I had a wart frozen off the ball of my foot six months ago, and now it’s returned in three spots. What causes plantars’ warts, and why has this one come back to haunt me?

ThWARTed Prince

Prince,

Great question, for athletes and others, as warts are a very common foot problem. Simply put, a wart is caused by a virus (and your skin’s reaction to it). Just as with “rhinoviruses” which causes COMMON HEAD COLDS (where your body’s local reaction is to enact coughing, sneezing and stuffiness), probably the only way you an get rid of a wart virus is to build up antibodies to it. Your body is much more able to fight off an upper respiratory infection than a wart because the wart virus is all the way on the OUTER layers of skin. This area is not so well patrolled by your immune system. Whooooa! Back up! Let’s review two systems first: your skin and your body’s inner defense system.

Recall from health class that your skin is made of many layers. The wart virus, which may be picked up just about anywhere, comes in contact with your skin and sets up housekeeping (that is, colonizes) in some of the outermost layers. The wart virus is contagious, and is often present at poolside, in the showers of your team locker room, or in the family bathroom. Apparently, not everyone is susceptible to wart viruses, but if it colonizes on the sole of the foot, it will cause what is termed a plantar wart. (Warts on different parts of your body are named by their location. A plantar wart has nothing to do with farmers.)

The wart tissue often appears like a callus on the bottom of your foot; on close inspection, it may have small black or brown dots. Squeezed from side to side, the wart may hurt worse than it does just from direct pressure. These dots and the pain are indication of the nerve and vessel bundles in the stalk of the wart tissue. To my patients, I often describe a wart as resembling a cauliflower or stalk of broccoli. The florets are like the callus on the outer skin; the stalk is full of nerves and vessels. There is a wide-based root below the top layer of skin, as the wart is “rooted” to the dermis layer (where your skin’s own nerves and vessels reside). Many people describe warts as “going down to the bond.” This is from the discomfort of walking on the “bundle of nerves,” not from the actual depth of the lesion.

The second “basic” we need to review is that your body has a surveillance system against foreign invaders (bacteria, fungi, viruses, allergens, and foreign bodies, to name a few). The immune system must “see” or be aware of the invader and then raise an army of defense cells and antibodies specific for the invader. (I won’t get any more technical, I promise.) It is difficult for the immune system to tune into a virus on the outer layer of skin. The longer the virus has been there, the more barrier (callus) it has developed in which to “hide.” Treatment of warts is often aimed at triggering your body’s awareness of the viral invader and encouraging an immune response.

Our Plan of Attack

There are many wart treatment options. This is not a good sign: if there were one “best” method, all doctors would use it. The treatment of choice depends on 1) the patient’s needs and demeanor, 2) the doctor’s preference, and 3) the appearance, location and duration of the wart.

Surgical removal of the wart may take one of several forms:


• Cryosurgery (spot freezing the lesion and “scooping” it out),
  
  
• Cutting it out with a scalpel or a round biopsy-style punch (like a very small cookie cutter),
  
  
• Electrical or laser surgery to destroy the lesion at its base, on the surface of the dermal layer of skin.

Any of these may be used (in the office or hospital setting) to remove the wart tissue. Local anesthesia may be necessary. Some post-operative soreness would be expected. The doctor will be careful not to “go too deep,” risking the chance of a permanent scar. You can guess that it would not be such a good idea to have a scar on a weightbearing part of the foot. It would not be so bad if it were on the top of the foot, on a finger or toe or on a knee. (We all have lifetime scars on our knees, right?)

Since the wart virus is so small (microscopic, to say the least), it is possible that it can evade total removal at the time of surgery. It may be harbored elsewhere on the skin, or still abundant at the place where you first picked it up (the bathroom tiles, for example). Because your immune system plays little or no role in surgical treatment of warts, you are not at all “immune” to reinfection or spread.

Alternative methods of treatment involve the recruitment of your immune system during the treatment course. Chemical removal of a wart (usually with serial acid applications) causes a local inflammatory-type reaction that serves two purposes:

• It helps to mechanically remove the wart tissue,
  

• It alerts the body to “survey” the area. The local inflammation (which) may need to be temporarily padded off for comfort) attracts attention to the site of treatment.

Chemical treatment may take several office visits wherein your doctor will pare down the lesions, causing (usually painless) pinpoint bleeding, and then apply the medication. Often, doctors will suggest home applications (of a slightly weaker, safer acid) between visits to decrease the number of weeks of treatment. After each treatment, you are usually able to go about your regular activities (or sport) without discomfort. (This is unlike surgical treatments, which may require your taking a few days off from sports to heal the surgical wound if it was on a weightbearing part of your foot.)

Sometimes, for some warts, chemicals other than acids are used in the serial treatments. These are irritants and/or medicines that will help raise the wart tissue off the dermal layer for a better “attack.” They usually cause a more aggressive inflammatory reaction and, therefore, may be more uncomfortable, temporarily.

No medical treatment is also an option. Your wart may spontaneously disappear (or “fall off”). This MAY be because your body recognized the invader on its own. (This is possibly an explanation to reports of wart cures by witches’ spells, planting a potato in the backyard, or other magic.) There may be ways, other than those expounded by traditional medicine, to trigger your body’s defense system and mount an immune reaction. (I always try to keep an open mind when it comes to wart cures.) The consequences of not treating the wart is that it may spread or enlarge and become more and more painful if it is on a weightbearing part of your foot. Over-the-counter medications may work if your wart is not too “entrenched.” However, there chemicals are weaker then prescription acids, and the periodic “scraping” your doctor does is critical to the cure.

In summary, there is no “best” treatment of warts. Each approach has its pluses and minuses in terms of: probably pain (although everyone has their own level of tolerance), scar potential, patient’s amount of home care responsibility, probable duration of treatment necessary, and chance of recurrence (or alternatively, the chance of developing a true immune defense). Your doctor (family practitioner, dermatologist, or podiatrist) will discuss treatment options with you. You two will decide on a plan of action. As a team, we often need to resort to plan B, or some combination of options before the wart is GONE. Warts can be tricky (and thereby frustrating) at times.

We welcome your comments and your questions. Please e-mail your concerns to Chesterfield Podiatry Associates, c/o Old Dominion X Press

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