PracticalDermatology

When we think of conditions that need patient education, we naturally think of complex, multifaceted illnesses like acne, psoriasis, and eczema. Patient education with regards to cutaneous warts almost exclusively focuses on explaining treatment options, including whether to treat at all. The focus on explaining treatment options is certainly crucial and has been covered in other articles.

There is another aspect to patient education that providers may address less frequently: educating the patient about wart etiology, autoinoculation, and transmission. This may not be necessary for uncomplicated cases. For more complicated cases, such education can greatly enhance patient satisfaction and improve outcomes. It can even be the difference between treatment success and failure. And it is not as time consuming as you may think.

Many patients feel stigmatized and embarrassed by their warts. When patients understand wart etiology, these feelings often are reduced. Educating the patient on strategies to limit autoinoculation and transmission empowers the patient to take steps to limit the spread of warts to themselves and others. The more complex and severe the case, the more valuable this extra education becomes. It doesn’t take long, and you will be surprised at the useful information you acquire in the process that ultimately leads to a more effective treatment plan. It is also beneficial to talk to patients about how the wart is impacting their life. Is it painful? How embarrassed are they?

Understanding the experience of the individuals with wart(s) not only makes them feel more understood, it can inform how aggressive the treatment should be.

Explaining Wart Etiology: What patients need to know

“How did I get these warts?” “What causes warts?” “Are they going to just keep on spreading?”

These are some of the most common questions patients have. Many patients don’t know that warts are caused by a virus, and they have little understanding of how warts are transmitted. A clear understanding of wart etiology empowers the patient, giving them the knowledge to limit autoinoculation and transmission.

The sidebar on the next page lists some basics that patients should know.

After mentioning these points you may get useful information, such as disclosure of a history of hyperhidrosis, eczema, or cuticle picking. Some women will admit to shaving facial hair. Once these factors are discovered, modifying them can be instrumental in reducing autoinoculation and transmission.

With a basic understanding about warts, many patients have an “Ah-ha” moment, clearly understanding how their wart infection happened. For example, one of my worst periungual wart cases (see image, next page) was in a truck driver who makes frequent stops to load and unload his truck. He wears gloves, and after I explained how warts infect and spread, he volunteered that he has hyperhidrosis. He felt much less stigmatized because he now understood what predisposed him to have such a bad case of warts. He was able to make some modifications like wearing lighter, more breathable gloves that were washed more often, removing the gloves between stops, and treating the hyperhydrosis.

Limiting Autoinoculation and Transmission

Limiting autoinoculation is key to successfully treating warts, especially in severe and widespread cases. If clear predisposing factors for having warts are identified or suspected, you now have a great opportunity to educate the patient and form a plan to prevent future outbreaks. This plan can be reinforced on subsequent visits. Patients need to know the basics of autoinoculation and transmission in terms they can understand using real world examples.

• Nail biting, picking of the cuticle, or picking warts are very potent ways to spread warts
• High risk activities for contracting warts include
  • Grappling sports like jujitsu, wrestling, and to a lesser degree striking arts
  • Sports where you may share the same equipment, like gymnastics, basketball, swimming (wet feet walking on a rough surface can spread plantar warts)
  • Using shared equipment at the gym, especially free weights
  • Walking barefoot at dance or fitness studios.

Gloves, tape, footwear (e.g., water shoes) and other barriers can effectively stop transmission. Sharing athletic equipment that comes in contact with the wart should be avoided as well. Sometimes future warts can be prevented, for example, if a patient can break the habit of picking their nails. Sometimes warts are challenging to prevent, for example, if the patient participates in year-round jujitsu. Even in those cases, however, the patient can be educated that given their activities, reinfection is common and regular self-inspection and early treatment are highly recommended.

One of the fears of wart patients, especially those with widespread warts, is that their warts will continue to spread out of control and to other parts of the body. You may notice in the clinic that the vast majority of wart patients only have one type of wart in one area. There are over 100 types of HPV that infect the human body.¹ Warts have evolved to specialize in infecting typically just one or occasionally two areas. Genital warts are a perfect example. Patients can be reassured that uncontrolled spread to unrelated body areas (from feet, to hands and face, for example) is highly unlikely. Immunocompromised patients can certainly have more widespread warts in one area but are still at low risk of warts spreading to unrelated areas.^2,3 This knowledge can be a source of great relief to many patients, especially those with hand warts who worry about spreading warts to every body part that they touch.

