skin; verruca 8 destructive therapy

Method Virusidal
A. Formaldehyde
Formasidal is virusidal agent and is in packaging gel 0.7% or 3% solusio. By cooling will accelerate the eradication of the virus verruca. Two hundred children with plantar verruca treated with 3% formaldehyde for 6 - 8 weeks to produce 80% verruca eradication. A control study comparing the use of formaldehyde with the soaking liquid and the second with saccharose showed no difference in eradication rates between the three groups.

B. Glutaraldehyde
Glutaraldehyde in solusio packaging or 10% formaldehyde gel and the like, this hardened skin and cause peeling easier. In studies without control by the use solusio 20% once a day at verruca eliminate 72% of 25 patients in three months. The disadvantage is that your skin is brown and there are reports of skin necrosis after the use of glutaraldehyde 20%.

Antimitotik Therapy
A. Podofillin / Podofillotoksin
Podofillotoksin, an active ingredient in a mixture of raw podofillin which acts as a binding coil antimitotik during mitosis. Inhibited cell division. This agent is used in therapy veruka anogenital, but weak in the penetration into the thick stratum corneum and podofillin more effective for treatment of skin verruca. Cessation of use after peeling verruca, may be effective, but there is a risk of inflammation, the formation of sterile pustules, and secondary infections.

B. Bleomisin
Bleomisin (blenoksan) is a kemoterapeutik agent that inhibits DNA synthesis in cells and viruses. Bleomisin is verruca alternative therapies that do not respond to other therapies or difficult verruca removed by surgery. Bleomisin in 1 - 5 unit vial diluted with 30 mL of physiological salt and 0.3 mL ( 0.15 units) injected into the verruca. Additional injections can be given every three or four weeks until resolution is reached. The pain is the biggest factor for therapy. Potential side effects is the formation of scar tissue, changes in pigmentation, nail damage, and Raynaud's phenomenon. Bleomisin recorded against pregnancy in category D, potentially absorbed after injection. One study reported that bleomisin used for the naughty verruca therapy. After the use of topical anesthetic, is injected into the bleomisin needle verruca. Resolution level reached 92%.
Although a number of RCT (randomized control trial) who reported that the level of effectiveness is low bleomisin, one article has been concluded that there was no consistent evidence on the effectiveness of therapy bleomisin intralesi in verruca nongenital and the data is not meant entirely for analysis. Another article based on RCT and a series of four different cases that present evidence of the effectiveness bleomisin, advocated its use as a third-line therapy for verruca vulgaris and plantar verruca.

C. Retinoids
Systemic retinoids have been used in the management of verruca for its ability to alter and accelerate the eradication keratinisasi way verruca induces irritant dermatitis. Small study reported etretinat effectiveness in children with a wide veruka. Etreninat not used widely in the United States, asitretin (soriatan) is now used. Etretinat dose of 1 mg / KgBB / day given no more than three months. In the 20 children who were included in this study, 16 of which showed complete resolution of verruca and without recurrence. Verruca relapse in four other patients after regression part.
One article found evidence supporting the use of topical retinoids based on one cohort study that examined the effectiveness of retinoids using a number of case reports and a number of experiments using systemic retinoids. Other articles from several case studies suggest the use of oral and topical retinoids as second-line therapy as a treatment verruca Plana.

Immune stimulation
A. Topical sensitization
Slow induction of hypersensitivity reactions have been used as verruca therapy. Dinitroklorobenzen and squarit dibutilester acid has been used, but many studies have seen difensipron effects. Two open studies have shown the difensipron great results. In one study, difensipron used every week for 8 weeks in 134 patients and provides approximately 60% response (complete resolution occurred in 44% of patients within 4 months). In another retrospective study, 48 patients were treated every 3 weeks, 88% of patients in verruca net 14 weeks. Return to this therapy that some patients can not sensitisation, while others have dermatitis reaction.

B. Cimetidin
Cimetidin have imunomodulator effects that are not clear and are used for therapies that have been advanced verruca. Open trial reported some effectiveness, but studies with controls showed no benefit compared with placebo.

C. Immunotherapy Intralesi
Intralesi Immunotherapy uses the immune system's ability to recognize viral antigens and certain fungi. Antigens for Candida skin test commonly used. It is believed that the slow type hypersensitivity reaction induced by this antigen improve the immune system's ability to identify and eradicate HPV. One study showed complete resolution of verruca participants and 47% ,75 - 99% resolution in 13% of participants. In the 34% who enrolled in this study had documented complete resolution of all verruca remote from the injection site. In 22% of participants, the level of 75 - 99% verruca resolution remote from the injection site has also been noted. Regression verruca remote from the injection site was not found on other therapies. Although some recent RCT has been published, an article states that intralesi Immunotherapy as second-line therapy for plantar verruca and third-line therapy for verruca vulgaris and verruca Plana.

