Treatment of Recalcitrant Periungual Warts

Introduction:

Warts are a form of skin infection caused by the human papillomavirus. Rough, skin-colored lumps develop on the skin due to the infection. The virus spreads easily. Warts spread through direct contact with an infected person. Periungual warts are seen around the fingernails or toenails. They begin as tiny, around the size of a pinhead, and gradually develop into rough, dirty lumps that can resemble cauliflower. They grow to form clusters eventually. Various treatment methods are available to treat periungual warts. However, they are difficult to treat, and the refractory rate is high.

What Is Periungual Wart?

• A periungual wart is a growth that develops next to the nails.

• These warts are tiny growths that initially have a smooth texture before developing a distinctively rough texture of other warts.

• Periungual warts differ from other warts in that they can grow to a certain size.

• These warts can enlarge quickly to the point that they have the power to remove a whole nail.

• Periungual warts can also permanently alter the shape of a nail and can cause more serious issues when they penetrate the nail plate and subsequently create a fungal infection.

What Causes Periungual Warts?

• Periungual warts are caused by human papillomavirus (HPV).

• Like other viruses, HPV enters cells, where the virus uses cells' internal mechanisms and resources to increase in number.

• One of the ways the virus affects the cells is by promoting cell growth, which causes the development of tiny structures known as warts.

• HPV enters the cells through minor wounds and scrapes.

• There are more than 130 strains of HPV. However, the strains responsible for periungual warts are HPV 1, 2, 4, 5, 7, 27, and 57.

• The HPV virus spreads quickly. Anyone can contract the virus by touching someone with a wart or exchanging towels, toys, or other personal objects used by someone with a periungual wart.

Who Gets Periungual Warts?

• Children and young adults frequently develop periungual warts, especially if they bite their nails. Although treating these warts is challenging, getting rid of them as soon as possible is beneficial.

• Individuals with weak immune systems are more likely to get warts. If they contract, it takes longer to disappear.

• People with atopic dermatitis are also more likely to develop periungual warts.

What Are the Symptoms of a Periungual Wart?

• Periungual warts are painless when they are small.

• When they grow, they may become painful.

• They may also impede the normal growth of the nails and split the skin surrounding them.

• Periungual warts can cause disfigurement to the cuticles and nails.

How Are Warts Diagnosed?

Periungual warts are diagnosed by looking at the lumps. Sometimes a biopsy is done to look for HPV in skin growth. A biopsy entails the removal of a small piece of tissue and studying it under a microscope to look for changes.

How Are They Treated?

Warts are not cured. Treatments aim to eliminate symptoms and clear up warts' appearance. Periungual warts are difficult to treat. They can recur and spread further, even after treatment. There are numerous therapy options and combinations. They are as follows.

1) Salicylic Acid: Salicylic acid eliminates warts by sloping off skin cells until the wart is gone. Additionally, the acid may cause an immunological reaction, which helps the area produce healthy skin cells. The salicylic acid solution frequently eradicates the wart with everyday application. Salicylic acid works slowly and requires frequent treatment for up to 12 weeks.

• Stages of Wart Removal Using Salicylic Acid: Removal of warts is typically irritating but not very painful. The different wart healing stages are as follows.

• Redness and Swelling: Redness and swelling are typically present during the first stage of wart eradication, regardless of whether salicylic acid or cryotherapy (use of extreme cold to freeze and remove abnormal tissue) is used. It occurs because the treatment being applied irritates the virus in the skin. Depending on the type of treatment employed, the wart may occasionally enlarge to twice its size or more. Mild stinging to dull throbbing pain may present.

• Wart Turns Black and Dry: The wart will dry and turn black at this stage. The skin containing the virus begins to die. Once the wart is completely black, pain may cease except for mild irritation in the surrounding area.

• Sloughing: The wart's dead skin tissue will begin to flake off.

• Completely Healed: As long as the wart is not gone, continue using the salicylic acid wart removal therapy as instructed. If treatment is stopped in the middle, the wart can regrow, and the patient will have to start from the beginning.

2) Cryotherapy involves applying extreme cold to freeze and destroy abnormal tissue. Cells cannot survive this severe cold and die after treatment. Various substances are used to create this extreme cold in cryotherapy. They are liquid nitrogen, liquid nitrous oxide, and argon gas. Two types of cryotherapies are as follows:

• Internal Cryotherapy: It is used to treat conditions inside the body.

• External Cryotherapy: It is used if the lesion is on the skin. The freezing agent is applied using a cotton swab. External cryotherapy causes frozen skin to break and peel off, so that healthy skin can grow. It might need fewer treatments than salicylic acid, frequently just three to four. This method is used in the treatment of recalcitrant periungual warts.

3) Antigen Injections: Antigens are injected into the wart. These antigens cause the immune system to attack the wart. Before using this treatment, the physician will check an individual's immune reaction to the antigen. It may cause itching and a burning sensation.

4) Use of Cimetidine for Recalcitrant Periungual Warts: A recent study shows Cimetidine is effective in treating periungual warts that are refractory to other conventional treatment methods.

• Photodynamic Therapy: It is found to be effective in treating warts that are resistant to routine methods. It is a two-stage treatment that uses a drug with light energy (photosensitizer), which destroys abnormal tissues after activation. The specific wavelength of light energy (laser) activates the drug. The drug is nontoxic until it is activated by light. After activation, it becomes toxic to the targeted tissue site.

• A study suggests that recalcitrant periungual warts can be treated by topical application of Fluorouracil and 5% Imiquimod cream. Intra lesion injection of Bleomycin sulfate.

• Hyfrecation: This method may be effective in treating warts that are resistant to routine methods. The procedure of hyfrecation uses a tiny needle with an electrical pulse that serves as a diathermy (a medical procedure that involves using energy sources to heat certain body parts intensely) to burn away small, undesirable lumps and bumps from the skin.

What Are the Possible Complications?

Periungual warts can cause permanent damage and disfigurement to the nails and nail beds. Warts may also lead to paronychia (infection of the tissues adjacent to the fingernail).

What Is the Outlook for People With Periungual Warts?

The placement of periungual warts makes treatment difficult. Their rate of recurrence is high, regardless of the treatment method.

How to Prevent the Spreading of Periungual Warts?

The first line of defense against the spread of warts is hygiene. A few steps, if followed, can prevent the spread of warts. They are as follows.

• Washing hands often.

• Do not bite the fingernails or pick the cuticles.

• Do not share personal items like nail clippers and towels.

• Do not touch other people's warts, toys, or other items they have used.

• Disinfect nail-cutting tools while using.

Conclusion:

Periungual warts are bumps in the fingernail or toenail caused by human papillomavirus. They are difficult to treat because of their location, and the recurrence rate is high irrespective of the treatment method. The best way to protect from warts is by maintaining proper hygiene. Consult the physician to determine the treatment method that helps to get rid of the wart