British Association of Dermatologists' guidelines for the management of cutaneous warts 2014

Abstract

The overall objective of the guideline is to provide up‐to‐date, evidence‐based recommendations for the management of infectious cutaneous warts caused by papillomavirus infection. The document aims to (i) offer an appraisal of all relevant literature since January 1999, focusing on any key developments; (ii) address important practical clinical questions relating to the primary guideline objective, i.e. accurate diagnosis and identification of cases and suitable treatment; (iii) provide guideline recommendations, where appropriate with some health economic implications; and (iv) discuss potential developments and future directions. The guideline is presented as a detailed review with highlighted recommendations for practical use in the clinic, in addition to an updated patient information leaflet [available on the British Association of Dermatologists' (BAD) website, www.bad.org.uk]. This guideline does not cover anogenital warts, bowenoid papulosis, focal epithelial hyperplasia or seborrhoeic keratoses (sometimes called seborrhoeic warts). The guideline development group consisted of consultant and specialty trainee dermatologists and an editor of the Cochrane Skin Group. The draft document was circulated to the BAD membership, British Dermatological Nursing Group, Primary Care Dermatological Society, British Kidney Patients Association and Royal Pharmaceutical Society for comments, and was peer reviewed by the Clinical Standards Unit of the BAD (made up of the Therapy & Guidelines subcommittee) prior to publication. This set of guidelines has been developed using the BAD's recommended methodology,1 with reference to the Appraisal of Guidelines Research and Evaluation (AGREE II) instrument (www.agreetrust.org).2 Recommendations were developed for implementation in the National Health Service using a process of considered judgement based on the evidence. PubMed and the Medline and Embase databases were searched for meta‐analyses, randomized controlled trials (RCTs) and non‐RCTs, case series, case reports and open studies involving warts, published in the English language from January 1999 to March 2014; search terms and strategies are detailed in the Supporting Information. The Allied and Complementary Medicine Database was also searched for ‘warts’ with the same time restriction. Additional relevant references were also isolated from citations in the reviewed literature. Each author screened their set of identified titles, and those relevant for first‐round inclusion were selected for further scrutiny. Working in pairs, the authors then reviewed the abstracts for the shortlisted references, and the full papers of relevant material were obtained; disagreements in the final selections were resolved by discussion among the entire development group. The structure of the 2001 guidelines was then discussed and re‐evaluated, with headings and subheadings decided; different coauthors were allocated separate subsections. Each coauthor then performed a detailed appraisal of the selected literature, and all subsections were subsequently collated and edited to produce the final guideline. This document has been prepared on behalf of the BAD and is based on the best data available when the document was prepared. It is recognized that under certain conditions it may be necessary to deviate from the guidelines and that the results of future studies may require some of the recommendations herein to be changed. Failure to adhere to these guidelines should not necessarily be considered negligent, nor should adherence to these recommendations constitute a defence against a claim of negligence. The proposed revision for this set of recommendations is scheduled for 2019; where necessary, important interim changes will be updated on the BAD website. Warts are caused by infection of keratinocytes (the predominant cell type in the epidermis) by human papillomavirus (HPV). The development of epidermal thickening and hyperkeratinization occurs following infection at the basal layer and clonal proliferation, which eventually results in a visible wart, weeks or even months later. There are over 150 genotypically different types of HPV, with classification based on defined variation of the viral DNA. The majority of common warts are caused by HPV types 1, 2, 4, 27 or 57, and plane warts by HPV types 3 or 10. The HPV types originally identified in epidermodysplasia verruciformis (EV) and their closely related genotypes are also found on the skin, often as subclinical infections, but they can be associated with squamous cell cancer and premalignant dysplasias, especially in cases of immunosuppression. The term ‘warts’ includes all morphological varieties of warts and may sometimes be used to name wart‐like lesions, such as seborrhoeic keratoses or seborrhoeic ‘warts’, which are not caused by HPV infection. In this guideline the term ‘warts’ deals only with warts due to HPV infection. HPV‐associated warts are subdivided on anatomical or morphological grounds into (i) common wart (Verruca vulgaris); (ii) wart on the sole of the foot, plantar wart (Verruca plantaris); (iii) flat wart or plane wart (Verruca plana) and (iv) genital wart (Condyloma accuminatum). HPV can spread from one individual to another by direct contact or via the environment. It is not known exactly how long the infectious virus can persist outside the body, but the related bovine papillomavirus is believed to retain infectivity for months or possibly years,3 and the same may be true for HPV. Warts are a common skin disease worldwide. Infection is common in childhood, but can occur at any age. Small cohort observational studies have suggested that 5–30% of children and young adults have warts.4 5 6 Warts can persist for years with little or no sign of inflammation. Spontaneous clearance of the infection, firstly with a reduction in size of the wart and then its disappearance, can occur at any time from a few months to years later. Clearance in children can occur after only a few months, with half clear at 1 year and about two‐thirds by 2 years.7 However, warts in adults can be much slower to clear, and persistence for 5–10 years is not uncommon. Diagnosis of common hand and foot warts is usually not difficult. Paring down a wart will often result in pinpoint bleeding as the capillary loops of the elongated dermal papillae are exposed. Warts need to be distinguished either clinically or histologically from on the or such as squamous cell or focal the and or can be with warts, but and should to be such as or may and plane warts may need to be distinguished from or or seborrhoeic of the especially usually results in of is for after or or due to warts may be and to Warts may be the of such as or infection, or warts should of infection is also associated with and squamous cell of the In a to and plane wart‐like in the which to squamous cell cancer in is to a and of certain HPV skin is in with these conditions HPV types plane warts, and also those types in the of which have a those found in on their and warts may be a the individual is then an to management is warts can be or with or may be a and when or on such as the these a of different may be There are for warts, and used or in they often have little for their also and may have some for potential should not may a to a and There is no that is for HPV, but some of the 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recommendations in clinical clinical trials not for different types of warts or warts in clinical The recommendations in 2 are based on available case or case reports or the Recommendations in clinical Recommendations in clinical In the were the following (i) (ii) (iii) of (iv) of In the was a patient information leaflet on The of cases is to variation in the results due to a and to different However, to this may to all cases in the are to and as as on the draft the randomized controlled with a of should not be used as a for a randomized controlled National for Health and Care of has and from and has been an at for This is an updated set of guidelines prepared for the British Association of (BAD) Clinical Standards which includes the Therapy & Guidelines of the Clinical Standards Unit have been are National Dermatological Nursing Dermatological Nursing and Clinical Standards in 2001 by the British Association of reviewed and updated search