Other Therapies
Many other therapies have been used to therapy verruca, although few are receiving these types of therapy. Traditional medicines are still used but without evaluation. Homeopathy uses a variety of drugs that contain calcium, netrium, and sulfur which showed the advantage over placebo. Hypnosis has been evaluated with a double-blind placebo-controlled trial of 40 individuals who were treated for more than 6 weeks. The group that got hypnosis lost more than verruca groups received topical salicylic acid or placebo. Local warming therapy has been tested on 13 patients. At 29 verruca who were treated, 86% net, while 41% of the placebo group, verruca regresses. Intralesi interferon has shown some effect on the experiment verruca open. Imiquimod 5% cream for 9-11 weeks has been used by a minority of patients with great results. Irradiation, one of the most commonly used, now no longer used for treatment of benign.

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skin; verruca 7 destructive therapy

Destructive Therapy

A. Salicylic acid
Salicylic acid is a slow acting keralolitik epidermis infected. Results with mild irritation may stimulate an immune response. Salicylic acid itself has shown the results of a resolution on 67% of patients with verruca in hand and 84% in patients with plantar verruca within 12 weeks.
There are many patented products salicylic acid, but no recent information to compare these products:
1. 11-17% salicylic acid in kolodio and gels such as kolodio lactic acid, copper
2. 26% salicylic acid in the basic poliakrilik designed to mix their own
3. salicylic acid with 25% podofilin in oinment, used for plantar verruca
4. 50% salicylic acid is used to ointment plantar verruca.
Before applying ointment verruca, keratin layer must first exfoliated or removed with sandpaper or a polished and smooth the surface by soaking in warm water. Kolodio products to form a layer of exfoliated before re-application. Product occlusion has been shown to increase the level of plantar verruca cleansing.
The comparison between the content of salicylic acid ointment and a single treatment with glutaraldehyde, folouroasil, podifilin, benzalklonium, cryotherapy with liquid nitrogen, does not prove more effective than salicylic acid.

B. Cryotherapy (Surgical Frozen)
Liquid nitrogen (LN2, 2196 8C) is the agent most frequently used. Mixture of dimethyl ether / propane (257 8C) is used as pleased with this product, but the effectiveness in making a sufficient temperature to necrotic cells was low. Cryotherapy have any effect on either resolution verruca necrosis by simple destruction keratinocytes infected with HPV and local condition inflammatory response to induce cell-mediated immune effective.
Different techniques between physicians with a variety of freezing time, the way the distance between the application and therapy. Many doctors use a cotton stick spray, but still widely used and better used in children or verruca close to the eye. Generally done freezing until halo around verruca lost and the time between 5-30 seconds depending on the location and size verruca. When an application re-LN2 with cotton sticks, to note that HPV and other viruses like HIV can survive in liquid nitrogen.
Verruca with surgical destruction of frozen every three weeks can give resolution results in 69% of patients with verruca in hand within 12 weeks. This study used liquid nitrogen with a cotton bud to disappear from the surrounding halo verruca (about 5-30 seconds). Cleanup levels increased when cryotherapy combined with salicylic acid ointment, although not significant.
Two cycles of freeze-liquid has been shown to improve resolution in plantar verruca but not in palmar verruca. The ideal interval between surgery frozen with the next one is not clear. Bunney study showed that the interval of more than three weeks, reducing the rate at 12 weeks of treatment, other studies show that the resolution depends on the amount of therapy, so that weekly therapy produces a more rapid resolution.
Patients should be reminded that the frozen surgical pain and heat. Need to be careful when passing tendon surgery and frozen in patients with little circulation. Can occur hypo and hyperpigmentation, especially in blacks. Therapy can be followed by onikodistrofi on verruca periungual.

