Warts, Foot Disorders, and Alopecia

Warts, Foot Disorders, & Alopecia

Objectives

• Design patient-specific treatment plans for warts, minor foot disorders, and alopecia.
• Recognize typical presentations of:
  • Warts (common and plantar)
  • Minor foot disorders (corns, calluses, bunions)
  • Alopecia
• Differentiate androgenic alopecia from other types of alopecia.
• List the pharmacologic category, brand/generic name, and dosing frequency of medications used to treat these conditions (see "drug tables").
• Identify exclusions to self-care.
• Identify appropriate medication options based on patient parameters (allergies, contraindications, cost, etc.).
• List nonpharmacologic recommendations to prevent spreading warts and prevent development of/minimize discomfort of foot disorders.
• Describe nonpharmacologic recommendations to minimize the appearance of alopecia.
• Discuss counseling points for nonprescription medications.
• Describe proper application of salicylic acid, DMEP, and nitrous oxide.
• Describe proper application for topical minoxidil solution and foam.
• Compare minoxidil treatment regimens in men and women.

Medications

• Salicylic Acid
  • Formulations:
    • Collodion (17%): Compound W Liquid, Compound W Gel, DuoFilm Liquid
    • Plaster/Pad (40%): Compound-W Pad, DuoFilm Patch, Curad Mediplast
  • Class/MOA: Keratolytic; destroys virus-infected cells and induces an immune response due to mild irritation.
• Dimethyl Ether; Propane (DMEP)
  • Formulation: Pressurized spray can with DMEP and foam applicators.
  • Brand Names: Compound W Freeze Off, Dr. Scholl’s Freeze Away Wart Remover
  • MOA: Cryotherapy – freezes tissue, leading to microthrombi, ischemic necrosis, and destruction of cells infected with the virus.
• Nitrous Oxide
  • Formulation: Pressurized spray can with nitrous oxide and foam applicators.
  • Brand Name: Compound W Nitrofreeze

What Causes a Wart?

• Virus (HPV)

Warts

• Patient demographics: More common in children and adolescents (peaks at 12-16 years old) than infants and adults.
• HPV enters through minor injuries/skin abrasions.
• Risk factors:
  • Previous or existing warts
  • Suppressed immune system
  • Going barefoot, especially on wet surfaces
  • Using swimming pools/public showers
  • Working in meat handling
  • Biting fingernails

Self-Treatable Types of Non-Genital Warts

• Common (Verruca Vulgaris)
  • Location: Hands
  • Population: Children & adolescents
  • Characteristics: Skin-colored or brown, dome-shaped, hyperkeratotic papules with a rough surface (cauliflower-like).
  • Self-Treatable: Yes
• Plantar (Verruca Plantaris)
  • Location: Feet
  • Population: Adolescents and young adults
  • Characteristics: Skin-colored, flat, callus-like, hyperkeratotic lesions with disruption of normal skin markings; located on feet.
  • Self-Treatable: Yes

Common Warts

• Medical term: verruca vulgaris
• Symptoms:
  • Skin-colored or brown on lighter skin;may appear lighter or darker on darker skin
  • Hyperkeratotic, dome-shaped papules
  • Rough, cauliflower-like appearance
  • Usually painless
• Characteristics:
  • Begins as a smooth surface papule that enlarges due to irritation
• Onset:
  • Incubation may be up to 8 months and may depend on individual immune response
• Location:
  • More common on the hands
• Aggravating:
  • Irritation causes the wart to enlarge
  • Risk factors:
    • Having previous or existing warts
    • Suppressed immune system
    • Working in meat handling occupation
    • Biting fingernails
• Remitting:
  • Prevent autoinoculation (spreading to oneself)

Plantar Warts

• Med term: Verruca plantaris
• Symptoms:
  • Skin colored (may be lighter or darker)
  • May be painful, especially if on weight-bearing location
  • Mosaic wart – multiple, clustered plantar warts in 1 location (may look like 1 large wart)
  • Distinguish from callus / corn – if remove outer layer see pinpoint bleeding (looks like small black seeds)
• Characteristics:
  • Enlarges with irritation
• Onset:
  • Incubation may be up to 8 month and may depend on individual immune response
• Location: feet
• Aggravating:
  • Enlarges with irritation
  • Risk factors:
    • Having previous or existing warts
    • Suppressed immune system
    • Going barefoot especially on wet surfaces
    • Using swimming pools/ public showers
• Remitting:
  • Prevention: footwear, cover to prevent auto-inoculation

Other Non-Genital Warts (Non Self-Treatable)

• Flat (Verruca Plana)
  • Location: Face
  • Population: Children
  • Characteristics: Smooth, flat-topped, yellow-brown papules; common in children but rare in adults
  • Self-Treatable: No
• Mosaic
  • Location: Feet
  • Population: Adolescents and young adults
  • Characteristics: Multiple, closely grouped plantar warts
  • Self-Treatable: No
• Periungual
  • Location: Nails
  • Population: Persons who bite their nails
  • Characteristics: Thickened, fissured, cauliflower-textured skin around the nail plate
  • Self-Treatable: No
• Filiform
  • Location: Face
  • Population: Children through adults
  • Characteristics: Flesh-colored, rapidly growing, with threadlike projections
  • Self-Treatable: No

