British Association of Dermatologists’guidelines for the management of cutaneous warts 2014
英国皮肤病协会关于皮肤疣诊疗指南--2014年版
编译 杜鑫、王静，审校 杨春俊、张学军
文章转自： 安徽医科大学第二附属医院皮肤性病科
Background（背景）
Warts are caused by infection of keratinocytes by human papillomavirus (HPV). There are over 150 genotypically different types of HPV, with classification based on defined variation of the viral DNA. The majority of common warts are caused by HPV types 1, 2, 4, 27 or 57, and plane warts by HPV types 3 or 10. The HPV types originally identified in epidermodysplasia verruciformis (EV) and their closely related genotypes are also found on the skin, often as subclinical infections, but they can be associated with squamous cell cancer and premalignant dysplasias, especially in cases of immunosuppression.
HPV can spread from one individual to another by direct contact or via the environment. It is not known exactly how long the infectious virus can persist outside the body, but the related bovine papillomavirus is believed to retain infectivity for months or possibly years,and the same may be true for HPV.
Warts are a common skin disease worldwide. Infection is common in childhood, but can occur at any age. Small cohort observational studies have suggested that 5–30% of children and young adults have warts. Clearance in children can occur after only a few months, with half clear at 1 year and about two-thirds by 2 years.However, warts in adults can be much slower to clear, and persistence for 5–10 years is not uncommon.
Diagnosis of common hand and foot warts is usually not difficult. Warts need to be distinguished either clinically or histologically from other keratotic lesions on the hands or feet, such as actinic keratoses, knuckle pads or, more rarely, squamous cell carcinoma or focal palmoplantar keratoderma. On the feet, corns and calluses or callosities can be confused with warts, but paring and close inspection should allow them to be distinguished. On limbs, other hyperkeratotic lesions such as lichen planus or angiokeratoma may cause confusion, and plane warts may need to be distinguished from lichen planus or thin actinic or seborrhoeic keratoses.
Impairment of the immune system, especially cell-mediated immunity, usually results in prolonged duration of warts. Warts may be the presenting feature of milder immunosuppressed states such as lymphoma, idiopathic CD4 lymphocytopenia or HIV infection,
so unusually severe or prolonged warts should prompt consideration of underlying immune deficit.
Depending on their site and size, warts may be just a minor nuisance. If the affected individual is immunocompetent, then an expectant approach to management is entirely acceptable. Some warts can be uncomfortable or interfere with function, or may be a major cosmetic bother and embarrassment when numerous or on sites such as the face. Under these circumstances, a number of different treatments may be considered.
这主要取决于疣的部位及大小。若疣影响到美观或者功能，或者造成患者的不适，可以考虑其他的治疗方法。
Interventional treatment （干预）
There are numerous treatments for warts, and whether used singly or in combination they often have little evidence base for their use. Ideally treatment should not leave scars, although many patients may prefer a permanent scar to a persistent, unsightly and troublesome wart. There is no antiviral treatment that is specific for HPV, but some of the available therapies interfere with the viral life cycle. The most common approach to treatment is to damage or destroy the infected epithelium.
11.Trichloroacetic acid and monochloroacetic acid （三氯乙酸和一氯醋酸）
12.Hyperthermia（温热疗法）
13.Surgical interventions （外科手术治疗）
14.Photodynamic therapy （光动力疗法）
1.2 Cryotherapy（冷冻）
Liquid nitrogen, delivered by cryospray or cotton bud, is the most commonly used method in medical practice. Techniques differ between practitioners, with variations in freeze times, mode of application and intervals between. Paring before cryotherapy can improve results in plantar warts, but not hand warts.The reported cure rate of cryotherapy for warts at all sites from randomized trials is highly variable, ranging from 0% to 69% with a mean of 49%.
A silver nitrate 10% solution was investigated in a placebo-controlled, doubleblinded study of hand and foot warts in 60 children and adults, and showed a clearance rate of 63% of patients after 6 weeks.
