Plantar warts
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Plantar warts, also referred to as foot warts or viral warts, are benign epidermal lesions caused by infection with specific types of the human papillomavirus, or HPV. They most commonly develop on the soles of the feet, especially in areas exposed to pressure and microtrauma. The pressure of body weight causes the lesion to grow inward into the epidermis, which is why the wart may resemble a corn and cause pain while walking. It appears as a single papule or a cluster of numerous, coalescing lesions called mosaic warts. Diagnosis is primarily based on clinical and dermoscopic presentation. The method of treatment is tailored to the number, size, location, and duration of the lesions, as well as age, immunity, and the vascular and sensory condition of the feet.
Plantar warts - where do they come from
The direct cause of plantar warts is the infection of keratinocytes, i.e., epidermal cells, with cutaneous HPV types. HPV types 1, 2, 4, 27, and 57 are most commonly associated with foot lesions. The virus reaches the deeper layers of the epidermis through minor damage to the skin barrier and then utilizes the maturation process of keratinocytes to replicate its genetic material.
Predisposing factors for infection and the clinical development of warts include:
- microtrauma occurring during walking, running, and playing sports,
- maceration, i.e., softening of the epidermis due to moisture,
- excessive foot sweating,
- walking barefoot on damp communal surfaces,
- using shared towels, footwear, or grooming accessories,
- habitual picking or scratching of the skin,
- atopic dermatitis and other epidermal barrier disorders,
- reduced cell-mediated immunity,
- immunosuppressive therapy and certain chronic diseases.
After entering, HPV may remain in the epidermis for some time without visible symptoms. The appearance of a wart depends on local antiviral immunity. In some individuals, the immune system gradually eliminates the infected cells, leading to spontaneous resolution of the lesion. In others, warts persist for many months, recur, or spread to adjacent areas of the foot.
Plantar warts are benign in nature. The HPV types responsible for typical foot warts belong to the cutaneous group of the virus and differ from the high-risk types associated with cancers of the anogenital region.
Plantar warts - what do they look like
A typical plantar wart presents as a well-demarcated, rough papule or flat plaque covered with a layer of hyperkeratotic epidermis. Its surface may be yellowish, grayish, brownish, or similar in color to the surrounding skin. Due to pressure, the lesion grows partially inward into the epidermis, which promotes pain when standing and walking.
After gentle removal of the superficial hyperkeratosis, red, brownish, or black dots may become visible. These are thrombosed or bleeding capillaries, not the “roots” of the wart. Disruption of the skin's natural skin lines (dermatoglyphics) is also characteristic.
Two common clinical presentations are distinguished:
- deep myrmecia-type wart – usually solitary, well-demarcated, and painful, often located on the heel or under the metatarsal heads;
- mosaic warts – multiple superficial lesions coalescing into an extensive plaque, sometimes covering a significant part of the sole.
A wart should be differentiated from a corn, callus, porokeratosis, foreign body, fungal lesions, and rare neoplasms with a verrucous surface. In a corn, skin lines usually pass through the lesion, and pain is aggravated by direct pressure from above. A wart is more often painful upon lateral compression, although the compression test itself has auxiliary significance.
Dermoscopy reveals disruption of dermatoglyphics and numerous red or black vascular structures. Atypical, bleeding, ulcerated, rapidly enlarging lesions, or those refractory to properly conducted therapy require dermatological evaluation. In justified cases, a biopsy and histopathological examination are performed.
Plantar warts - are they contagious
Plantar warts are infectious lesions. HPV is transmitted through direct contact with the affected epidermis, as well as indirectly via contaminated surfaces and objects. A moist environment promotes softening of the stratum corneum, while minor cracks in the skin create an entry route for the virus.
Transmission can occur, among others:
- in shared showers, swimming pools, and locker rooms,
- during the use of shared towels, files, rasps, or footwear,
- as a result of healthy skin coming into contact with the surface of the wart,
- through autoinoculation, that is, the transfer of the virus to another area of one's own body,
- during mechanical damage to the lesion and the shedding of infected epidermal cells.
Exposure to HPV alone does not always lead to the development of a wart. The condition of the skin barrier, intensity of contact, environmental humidity, and the host's immune response all play a role.
Prevention includes drying the spaces between the toes, wearing flip-flops in shared facilities, covering the lesion with a waterproof dressing while using the swimming pool, and using personal hygiene items. Tools coming into contact with the wart should be disposable or subjected to proper disinfection and sterilization.
