooth or dry small papules often numerous most often face, hands and shins. Intraoral warts are usually misplaced genital types but those on the lips may also be common or filiform variants. Immunosuppression can result in malignant transformation of warts on non-genital sites, most commonly ten or more years after organ transplantation.
Rarely, longstanding non-genital warts can cause verrucous carcinoma (large solitary well differentiated squamous cell carcinoma usually found on plantar surface). In children, even without treatment, 50% of warts disappear within 6 months; 90% are gone in 2 years.
Daily application of paints or gels containing keratolytics such as 15 to 60% salicylic acid.
Cryotherapy with liquid nitrogen (cotton bud or cryospray) to wart and 1-2 mm rim of normal tissue.
If the chemical makes the skin sore, stop treatment until the discomfort has settled, then recommence as above.
If simple treatments do not prove effective, there is little point in pursuing more elaborate and sometimes very expensive options as the success rates are little better. Podophyllin (podophyllum resin), a cytotoxic agent present in a resin extracted from the May Apple plant and available as over-the-counter ointment or paint. Podophyllotoxin (refined podophyllin), applied to genital warts for 4-day courses each week for several weeks. Trichloacetic acid 80% applied weekly by the physician, resulting in immediate superficial (and sometimes deep) tissue necrosis. Cantharidin (extract of blister beetle), applied weekly by the physician, resulting in superficial blisters and necrosis. Contact allergens such as dinitrochlorobenzene (a mutagen) or dibutyl squaric acid, which cause local inflammation.
Laser vaporisation using carbon dioxide laser, used for diffuse warts or deep plantar warts. HPV vaccines in development have the potential to reduce the substantial morbidity and mortality associated with cervical cancer and other HPV-associated diseases. Herpes zoster, or shingles, is a painful blistering rash caused by reactivation of the herpes varicella-zoster virus. Herpes zoster can occur in childhood but is much more common in adults, especially the elderly, sick or immune suppressed.
The first sign of herpes zoster is usually pain, which may be severe, in the areas of one or more sensory nerves, often where they emerge from the spine. Post-herpetic neuralgia is defined as persistence or recurrence of pain more than a month after the onset of shingles.
The chosen drug should be stopped if it does not produce the desired effect or causes unacceptable side effects at appropriate dose and duration.
Amitriptyline, imipramine, dothiepin, clomipramine, desipramine and doxepin have been shown to have analgesic effects in patients with neuropathic pain, independent of their antidepressant action. Tricyclics may also have analgesic effect when used topically, but no topical formulation is available in New Zealand.

Although SSRIs have some analgesic properties and are safer, they appear to be less effective than the tricyclics.
These have widely differing methods of action so it is logical to try other agents if the first is unsuccessful. Gabapentin may have an action on the alpha delta 2 subunit of a calcium channel and inhibit glutamate release. An asymptomatic, pinkish papules with central umbilication invoved the scrotum of a 12-month year infant of one month duration.
A 24-year-old man suffered a painful vesicular rash involving the left side of the chest of 5 days duration.
A 14-year-old boy presented with fever, malaise, and myalgia followed one day later by sudden eruption of generalized rash involving mainly the face and trunk. A 5-year old boy presented with few brownish flat-topped papules on the cheek of three months duration.
A 7-year-old boy presented with generalized polymorphous rash involving the trunk, proximal parts pf extremities and the oral mucosa (soft palate) of three days duration.
An 8-year-old girl presented with three asymptomatic pearly-colored slightly irritated papules with characteristic central umbilication involved the nose, upper lip and infraorbital region of one month duration. Sign up to stay informed with the latest womens health updates on MedicineNet delivered to your inbox FREE! Viral warts are particularly common in childhood (affecting about 15% of school children) but may arise at any age.
The keratinocyte proliferation by basal cells is driven by viral replication within the granular layer of the epidermis.
Types 6 and 8 are the most common to cause symptoms but types 16 and 18 are more likely to result in cervical, penile and vulval intraepithelial neoplasia and invasive cancer. It may be helpful to pare the surface to reveal small black dots, which are thrombosed capillaries. It requires viral DNA amplification using polymerase chain reaction followed by Southern blot hybridisation. The depth of freeze should be sufficient to cause a little blistering and should be repeated every 2-4 weeks on 4-6 occasions. Under local anaesthetic, the growth is pared away and the base burned by diathermy or cautery.
Persevere for twelve weeks or longer; up to 70% of warts will resolve with wart paints, and removing the keratinised surface relieves discomfort.
The hard skin should be rubbed away from the wart surface with a piece of pumice stone or emery board.
These require prescription by a dermatologist and have mucocutaneous and systemic side effects. Large-scale efficacy studies that are planned or underway will provide additional information about vaccine tolerance and efficacy. It is infectious, resulting in chickenpox in those who have never developed primary immunity, both from virus in the lesions and in some instances the nose and throat. In uncomplicated cases recovery is complete in 2-3 weeks in children and young adults, and 3 to 4 weeks in older patients. Polypharmacy can be useful to allow lower doses to achieve analgesia but side effects and drug interactions can be risky. More potent opioids are sometimes required short term, but can result in escalating dose requirements.

They have an effect on the inhibitory serotonergic pathway, noradrenergic pathway, sodium channels, NMDA receptors and adenosine receptors.
In doses of up to 500 mg bd it is associated with many adverse effects including severe allergic rashes (toxic epidermal necrolysis), hepatic enzyme induction, hyperlipidaemia, hyponatraemia and weight gain. All lesions were successfully treated with 10% KOH solution applied once daily within 3-4 weeks. One day before, the rash was preceded by severe left- sided chest pain with burning sensation.
Usually after 3 days most lesions in chicken pox will be covered with hemorrhagic crustation as evident in this patient. Typical grouped vesicles and pustules with erythema and edema of three contiguous thoracic dermatomes on the posterior chest wall. The wound heals in about two weeks; even then 20% of warts can be expected to recur within a few months. Protect interdigital spaces from irritation by first applying a barrier cream or petrolatum. Like herpes simplex, the virus persists in selected cells of dorsal root ganglion before it is reactivated.
Within one to three days of the onset of pain, crops of closely grouped erythematous papules develop within the unilateral dermatome(s).
Muscle weakness arises in about one in twenty patients because the motor nerves are affected as well as the sensory nerves. Anticholinergic effects include dry mouth, blurred vision, constipation, urinary hesitancy, tachycardia and ejaculatory difficulty. The dose should be very slowly increased over six weeks up to 400mg once daily, to reduce the risk of skin rash. On examination, a classical zosteriform vesicular rash on erythematous background  involving T3-T4 dermatomes was seen. Varicella occurring in late childhood or adulthood may present with more severe prodromal symptoms and rash. Side effects include pain, injury to underlying tendons and superficial nerves (avoid the sides of digits), postinflammatory depigmentation, scarring and recurrent warts (often as a ring around the treated site).
It works better if covered with adhesive tape (particularly recommended when the wart is on the foot). New papules continue to appear for several days, each blistering or becoming pustular then crusting over.
The pain may be continuous and burning with increased sensitivity in the affected areas, or a spasmodic shooting type, or, rarely, itching and crawling (formication).
As there are differing adverse effects, it is sometimes worth trying several different agents. There is a 50% chance of complete recovery and in time some improvement can be expected in nearly all cases. The overlying skin is numb or exquisitely sensitive to touch (hyperaesthesia and allodynia).
Other side effects include dry mouth, peripheral oedema, weight gain, abnormal gait, amnesia, confusion, hypaesthesia, abnormal thinking, dyspnoea, amblyopia.

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