C. Termokauter or Kuretase and cautery
Verruca surgery has been practiced mainly with a blunt kuretase or surgery followed by cautery. This method is particularly used in verruca filiformis on the face and extremities. In an open study, the success rate of patients reported an average of 65-85%. This procedure usually leaves scar tissue and recurrence occurs more than 30%. The growth of scar tissue on the soles of the feet is a relative contraindication in this surgical method.
A study conducted in India, which compare the effectiveness of 5-flouroasil (pyrimidin fluorine which cuts the viral DNA synthesis) with electrosurgery performed on 50 patients who were divided into two groups, showed 52% of patients showed good response to 5-flourourasil, whereas 72 patients showed good response to electrosurgery. 5-flouroasil give a better effect on verruca Plana, verruca plantar, and condyloma akuminata, whereas electrosurgery provides a better response to the verruca vulgaris especially in the case verruca filiformis. Electrosurgery side effect of pain, secondary infection, the growth of scars, and hipopigmentasi, while 5-flouroasil have side effects of eritem, photosensitive, and hiperpigmentasi.8

D. Chemical cautery: Batang Silver Nitrate
Chemical cautery with daily re-use silver nitrate sticks can cause destruction to effect adequate resolution verruca, but sometimes hyperpigmented scars formed. In a placebo control study in 70 patients, three silver nitrate application all verruca resolution at more than 9 days at 43% and 26% probandus improvement verruca one month after treatment compared to 11% and 14% in the placebo group.

E. Carbon dioxide laser
Destruction produced by CO2 laser has been used to therapy virus verruca. Periungual and subungual lesions are difficult resolusition with other treatment methods, appropriate when using this method. The level of recovery was reported in two cases of 64-71% after 12 months, but pain can occur after an operation scar tissue growth.

F. Pulsed Dye Laser
Therapy with vascular lesion laser, also known as pulsed dye laser therapy that can selectively target a hemoglobin contained in verruca. When hemoglobin heat, thermal energy dissipated into the surrounding tissue, causing the blood vessels cautery. The result is a frequent necrosis verruca peeling. The use of pulsed dye laser absorption of energy depending on the capillary matting in verruca and local tissue necrosis. Pain and less scarring than the laser occurs CO2.1 Many studies have studied the effectiveness of pulsed dye laser therapy after about two or three times a therapy reported cure rates of about 48-93% verruca at various locations. One study showed a resolution rate of about 72%. Highest resolution level of 85.7% in periungual and verruca lowest level in 50% verruca plantar.
In a separate study comparing the pulsed dye laser therapy with cryotherapy and cantaridin. In patients treated with cryotherapy and cantaridin, 70% showed the cleaning, while 66% of patients showed eradication after pulsed dye laser therapy. The researchers conclude that pulsed dye laser therapy effective as conventional therapy. Pulsed dye laser therapy is recommended as second-line therapy in verruca and third-line therapy for verruca vulgaris and verruca Plana. However, another article found EBM weak to support the use of pulsed dye laser as sole therapy for this study method can only be used for therapy verruca located on the hands and feet.

G. Fotodinamik Therapy
This therapy depends on the chemical capture by abnormal cells, usually an amino acid-levulinat (AAL) was involved in track and photograph porphyrin oxidation by irradiation using laser or non laser that affect the network. Comparison of responses in 45 patients who received three laser therapy with wavelengths of 589-700 nm after the AAL 20% cream or placebo cream showed that active treatment resulted in an increase or reduction of the size of the resolution after 4 months verruca with AAL and irradiation.

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skin; verruca 6 Management

Management
There is no single therapy is one hundred percent effective, and various kinds of therapy should be combined. Research on the effectiveness of therapy should take into account the possibility of spontaneous regression. Any decision taken therapy which must be made case by case basis based on the physician experience, patient selection, and implementation of evidence-based medicine. Immunocompromised patients may experience with verruca incomplete cleaning and verruca become resistant to therapy. Verruca left without treatment is a valid management option if the patient is acceptable, but plantar verruca cause pain and verruca the invisible hand and less influence on school activities or led to difficulties at work. Verruca in adults with a long duration of infection and in immunosuppressed patients have little chance to heal spontaneously and more difficult to be treated.
Verruca with different types and different locations require different therapies. Verruca on the face should not be treated with ointment verruca severe irritation because of the risk. Verruca Plana with Koebner phenomena with any destructive techniques can aggravate the disease. Most verruca can be treated by general practitioners and even by the nursing staff.
The main goal is verruca management:
(1) to eliminate verruca without recurrence
(2) without cicatrix's
(3) create a long-term immunity.
General principles of management verruca must see things as follows:
1. not all be eliminated verruca
2. indication to be removed are: pain, interfere with the activity, cosmetic factors, and the risk of malignancy
3. there is no treatment success rate is very high (about 60-70% net in three months)
4. immune response is an important factor in the net verruca. Immunocompromised individuals may not show the net verruca
5. the highest level of cleanliness for the management of a variety usually the younger people who have a short duration of infection.