Plantar warts - what not to do
Self-directed, aggressive manipulation of a wart increases the risk of injury, HPV spread, bacterial infection, and scarring. Particularly harmful is cutting out the lesion with scissors, clippers, a razor blade, or another non-sterile tool. Bleeding indicates damage to living, vascularized tissue and can facilitate the transmission of infected cells.
In daily practice, the following should be avoided:
- scratching, piercing, and tearing at the wart,
- biting the skin or nails after touching the lesion,
- using the same file for healthy and affected skin,
- walking barefoot in communal spaces,
- borrowing footwear, socks, towels, and pedicure tools,
- applying caustic preparations to healthy skin,
- covering a moist foot with airtight material for an extended period,
- performing a cosmetic pedicure on an active lesion without a prior diagnosis.
Keratolytic preparations require particular caution in individuals with diabetes, neuropathy, circulatory disorders, a tendency toward hard-to-heal wounds, and reduced immunity. In such situations, therapy should be planned by a doctor or an experienced podiatry specialist collaborating with a doctor.
Prompt consultation is required for: severe pain, redness, swelling, exudate, ulceration, spontaneous bleeding, rapid growth of the lesion, sensory disturbances in the foot, and doubts regarding the diagnosis.
Plantar warts - how to remove
The goal of therapy is to remove HPV-infected epidermal cells with as little damage to healthy skin as possible. No method guarantees a cure after a single procedure, as efficacy also depends on the immune response. Recurrences and the emergence of new lesions due to re-exposure or the presence of subclinical infection are possible.
Methods used in the treatment of plantar warts include:
- salicylic acid – acts keratolytically, gradually loosening the bonds between the cells of the stratum corneum; regular application requires protection of healthy skin and periodic, safe debridement of hyperkeratosis;
- other controlled acid therapies – cause chemical exfoliation of the infected epidermis; the type of product and concentration are selected by a specialist;
- liquid nitrogen cryotherapy – leads to freezing and necrosis of the infected tissue and can stimulate a local immune response;
- electrocoagulation – uses electrical energy to thermally destroy the lesion;
- laser therapy – can have an ablative effect or selectively damage the blood vessels feeding the wart;
- curettage or surgical excision of the lesion – used in selected cases, taking into account the risk of pain and scarring in areas bearing weight during walking;
- intralesional treatment – includes, among others, bleomycin or immunotherapeutic methods, used by physicians primarily for recalcitrant and recurrent lesions;
- controlled hyperthermia – involves repeated heating of the lesion according to a strictly defined protocol.
The diagnosis must be confirmed before treatment. Mechanical debridement of hyperkeratosis may expose the wart and facilitate the action of the preparation, but the removal of the stratum corneum alone usually represents only a stage of therapy rather than the complete treatment of the infection. The selection of the method takes into account pain, healing time, risk of scarring, location in a weight-bearing zone, and previous therapeutic attempts.
Podiatric treatments for plantar warts
At Ambasada Urody, plantar wart therapy begins with a specialist podiatric assessment. The podologist analyzes the appearance, location, depth, and number of lesions, differentiating them primarily from corns and calluses. In the case of an atypical presentation, an appropriate step is a dermatological consultation and possible histopathological diagnostics.
Treatments available at Ambasada Urody directly related to plantar warts include:
- electrocoagulation of foot warts – electrical energy induces a controlled thermal effect within the pathological tissue; after the procedure, an area is created that requires protection and proper healing;
- organic acid therapy – involves the precise application of a formulation that causes controlled exfoliation of the infected epidermis; it works well, among others, for superficial, multiple, or extensive lesions;
- combined therapy – electrocoagulation and acid preparations can be applied in stages if indicated by the nature of the lesion and the skin's reaction;
- specialist debridement of hyperkeratosis – removes excess stratum corneum covering the wart, facilitates the assessment of its borders, and increases therapy access to the altered tissue;
- podiatric dressing – protects the post-procedure site, reduces friction and contact with contaminants, and supports proper healing;
- follow-up visits and recurrence prevention – serve to assess the response to therapy, re-treat the lesion, and adjust home care.
Treatment of mosaic, deep, and multifocal warts usually requires a series of visits. The completion of therapy is evidenced by the restoration of normal skin structure, the return of papillary line continuity, and the absence of characteristic vascular structures. Flattening of the surface alone may only indicate a reduction of the stratum corneum, which is why the evaluation of the outcome should be conducted by a specialist.
