Friday, July 21, 2006


I had a dream about warts last night. Not something one would choose to dream about, but I guess it was expected, as we had just had a lecture on warts and I ended up seeing a patient with multiple warts.

There are many types of warts, and while they may look different, they have a good number of similarities. They're all caused by a virus (human papilloma virus) which loves the skin, they are hard to treat, and they are infectious. Warts are skin cells infected with the virus, so if you have a cut near a wart and the cut gets some of virus particles, a new wart could be in the making. This is often a problem in children, where the little petri-dishes get the warts from each other and then do things like bite their nails and end up with warts around their nails and around their mouth. And although anyone can get warts, people who have compromised immune systems are more prone to getting them, get more of them, and those warts are even more resistant to treatment.

The concept behind treating warts is that 90% of them will resolve in 5yrs and the wart is not medically harmful. Which means that treatment should be conservative and not lead to long-term effects like scarring. Treatments for warts are not very effective and take months before the full effect is seen. Some people say the goal is to treat the patient, but what you're really doing is buying time and waiting for that 5year mark.

So the poor man I saw in clinic was a HIV-infected man who had been struggling with numerous large warts for many years. He was a really sensitive guy who had just gotten over losing his partner, was trying to pull his life together, and was very embarrassed by how people responded to the lesions. Actually, he had been so frustrated that he had been using a BLOW TORCH to try to get rid of the warts. One of the first things out of his mouth was "I'll do anything - I'll be the most compliant patient." This is one of those things that is drastically different in internal medicine. In those clinics you can have patients with bad heart failure, diabetes, cirrhosis, diseases that will kill them, who because they can't see and often can't feel the effects of their disease, refuse to make changes that will improve or stabilize their health. Whereas in derm, diseases that are relatively "superficial" and benign - warts, acne, etc - really affect the patient and motivate them to help themselves. And while no one has ever thanked me for adjusting their blood pressure medicine or their insulin regimen, I was thanked profusely over and over again by this man - just for starting a treatment for the common wart.


Blogger Intelinurse2B said...

I recently took my dtr in for wart treatment. I was shocked to learn the same fact about warts as outlined in your post. I also learned that warts can be treated by starting an immune system response, in the form of hipnosis, or in many kids, puberty is all it takes to shake the immune system up. I have also, in all seriousness, been told that duct tape can cause that same change in immune response.
great post-and my hubby has now been instructed to thank his internest everytime his anti-hypertensive needs adjusting : )

12:17 PM  
Anonymous David Harmon said...

Oh yeah, warts are the classic case for placebo effect!

One classic experiment involved putting masking tape on patients' warts, telling them it was special "wart tape". Something like a third of the patients had their warts just fall off. Oddly enough, my own mother just told me that she "just puts a bit of tape on"... and they fall off. An interesting memetic mutation indeed! (And yes, I kept my mouth shut. ;-))

My own example is just odd enough to mention. In college I had a wart that I'd removed several times in various ways (acid, LN2, steel...). It kept growing back. :-( Then, working in the cafeteria, the wart got chopped off in a startling (but ultimately minor) accident. Then the wart stayed gone.

3:21 PM  
Blogger always learning said...

Actually, duct tape is a method of treatment. Except it's highly impractical because it needs to be kept on for 6.5 out of 7days in a week... immunomodulators are also used - there are a number of ways to do this. One of which is to put an irritating substance on the wart to get an allergic reaction that hopefully will get the body to "notice" the wart.

Intelinurse2B - am very glad to hear about thanking the internist. Those physicians are seldom thanked for what they do... :)

David - like the story. I wonder if it was about time for the wart to go anyways (ie approximately 5 yrs?), or perhaps it was scared off :)

7:47 PM  

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