There is also evidence from genital wart studies that warts are more infectious in their first two to three months and much less likely to spread after 12 months.⁴ This correlates with clinical experience with cutaneous warts. Many patients have warts that have been stable for years and have not spread. Warts tend to grow most early on and stabilize with time. The increased viral activity in the early, fast-growing months could explain increased transmission rates in the first three months.

Understanding the Patient Experience

Warts can be embarrassing and stigmatizing. Not knowing anything about warts or how they are transmitted only compounds these feelings. A 2003 study on the quality of life of wart sufferers revealed that 81.2 percent were moderately to extremely embarrassed by them and 70.5 percent were moderately to severely concerned about negative appraisal by others for having them.⁵

Patients with plantar warts had less embarrassment but significantly more pain than other wart sufferers. The study also revealed that patients with hand warts suffer from more embarrassment than patients with other warts. Here are a few examples of how understanding the patient experience, their embarrassment, pain, and discomfort, may influence clinical decision making.

Consider a 42-year-old male mail carrier who presents with a plantar wart. You ask the patient how much it hurts. The patient reports severe pain, which makes it hard to get through the day at work. This information lets you know the patient may be open to a more aggressive intervention, even if he has to take time off work to heal.

Alternatively, consider a 10-year-old girl who has a wart on her thumb. After you explain wart etiology, there seem to be no clear factors leading to the growth of the wart (hyperhidrosis, nail picking, sports, etc.). After probing the patient’s level of embarrassment, she states she just puts a bandaid on the wart while at school and nobody pays much attention to it. The patient denies pain, she is an only child and plays no sports.

This patient has little embarrassment and a low chance of autoinoculation and a relatively low transmission risk to others. This patient may be content to wait until the wart resolves on its own. The parent may feel the same way or may want to get rid of the wart immediately. Because you have asked the right questions and gained additional insights, you can find the treatment that is the best fit.

Finally, imagine a 16-year-old female who presents with multiple common and periungual warts on both hands. After receiving education on wart etiology, autoinoculation, and transmission, she states she is on the basketball team and that off and on she gets small blisters on her fingers—which was diagnosed as eczema by her pediatrician who gave her a cream that didn’t work. You inspect the patient and see signs of dyshidrotic eczema. The patient states that she is very embarrassed about her warts; they sometimes interfere with her ability to play basketball and cause her pain.

Because you explained wart etiology, autoinoculation, and transmission, the patient now understands why she has such a bad case of warts and feels less stigmatized. She will likely now be more adherent to dyshidrotic eczema treatment, knowing how it can contribute to formation of more warts. She now knows that she most likely got warts playing basketball and can pass them to her teammates as well. A conversation about transmission is very important here. This would include providing instructions on covering warts during basketball and working to resolve them as quickly as possible. A patient like this will most likely be open to aggressive treatment with frequent follow up until the warts resolve.

An Educated Patient is an Empowered Patient

The first visit for warts has traditionally been short and focused mainly on educating the patient about treatment options. Little time may be spent discussing wart etiology, autoinoculation, and transmission. This is fine for many uncomplicated cases. We have found that wart patients, especially those with severe disease, greatly benefit from additional education, as discussed in this article. Understanding and listening to the patient’s experience with warts allows us to fine tune our treatment choices and shows the patient that we empathize with and understand their situation. The goal is to have the wart patient understand not only their treatment, but also wart etiology and how to avoid autoinoculation and limit transmission. The patient will also know that we understand how their warts affect their lives and care enough to take the extra time to help them get rid of their warts as quickly as possible.

1. https://www.fda.gov/consumers/women/hpv-human-papillomavirus

2. Savin JA, Noble WC. Immunosuppression and skin infection. Br J Dermatol. 1975 Jul;93(1):115-20.

3. Morison WL. Viral warts, herpes simplex and herpes zoster in patients with

secondary immune deficiencies and neoplasms. Br J Dermatol. 1975 Jun;92(6):625-30.

4. Cobb MW. Human papillomavirus infection. J Am Acad Dermatol. 1990 Apr;22(4):547-66.

5. Ciconte A, Campbell J, Tabrizi S, Garland S, Marks R. Warts are not merely blemishes on the skin: A study on the morbidity associated with having viral cutaneous warts. Australas J Dermatol. 2003 Aug;44(3):169-73.