一项针对60例儿童和成年人手足疣的治疗报道，使用10%硝酸银溶液治疗6周后清除率可达到63%。
1.4 Phenol（苯酚）
Phenol is a caustic agent that has been compared with cryotherapy in a single-blinded, randomized study of 60 patients with hand warts. The cure rates of patients were 70% with cryotherapy and 83% with phenol.
苯酚是一种腐蚀性的液体。在一项和冷冻治疗对比的研究中，治愈率为83%，而冷冻为70%。
1.5 Cantharidin（斑蝥素）
This is a blistering agent that triggers acantholysis. The superficial nature of the injury reduces the risk of scarring. A study of 15 patients who were treated with a cantharidin 0.7% solution to treat plane facial warts showed clearance of warts in all 15 patients within 16 weeks with one to four treatments.
Glycolic acid is an a-hydroxy acid that acts as a peeling agent. In a case series of 15 children with facial plane warts it was well tolerated, cleared all of the cases and did not produce scarring.
在一项15例儿童扁平疣的治疗中，耐受性好，清除率高，并且不留下疤痕。
1.7 Pyruvic acid（丙酮酸）
Pyruvic acid is used as a peeling agent. In a case series investigating the response of common warts to pyruvic acid 70% alone or in combination with 5-FU 0.5%, 80% of patients showed improvement.
丙酮酸是一种剥离剂。在一项和5-FU联用治疗寻常疣的研究中，80%患者显示疗效。
1.8 Citric acid 50%（柠檬酸）
Citric acid was compared with tretinoin in a prospective randomized, doubleblinded study of 75 patients with plane warts on the body.After 6 weeks 64% of citric acid-treated lesions were cleared, vs. 54% of the tretinoin-treated lesions.
在一项和维甲酸治疗寻常疣的双盲研究中，柠檬酸治疗清除率为64%。
1.9 Formic acid（甲酸）
As an acid, it is stronger than SA but weaker than trichloroacetic acid. A number of studies have suggested its efficacy.
其疗效强于水杨酸，但弱于三氯醋酸
1.10 Trichloroacetic acid and monochloroacetic acid（三氯乙酸和一氯醋酸）
Trichloroacetic acid is used regularly to treat genital warts,and has been used without adequate trial evidence to treat common warts.
三氯乙酸常用来治疗生殖器疣，但是治疗寻常疣仍需要更多的证据。
1.11 Hyperthermia（温热疗法）
Two randomized trials have studied the effects of localized heat on warts. The more recent trial involved 60 patients with plantar warts randomized to hyperthermia with red light (up to 44 °C for 30 min on three consecutive days) or placebo red light alone. localized hyperthermia can be effective and is reasonably safe.
几项研究表明，温热疗法有效且安全。
1.3 Photodynamic therapy （光动力疗法）
There was a significant difference in wart clearance after 14 weeks in 45 patients with palmar and plantar lesions treated with 20% aminolaevulinic acid photodynamic therapy (ALA-PDT) compared with placebo-PDT. In total, 75% of plantar warts completely resolved in 6,7 ALA-PDT-treated patients compared with 23% in the placebo group.
一项研究表明，经过6到7次的ALA-PDT治疗，75%的疣体清除，而安慰剂只有23%的清除率。
2. Virucidal agents（杀病毒治疗）
Formaldehyde（甲醛）
Glutaraldehyde（戊二醛）
3.Antiproliferative agents（抗增殖治疗）
Vitamin D analogues（维生素D衍生物）
Dithranol（地蒽酚）
Podophyllin and podophyllotoxin （鬼臼毒素）
5-Fluorouracil
Bleomycin（博莱霉素）
Retinoids（维A酸）
Cidofovir（西多福韦）
4. Immunological therapy（免疫疗法）
Imiquimod（咪喹莫特）
Contact immunotherapy （接触性免疫疗法）
Intralesional immunotherapy（内部免疫疗法）
H2 receptor antagonists（H2受体拮抗剂）
Other systemic immunotherapy
Zinc oxide and zinc sulfate（氧化锌及硫酸锌）
5. Complementary and alternative treatments（补充和替代疗法）