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skin; verruca 5 Veruka and Malignancy

Diagnosis Banding
Verruca plantar must be distinguished from regions where lesions callositis waxy, thick, yellowish and there are no capillaries in the peel. Cron occur in places affected by pressure and are usually smaller and pain with blockage in the middle.
Veruka Plana should be distinguished liken Planus which shows a purplish and diskolorasi Wickham stria. Planus liken lesions usually associated with itching and certain mucosal lesions.
Nevus epidermal similar verruca digitata or verruca filiformis. Molluscum contagiosum lesions are white with papul seen umbilikasi or in the middle of the curve.

Verruca and Malignancy
Verruca benign in individuals imunokompeten almost never become malignant. There are a few reports of lesions that begin as verruca and later became squamous cell carcinoma is invasive. The combination of verruca periungual with genital HPV disease should be special attention.
Verukous many lesions occur in individuals with immunosuppression and in patients who receive organ transplants is about 50% of patients with renal transplants develop into verruca, five years after transplantation. Exposure to sunlight increases the incidence of lesions verruca and act as kokarsinogen. Changes displasi almost certainly happen and very little relationship between the clinical symptoms with the histological picture. The lesions are a particular form of the virus verruca, Keratosis Bowenoid or diesel or keratoakantoma or squamous karsinomata. Some types of HPV have been found in benign squamous lesions and malignant in patients with immunocompromise and a role in the initiation and progression of malignant processes.

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skin; verruca 4 diagnosis

Special forms

Epidermodysplasia verruciformis
Epidermodysplasia verruciformis is inherited disorder in which there are subtle defect-mediated immunity by cells and is an area of HPV infection and persistent. Lesion is very diverse forms, can be flat, resembling verruca lesions, macular hyperpigmentation, red, or atrophy, or plaque-like Pityriasis versicolor. Flat form and which resemble lesions frequently located in verruca extremities and face and a thicker plaque can mimic seboroik Keratosis. Lesions found to contain many types of HPV that cause verruca including Plana, but some types that do not cause disease in normal individuals. There is a risk of developing into squamous cell carcinoma of the skin exposed to the sun (sun-exposed).

Bowenoid papulosis
Also known as intraepitelial neoplasms of the vulva, penis, and anal (NIV, NIP, NIA). Bowenoid papulosis appears as a small papul, usually multiple, sometimes located on the surface of pigmented mucosa and skin in the anogenital region of both sexes. Usually found in young adults but no association of age and there is a strong relationship with HPV type 16 infection.

Focal epithelial hyperplasia
Also known as Heck's disease, is a rare benign lesions, which reduced noise without gender predisposition. Lesions characteristic of multiple noduler firmly bounded on the oral mucosa. The disease is usually found in native Americans and the Inuit in Greenland, is reported rarely found in other countries. HPV types 13 and 32 as an agent cause in patients with genetic predisposition.

Epithelioma carcinoma cuniculatum and verukosa
Epitelioma kunikulatum a squamous cell carcinoma appears as mass with a smooth consistency bulbus software on your feet. Multiple sinus open to the surface and when pressed, the lesions become like a giant plantar verruca, but the difference between rapid growth and local invasion.
Verukosa carcinoma developed in the cavum of oral and genital mucosal lesions, and look like cauliflower.

Diagnosis
Verruca diagnosis is established based on clinical examination but can also be supported by the histological picture of epidermal acanthuses with papillomatosis, hiperkeratosis, and parakeratosis with a protrusion and grooves in the middle of verruca. Dermis capillaries protruding and blood clot blockage. There are a wide keratinocytes with eccentric piknosis cell nucleus surrounded by a halo perinuklear (koilosit is characteristic of papilloma associated with HPV). HPV-infected cells had few granules and a lump of eosinophils keratohialin basofilik granules. Verruca Plana acanthuses only slightly and does not occur hiperkeratosis and parakeratosis or papillomatosis.
Characterization of HPV is very little done, but useful in some cases of genital verruca in children with suspected sexual abuse. Knowledge of the genotype of HPV in benign verruca therapy does not affect the election.

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skin; verruca 3 aetiology, histopatology, and classification

Aetiology
The virus causes fall into papilloma virus (group papova) diameter of 45 nm. Is a DNA virus replication occurs internuclear characteristics.
Histopathology
Verruca is-epithelial hyperplastic lesions. Happened here acanthuses irregulars and hiperkeratosis. Focal sections of cells that have the irregulars through vakuolisasi stratum granulosum and caused protrusion parakeratotik in Stratum corneum, which consists of material basofilik inclusions in the nucleus. Tues lower stratum spinosum and stratum basalis is not affected.

