Tiny Bumps on Tiny Toes

I get a lot of foot pics sent to me captioned “What is this?” One of the most common are from mom’s holding their wiggly child trying to snap a photo of bumps that have appeared on their foot. 

These bumps can be tender to touch, sometimes itchy. They occur on the plantar skin, the thicker bottom side skin seen in the photo above. The bumps we are talking about are warts, more specifically plantar warts.

Warts are caused by HPV (human papilloma virus). This virus infects the skin and then manifests as a wart. There are over 200 distinct HPV subtypes; HPV type 1 commonly infects the soles of the feet and produces plantar warts. 

Infection occurs with direct contact of the HPV virus to traumatized skin, from a simple scrap or cut. It can also pass through macerated-really wet porous skin, like after swimming.  Summer time barefoot activities, camp and swimming are optimal environments for kids to contract a plantar wart or two.

Warts are diagnosed upon inspection from a physician.  Often for plantar warts the top layer of skin may be scrapped off to better confirm that the bump is a wart and not callus or corn. 

It is important to note that spontaneous resolution of warts may occur in as many as 2 / 3 of children within two years of presenting. However, they may also spread or persist longer; the course is truly unpredictable.  Recurrence is also common, so they may come back.

First line treatment options:

• Salicylic Acid : The most common initial treatment- found in brands like CompoundW and other over the counter treatments. It can be found as a liquid, adhesive patches or on a medicated band-aid.  Sal acid comes in various strengths 17-50%. The higher 40-50% percent is usually reserved for skin on palms and soles. This treatment is most effective when the hard callused skin is removed.

  • Pro Tip :  To safely remove skin use a thin emery board type nail file, or pumice stone. Dry skin well before applying medication. This can be repeated daily. If you are covering the area with non-porous tape repeat every 48 hrs.

  •  Most common side effect is local surrounding skin irritation, this is common and expected. If this occurs decrease the frequency of application and consult the prescribing physician. 

• Cryotherapy - or cold therapy/freezing the warts is also a common wart treatment used for older children. The major disadvantage is that the application is painful, redness and blisters may form in the treatment area. Healing occurs in 4-7 days. Treatment is repeated every two to three weeks until wart resolution. If a response does not occur within six treatments, it is reasonable to transition to an alternative treatment [2].

• Duct Tape - A study of 61 children and adolescents (ages 3 to 22) concluded that covering warts with duct tape was more effective than cryotherapy [3]. Treatment involved keeping the wart covered with duct tape for cycles lasting six days and then removing the tape, soaking the wart,  removing dead skin and wart tissue with an emery board or pumice stone, and then leaving the wart uncovered on the sixth night; the duct tape was reapplied the next morning. Treatment was continued until wart resolution or for a maximum of two months.

Really DUCT TAPE !?

Well - A second study [4] had somewhat conflicting results and showed similar efficacy between duct tape and salicylic pads. However this second study did use both clear and silver type of duct tape- achieving better results with the silver duct tape.

So, it remains uncertain whether duct tape is as or more effective than cryotherapy. But its safe to say that for those who are treating with duct tape, it would make sense to choose a silver brand that is sticky to adequately remain on the skin.[5]

Here is a list of other wart treatments used by physicians: 

• Cantharidin- “Beetle Juice”

• Oral cimetidine

• Surgery - a procedure to cut the wart tissue out of the skin

• Topical immunotherapy with contact allergens

• Intralesional bleomycin

• Imiquimod

• Trichloroacetic acid  

• Intralesional immunotherapy with antigens (ie, mumps, Candida, or Trichophyton)  

Many of the other wart therapies available, are NOT are applicable for kids. Discuss treatment options with your physician after proper diagnosis. Plantar warts can be treated by a pediatrician, a podiatrist or dermatologist. 

 - Be well, Dr. D

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Sources

1. Kwok CS, Gibbs S, Bennett C, et al. Topical treatments for cutaneous warts. Cochrane Database Syst Rev 2012; :CD001781.

2. British Association of Dermatologists' guidelines for the management of cutaneous warts 2014. Sterling JC, Gibbs S, Haque Hussain SS, Mohd Mustapa MF, Handfield-Jones SE Br J Dermatol. 2014 Oct;171(4):696-712. Epub 2014 Oct 1. 

3. The efficacy of duct tape vs cryotherapy in the treatment of verruca vulgaris (the common wart). Focht DR 3rd, Spicer C, Fairchok MP  Arch Pediatr Adolesc Med. 2002;156(10):971.

4. Efficacy of duct tape vs placebo in the treatment of verruca vulgaris (warts) in primary school children. de Haen M, Spigt MG, van Uden CJ, van Neer P, Feron FJ, Knottnerus A  Arch Pediatr Adolesc Med. 2006;160(11):1121

5. https://www.uptodate.com/contents/cutaneous-warts-common-plantar-and-flat-warts/abstract/52

6. British Association of Dermatologists' guidelines for the management of cutaneous warts 2014. Sterling JC, Gibbs S, Haque Hussain SS, Mohd Mustapa MF, Handfield-Jones SE Br J Dermatol. 2014 Oct;171(4):696-712. Epub 2014 Oct 1