Warts: Exclusions to Self-Care

• Age < 4 years (Referral: Soon)
• Chronic, debilitating conditions that affect sensitivity or circulation of the hands or feet (diabetes, peripheral vascular disease, neuropathy) (Referral: STAT)
• Poor blood circulation (Referral: STAT)
• Large or multiple warts (greater than 10) located on one area of the body (Referral: STAT)
• Debilitating plantar warts (difficulties walking) (Referral: STAT)
• Face, breasts, armpits, toenails or fingernails, anus, genitalia, and/or mucus membranes involved (Referral: STAT)
• Immunocompromised patients/immunosuppressive medication (Referral: STAT)

Warts Non-Pharmacologic Treatment with Referral

• Pregnancy or breastfeeding (Referral: Soon, Non-Pharm: Y)
• Uncomfortable plantar warts (Referral: If pain continues, Non-Pharm: Y)

Salicylic Acid

• MOA: keratolytic (tissue destruction leads to immune response)
• Allergy? to ASA
• ADRs: irritation if contact with healthy skin
• Plasters/Pad: 40%
• Collodion / Gel 17%

Salicylic Acid: Administration

• Wash and dry area before applying (after shower may be best)
• Collodion / Gel 17%:
  • Apply BID
  • Apply 1 drop at a time
  • Apply only to affected skin (protect healthy skin)
  • May repeat for up to 12 weeks
• Plaster/ pad 40%:
  • Cut to wart size (avoid contact with healthy skin)
  • Apply and cover with an adhesive
  • Apply and remove every 48 hours for up to 12 weeks
  • Common or Plantar
• Common Only

Dimethyl Ether and Propane (DMEP) & Nitrous Oxide

• MOA: cryotherapy (tissue destruction leads to immune response)
• Nitrous Oxide reaches lower temp than DMEP
• Administration:
  • See product-specific instructions
  • After application, a blister will form under wart
  • After 10 days, the wart may fall off
  • May repeat after 14 days up to a total of 4 times
  • Careful not to touch neighboring skin
• ADRs: irritation, burning, aching, and itching/ drying

Combination Products

• Contain both cryotherapy and salicylic acid
• May be more effective
• Avoid on sensitive skin

Key Counseling Points for Salicylic Acid & Cryotherapy

• Review exclusions to self-care
• Do not use on irritated skin or area that appears red or infected
• ADRs: tissue destruction = painful if applied to healthy skin
• Visible improvement after 1-2 weeks, but full resolution may take up to 3 months!

Duct Tape?

• Mixed results from clinical trials
• Clear duct tape does NOT work
• Application:
  • Cut tape to size of wart, cover with tape, then over the wart for 6-7 days with the tape.
  • Soak the area in water and debride the wart with a clean emery board.
  • Repeat this process for up to two months

Non-Pharmacologic Interventions

• Wash hands frequently, especially after touching a wart
• Use a specific towel to dry the affected area; use a separate towel on other parts of the body
• To prevent spreading if on hands: Keep covered with a band-aid
• To prevent spreading if on feet: Do not walk barefoot (or keep covered)

Minor Foot Disorders

• Corns
• Calluses
• Bunions

Differentiating Corns, Calluses, and Warts

Corns (Clavis)

• Sharply demarcated, well-circumscribed margins, hyperkeratotic lesion with a central core
• Caused by pressure from underlying bony prominences or joint
• Has a hard center
• Color: flesh-colored to white or yellowish gray
• Base is on the surface of the skin; apex points inward = painful
• Caused by pressure from inappropriate, tight-fitting shoes

Callus

• Broad base with relatively even thickening of skin
• Usually found on the bottom of foot – heel, ball of foot, toes, or sides
• Indefinite border; size may be up to several centimeters
• Usually raised and yellow with normal pattern of skin ridges
• Caused by friction (loose-fitting shoes), walking barefoot, structural biomechanical problems

Ingrown Toenail (Onychocryptosis)

• Typically caused by incorrect trimming of nails (should cut straight across / no tapered corners)
• Pointed shoes, tight shoes, or too-tight hosiery may also contribute
• Contributing factors:
  • Hyperhidrosis
  • Trauma
  • Obesity
  • Excessive pressure on the toes
  • Bedridden (tightly tucked bedcovers)
  • Nail curling (heredity)
• Symptoms: toe embedded into flesh at corner and becomes inflamed/may become infected

Minor Foot Disorders Exclusions to Self-Care

• Patients with inappropriate gait (Referral: STAT)
• Patients with malformations of the foot (Referral: STAT)
• Diabetes or peripheral circulatory diseases (PVD) (Referral: STAT)
• Poor blood circulation (Referral: STAT)
• Pus or oozing discharge (Referral: STAT)

Minor Foot Disorders Non-Pharmacologic Treatment with Referral

• Pregnancy or breastfeeding (Referral: Soon, Non-Pharm: Y)

