Host side effects of note

Risk of injury for diabetics

Diabetics with palmoplantar warts may experience greater injury or prolonged ulceration post treatment related to diabetic neuropathy. On the other side, diabetics with untreated plantar warts may develop ulcerations from the chronic pressure of the wart. While treatment should be given for all diabetics' warts, aggressive therapy is contraindicated in diabetics with neuropathic disease. In the pediatric age group, older adolescents with an infantile onset of insulin-dependent diabetes mellitus are most at risk [44].

Table 4. Conditions associated with excessive numbers of warts

1. Immunosuppression'

Cardiac allograft Chemotherapy

Renal allograft

2. Genetic syndromes

Common variable immune deficiency Epidermodysplasia verruciformis* Immunodeficiency syndromes

WHIM syndrome (chemokine receptor gene CXCR4)

3. Activity

Butcher

Locker room bathers Participants in sports Sexual intercourse*

*Conditions associated with malignant conversion of HPV infected skin

Psychological disturbance

Patients are often highly distressed by the appearance of their warts, particularly when they are on the dorsum of hands [45]. When patients are highly distressed by their warts, an underlying psychiatric condition should be considered, including obsessive compulsive disorder and body dysmor-phic condition. These diagnoses are rare in early childhood but become more common in the teenage years. Aggressive therapies, such as CO2 laser, may be needed in patients with severe psychological distress.

Vascular insufficiency

Patients with vascular insufficiency (e.g., from Raynaud phenomenon/disease, collagen vascular disorders, and diabetes mellitus) should not be treated with cryotherapy at sites overlying the digital vasculature, nor should they receive injectable bleomycin in any site.

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