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Veruca right foot

Image: “Showing a veruca just behind the toes on the right foot of a 49 year old female. Note that the skin striæ can be observed as going around the lesion, at least on one side.” by Simon Nuttall assumed (based on copyright claims). License: CC BY-SA 3.0


Non-genital warts are defined as focal epithelial lesions that are characterized by hyperplasia and are caused by human papillomavirus (HPV). Non-genital warts, as the name implies, are located on body surface areas that are not part of the genitalia. The lesions can be raised and circular, flat, deep, or present as plantar cysts.

Epidemiology of Non-Genital Warts in Children

The estimated annual incidence of non-genital warts is about 3–5 cases per 100 children aged 5–14 years. The prevalence of non-genital warts in school-aged children is quite high and is estimated to be around 33%. Approximately 10–21% of dermatology visits by children are related to warts.

The most common mode of transmission of non-genital warts is prolonged skin-to-skin contact with someone with a wart. Additionally, the use of skin-care equipment can also transmit the disease between children. Swimming pools and communal showers have also been considered as potential places where a child might acquire the causative viral agent, HPV, and develop non-genital warts.

Non-genital warts are more common in white children compared to African American or Asian children. Focal epithelial hyperplasia, also known as Heck disease, is more common in American Indians. There is no sex predominance. Non-genital warts are rare during infancy and early childhood.

Etiology and Pathophysiology of Non-Genital Warts

Non-genital warts are caused by HPV, which is associated with other abnormal epithelial growth disorders including squamous cell carcinoma. There are different types of HPV and each is associated with a specific type of non-genital warts.

Common warts, also known as verruca vulgaris, are usually caused by HPV types 1–4, types 26 and 27, and type 41. Plantar cysts are usually linked to the same types. Flat warts are commonly associated with HPV types 3, 10, 38, and 49, but other types seen with common warts can also cause flat warts.

Another skin lesion that resembles common warts is caused by a completely different virus known as Molluscum contagiosum (MC). Skin lesions that are caused by MC typically have a round configuration with a central umbilication. The condition is self-limiting and not associated with squamous cell malignant transformation.

These viruses encode for a variety of signal molecules that are responsible for the induction of uncontrolled epithelial cell growth and proliferation. The increased epithelial proliferation is usually associated with nuclear dysplasia and loss of the apical configuration of normal epithelial cells.

HPV types 6, 11, 16, and 18 have been linked to an increased risk of malignant transformation, especially in immunocompromised patients.

Clinical Presentation of Non-Genital Warts in Children

Patients can develop new non-genital warts by autoinoculation, by acquiring the causative viral agent from skin-to-skin contact with an infected individual, or by the use of shared equipment with someone who has warts. The incubation period for HPV is quite long and can range from 1–6 months which explains why most patients do not recall being in contact with someone who has had non-genital warts at the time of presentation.

Once warts develop, the clinical presentation and the characteristics of the lesions differ depending on the classification of the non-genital wart.

Common warts are characterized by hyperkeratosis; they appear as papules, are rough and have irregular surfaces. Their size can range between 1 mm and 1 cm. They are most commonly seen on the hands and knees of children.

Deep palmoplantar warts begin as small shiny papules that eventually develop into deep lesions that are round and are sharply defined with a rough hyperkeratotic surface. Because of the location of these lesions and due to their deep location, they can cause pain. They are found on weight-bearing areas, such as heels and metatarsal heads. On the hands, they are found in periungual and subungual regions.

Flat warts can be flat or slightly raised, are usually smooth and mildly hyperkeratotic. These lesions are usually smaller than common warts and occur on the face, hands, and shins. Size varies from 1–5 mm, and the number may be from a few to hundreds.

Heck disease is characterized by buccal, gingival, or tongue involvement in children. The lesions form small plaques that are typically less than 5 mm in diameter and are most commonly seen in children of American Indian origins.