Classification and Clinical Symptoms
The disease has verruca clinical forms:
1. verruca vulgaris with variant verruca filiformis
2. verruca Plana juvenilis
3. verruca plantar
4. verruca akuminatum (Condyloma acuminatum)
5. special form
Verruca vulgaris (warts)
This form is most common in children, but also in adults and the elderly. Predileksi place mainly in the extensor extremities, although this could spread to other parts of the body including the mouth and nasal mucosa. These warts round, gray, or if lentikuler size confluention shaped plaque, rough surfaces (verukosa). With a stroke can occur throughout the scratch autoinokulasi (Koebner phenomenon).

Parent is also known wart at some point will cause warts children in large numbers. There are opinions that characterize the disease recover without treatment
Verruca vulgaris variant found in the face, eyelids, nostrils, and skin heads are shaped as a protrusion perpendicular to the surface of the skin and surface verukosa called verruca filiformis. The lesions are usually single, soft, thin, like yarn. Lesions in the scalp rather difficult to be eliminated because it can grow new lesions due to scratching or because the use of a comb.

Verruca Plana juvenilis
This verrruca size milier or lentikuler. Smooth or flat surface, same color of skin color or slightly brownish. Spread especially in the face and neck area, dorsum manus and pedis, wrists, and knees. There is also a Koebner phenomenon and includes diseases that can heal itself without treatment. The number of lesions can be very many. Mainly occurs in children and young people, although can also be found in the elderly.

Verruca plantar
These forms are in the soles of the feet, especially in areas experiencing stress. The form of the hard ring in the middle of a bit soft and yellowish color. Slippery surface due to friction and leading to pain during walking, which caused the suppression by the masses is in the middle of the ring.
There are two types of plantar Verruca:
• Solitary verruca a single verruca. Verruca its size is often increased and even multiply, forming satellite verruca.
• Verruca mosaic is a group of several small verruca that confluen in one place. Mosaic Verruca more difficult to treat than solitary verruca.

Condyloma akuminatum
Condyloma akuminatum is shaped skin disorder with surface-stemmed vegetation in the genital area predilection place. The disease is discussed separately.

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skin; verruca 2 definition and epidemiology

Definition
Hiperplasi epidermal Verruca is caused by human papilloma virus (HPV) a particular type. HPV genotypes are divided into separate based on DNA content. Different types of HPV that can infect both the stratum corneum squamous epithelium or mucous membrane layer that has no horns. Appearance of lesions is not only influenced by the type of virus but also by environmental factors and the host.
More than 100 types of HPV that infektion skin and mucous membranes have been identified. Types of HPV that infect the skin will develop into verruca vulgaris. Specific type of high-risk HPV that infect the mucosa tissue in the genital area has a carcinogenic effect. High-risk HPV is also found in the head and neck cancer that develops in the tonsils.
There is also a low-risk types of HPV that cause benign lesions in the genital area, such as genital verruca. Some types of HPV infect the skin and cause verruca at various locations in the body. HPV types cause benign growth, or papilloma on the vocal cords.

Epidemiology
Verruca the spread of cosmopolitan and transmission through skin contact or autoinokulasi. Higher risk of infection if the skin is not infected with HPV had an injury or in wet conditions (eg in the pool or in the general cleaning) and contact with the skin on verruca.
This virus can also spread to other parts of the body. For example, it can spread to verruca around nails, lips, and surrounding skin if we verruca often bite on the finger or the nail, or if we like to suck fingers with verruca. If you have the immune system bad, it can develop into a much verruca and difficult to remove (eg in AIDS patients, in patients undergoing chemotherapy, etc.).

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skin; verruca 1

A lot of people who have experienced infection Human Papilloma Virus (HPV) in their lives. One manifestation of this virus infection is a verruca / verruca or often referred to as warts or warts cuplak or in English.
Warts appear on the layer of the epidermis with a variety of forms. Verruca vulgaris, verruca plantar, verruca Plana, and Condyloma akuminuta are some clinical manifestation of HPV infection.
Prevalence of viral warts in the United States in children and adults was recorded between 3.9% to 4.9%. Another survey said the prevalence of this virus in the state located in the northern United States ranged from 3% in children, 20% in adolescents, 3.5% in adults aged 25-34 years.1 greatest incidence occurs at age 12-16 years and more attacking women than men.
Actually verruca warts or harmless, but sometimes not visible. Verruca that arise on the sole of the foot sometimes causes a sense sick.3 In one study says, verruca will recover spontaneously within two years without treatment in children 40% of patients.

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