PLANTAR WART IN CHILDREN

Plantar wart in children How is it identified?

– “Plantar Wart”

What are plantar warts?

Plantar warts are one of the most frequentcauses of warts in the clinic. They are a papilloma virus infection infecting keratinised skin.(1) They have an annual incidence of 14% in the general population.(2) The vast majority of plantar warts are histologically benign, with malignant transformation, such as verrucous carcinoma, occurring only rarely. (3-5) In a randomised controlled trial, 88% of plantar warts were caused by HPV-1, -2, -27 or -57.(6) However, the most frequently implicated serotypes are HPV-1 AND HPV-2. (1,7) (1,7)

Annually, 2% 2% of the adult population 6% and 6% of the paediatric population seek medical attention for plantar warts.(8) Plantar warts occur most frequently in children and adolescents.(9-10) The peak incidence of plantar warts occurs at 13 years of age among females and at 14-15 years of age among males. (11) In childhood, girls have been found to be at higher risk than boys.(12) In adulthood, there is a decline in the rates of plantar warts in the general population (8) but when they do appear they tend to be longer lasting and more resistant to treatment.(13)

Age, sex, race, health status, etc. are aspects that will influence the incidence of plantar warts. In addition to other factors such as geography, seasonality (being more common in winter(14)and socio-economic factors (2,15). SilverbergJI and SilverbergNB conducted a study in which they concluded that black people are associated with a lower incidence of warts.(2,15) It is estimated that only 0.84% of the US population has plantar warts, while 12.9% of the Russian population has been shown to have plantar warts.(16) A higher incidence has also been observed in populations living in the north of England compared to populations in the south.(17). Across all regions, are observedto increaseduring the wintermonths.(14)

Increased exposure to HPV and inadequate immune responses (immunocompromised patients) will result in an increased risk of penetration of the epidermal barrier. (2,18) (2,18)

How are they diagnosed?

Diagnosis is usually made clinically(19) but in cases ofuncertaintyor resistance to treatment,biopsywith histopathological evaluation may be performed.. (14) A key feature is the alteration of the normal skin lines, the dermatoglyphs, which are restored when the plantar wart resolves.(20-21) Another distinctive feature is the presence of small black dots,formed by thrombosed capillaries within the lesion,which show punctate bleeding when the wart is detached. Therefore, visualisation of the thrombosed capillaries and punctate haemorrhage, together with the loss of normal dermatoglyphs, will allow differentiation of a plantar wart from other skin lesions, such as calluses.(22) On physical examination, they are rough on palpation and are tender when squeezed along the sides. (23)

What are the risk factors?

Two of the most significant risk factors are: having a plantar wart or being in close contact with a person who has a plantar wart. (2,14) (2,14) Plantar warts have a very high viral load, so the likelihood of infection is very high if adequate prevention is not achieved. (24,14) (24,14) Measures to take into account:

• Avoid sharing shoes, socks, towels, or other unwashed personal items

(19,17) Change socks daily (25)

• Do not reuse nail files and pumice stones previouslyused on plantar warts on other areas of the skin (26).
• Avoid walking barefoot, as this increases the likelihood of coming into contact with HPV, especially if walking barefoot in an area where others have walked barefoot, e.g. in swimming pools. (9,24,14) (9,24,14) Special care should be taken by athletes, gymnasts or dancers, who have a predilection for practising their sport without shoes. (23) (23)
• Wear flip-flops or other protective footwear in communal showers and changing rooms. One study showed an incidence rate of plantar warts of 27% for users of communal showers compared to an incidence rate of 1.25% for non-users of communal showers. (27) (27)
• Avoid excessive sweating. Hyperhidrosis of the feet is associated with an increased risk of plantar warts. (21) (21)

Treatments for plantar warts

There are numerous treatment options for plantar warts. Each therapeutic method has been found to have different success rates and adverse effects. (11,20) (11,20) The choice will depend on the number and size of warts location,, pain,, treatment history, age,as well as patient tolerability.(1,8,22,28) It is worth choosing a treatment modality that has a relatively benign side-effect profile and low cost. (20) Prevention of the lesion will reduce shedding and transmission of the virus and thus reduce the risk of HPV infection and plantar warts in the population.. What does this mean? The treatment modality chosen will be aimed at treating the lesion itself but will not manage the risk of transmission of the lesion, which is intrinsic to the pathophysiological mechanism causing the development of the wart and the shedding of its viral particles,which is why it is vitally important to take into account the preventive measures outlined above and to consult a professional if papillomavirus or plantar wart is suspected in order to treat as soon as possible and thus avoid possible contagion. (11,27,20). (11,27,20)

1. Albizuri F, Laguna R. Los pies en los niños.Dermatol.2016;26:5-15

2. BrugginkSC, EekhofJA, EgbertsPF, BlijswijkSC, AssendelftWJ, GusseklooJ.Warts transmitted in families and schools: a prospective cohort.Pediatrics.2013;131(5):928- 934.

3. DoorbarJ, EgawaN, GriffinH, KranjecC, MurakamiI.: Human papillomavirus molecular biology and disease association.Rev Med Virol.2015;25(suppl 1):2-23

4. PempinelloC, BovaA, PempinellpR, LuiseR, IannaciG. Verrucous carcinoma of the foot with bone invasion: a case report. Case Rep Oncol Med. 2013;2013:135307

5. BhattY, SinghS, VaghaniS, DoshiP. Verrucous carcinoma of the foot- a series of 4 cases. Int J Biomed Res. 2015;6(8):591-595.

6. BrugginkSC, de KoningMN, GusseklooJ, et al.Cutaneous wart-associated HPV types: prevalence and relation with patient characteristics.J Clin Virol.2012;55(3):250-255

7. WatkinsP.Identifying and treating plantar warts.Nurs Stand.2006;20(42):50-54

8. BrugginkSC, GusseklooJ, de KoningMN, et al.HPV type in plantar warts influences natural course and treatment response: secondary analysis of a randomised controlled trial. J Clin Virol.2013;57(3):227-232

9. GhadgepatilSS, GuptaS, SharmaYK. Clinicoepidemiological study of different types of warts. Dermatol Res Pract. 2016;2016:7989817

10. LipkeMM. An armamentarium of wart treatments. Clin Med Res.2006;4(4);273-293

11. BacelieriR, JohnsonSM. Cutaneous warts: an evidence-based approach to therapy. Am Fam Physician. 2005;72(4):647-652

12. KrishnaSK, JethwaAS. Human papillomavirus infections in adults and children. Am J Epidemiol Infect Dis. 2013;1(2):11-19

13. BrugginkSC, GusseklooJ, BergerMY, et al. Cryotherapy with liquid nitrogen versus topical salicylic acid application for cutaneous warts in primary care: randomized controlled trial.CMAJ.2010;182(15):1624-1630

14. KhondkerL, ShahMOR, KhanMSI. Verruca: need to know about human papilloma virus (HPV) infection. J Bangladesh Coll Phys Surg. 2012;30(3):151-158