Finally, patients who develop cystic warts present with a single nodule on the sole of their feet. The lesions may or may not be hyperkeratotic. These lesions are cystic and, if incised, a cheesy material can be expressed from the lesion.

Diagnostic Workup for Non-Genital Warts in Children

The diagnosis of non-genital warts is a clinical one and is not dependent on laboratory findings. For research purposes, one can detect HPV structural proteins from a biopsy taken from a lesion by immunohistochemical staining. HPV can be detected in newer lesions and cannot be found in long-standing lesions. Viral DNA identification is also possible with PCR assays or Southern blot hybridization techniques.

The detection of HPV and the subclassification of the virus type can be helpful in predicting the risk of malignant transformation, especially in immunocompromised children.

Paring warts are useful in confirming the diagnosis of common warts as it can reveal small black dots within a pale background, a sign that is suggestive of thrombosed capillaries.

If a biopsy is taken, which is rarely performed currently, the different histological patterns that can be seen are dependent on the type of the wart.

Common warts usually show digitated epidermal hyperplasia, acanthosis, and papillomatosis. Deep plantar warts appear like common warts but are usually located deeper in the skin. Flat warts are identical to common warts histopathologically with the exception of more basophilic nuclei within the granular cell layer.

The main difference between common warts and Heck disease on histopathological examination is the presence of a thinner layer of keratin and intracellular edema in the latter.

The wall of cystic warts is composed of basal, squamous, and granular cells that are dysplastic and have large nuclei with eosinophilic cytoplasmic inclusion bodies.

Treatment of Non-Genital Warts in Children

Management options for non-genital warts include destructive methods, a wait-and-see approach, immunomodulation, antimitotic drugs against the increased epithelial cellular proliferation, and surgery. Treatment should be started with the least expensive, least painful, and least time-consuming methods. Invasive procedures and expensive treatments should be preserved for refractory and large warts.

Asymptomatic Painful or cosmetically troubling Plantar warts Molluscum Bodies
Spontaneous resolution
  • Salicylic acid
  • Cryotherapy with liquid nitrogen
  • Duct tape
  • Some advocate for debridement prior to topical therapy
  • Others apply topical salicylic acid alone
  • Disappear spontaneously after 6–12 months or longer
  • Topical antibacterial for ruptured lesions or scratched lesions to prevent secondary infection
  • Cryotherapy for older children
  • Avoid sharing towels, sheets

Wait-and-see approach is a reasonable option for children with common warts because approximately two-thirds of the cases will resolve spontaneously. However, when the warts are large and very disfiguring, treatment can be sought by the child or his or her caregivers.

The most common destructive therapy for non-genital warts in children is salicylic acid. Cryotherapy can be also used in children with non-genital warts with excellent results. Surgery should be reserved for difficult cases and for where rapid resolution is required. Complete clearance of warts has been reported to be highest with curettage and electrodesiccation, followed by cryotherapy, and least successful with podophyllin. Laser therapy should be avoided in children because it is painful and can cause scarring.

Immunotherapy can be also used to treat non-genital warts in children. The most commonly used agents are cimetidine and imiquimod. Cimetidine should be used systemically, while imiquimod can be applied topically to the lesion.

Antimitotic drugs such as 5-fluorouracil and bleomycin should be avoided in children because they have not been tested in the pediatric population, and are associated with extensive skin damage, ulcer formation, and scarring. The antiviral cidofovir was used in a single study that involved only 7 children. While the antiviral resulted in complete resolution of multiple hand and feet warts in 4 children within 12 weeks, generalization to other groups of children should not be attempted.


Sixty-five percent of lesions resolve spontaneously within 2 years. Recurrence is common in immunosuppressed patients, and they are refractory to treatment.

Malignant changes are rare but have been reported; the condition is known as verrucous carcinoma. It is a slow-growing locally destructive squamous cell carcinoma and can rarely metastasize.


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