Corns & Calluses: Nonpharm Options

• Daily soaking (for at least 5 minutes in warm water)
• Remove dead tissue gently
• Callus file or pumice stone
• Avoid razors/ sharp knives
• Proper fitting shoes (not narrow)

Corns & Calluses: Nonpharm Options

• Cushioning padding:
  • Circular foam cushioning pads (relieve pressure)
  • Silicone toe sleeve – impregnated with mineral oil softens skin
  • Foam spacer
  • Lamb’s wool / mole skin

Corns & Calluses Pharmacologic Treatment Options

• Salicylic acid
  • Plasters and liquid/ gel (collodion)
  • Pad shaped like corn/ callus
  • Counseling points – see warts

Ingrown Toenail: Treatment Options

• Non-pharm:
  • Warm water soaks will soften area
  • Insertion of “cotton wisp” or dental floss under impinged nail edge
• OTC treatment options:
  • Sodium sulfide 1% gel:
    • Softens the nail/ hardens the nail bed
    • Apply BID for up to 7 days
    • Apply with a retainer ring around the product helps keep product at the site of action
  • Benzocaine products available to help with pain
  • Oral analgesics may be helpful for pain
• Surgery may be necessary

Alopecia

• Minoxidil (Rogaine)
  • Pharmacologic Category/MOA: Nitrate/vasodilator
  • Solution 2% or 5%
    • 2% Solution: 1 mL BID
    • 5% Solution: Men only 1mL BID
  • Foam 5%
    • Foam (5%) Men: ½ capful BID
    • Foam 5% Women: ½ capful once daily
• Finasteride (Propecia)
  • 5-alpha reductase inhibitor
  • 1 mg once daily

Common Causes of Hair Loss

Common Types of Alopecia

• FPHL may also present with S&S of hyperandrogenism, such as acne, hirsutism (hairiness in other parts of the body), menstrual irregularities & infertility

Androgenic Alopecia

• Only type that can be treated with nonprescription medication
• Inherited condition
• Testosterone is converted to dihydrotestosterone (DHT) via 5-alpha reductase
• Scalp is sensitive to DHT: DHT is a primary repressor of hair growth (binds 5x more readily than testosterone to androgen)

Alopecia Exclusions to Self-Care

• Age < 18 years (Referral: SOON)
• Hair loss related to a history of endocrine dysfunction (hyper/hypothyroidism) or medical treatment (chemotherapy) (Referral: STAT)
• Sudden or patchy hair loss (Referral: SOON)

Non-Pharmacologic Treatment with Referral

• Pregnancy or breastfeeding (Referral: Soon, Non-Pharm: Y)
• Postpartum patients with hair loss (Referral: Soon, Non-Pharm: Y)

Topical Minoxidil: MOA & Dosing

• MOA: vasodilator (originally approved for hypertension)
  • Increases cutaneous blood flow, promotes and maintains vascularization of hair follicles
• Available OTC as solution (2% or 5%) or foam (5% only) – approved for use in patients >18 years
  • Solution: 1mL applied BID
    • 2% solution approved for men and women
    • 5% solution approved for men only
  • 5% foam approved for men (½ capful BID) and women (½ capful once a day)

Topical Minoxidil: Treatment Expectations

• Increase in hair loss within 1st few weeks of use
• Several months before hair growth will be seen
• Patient must continue use indefinitely to maintain new growth; once discontinued, hair density returns to pretreatment levels in months
• If no increase in hair density after 4-6 months, discontinue use
• Side effects:
  • Local itching, irritation, dryness, scaling may occur – more common with solution formulation
  • Transient hypertrichosis on forehead and cheeks; if on chest, back, forearms, or ear rims – could indicate overuse
  • Rare: acne at site of application, inflammation of hair root, redness/swelling of the face, allergic contact dermatitis
  • Systemic effects are rare

Topical Minoxidil Solution – Proper Application

• Apply to clean, dry scalp and hair
• Rub 1mL of the product into the affected area of the scalp BID
• Wash and dry hands after application
• Allow 2-4 hours for the drug to penetrate the scalp; do not participate in any activity that may wash away or dilute the drug (e.g., bathing, swimming)
• When applying the nighttime dose, apply 2-4 hours before bedtime; if not allowed to dry completely, may stain clothing/ bedding
• Can use a hair dryer on a low setting to help speed drying time
• Apply any hair styling products (mousses, gels, hair spray) after minoxidil has dried completely
• Avoid within 24 hours of having a perm or hair color treatment to reduce irritation

Topical Minoxidil Foam – Proper Application

• The foam may “melt” on contact with warm skin; wash hands in cold water and dry them thoroughly before applying foam
• Within the thinning hair area, part the hair into one or more rows to maximize contact of the foam with the scalp.
• Hair should be completely dry before application
• Use product cap to measure dose (1/2 capful)
  • Men use BID
  • Women use once daily
• Using fingertips, spread the foam over the thinning scalp area, and then massage gently into the scalp.
• Wash hands after use
• Apply the product and allow to dry completely before lying down or applying styling products
• Avoid within 24 hours of having a perm or hair color treatment to reduce irritation

Nonpharmacologic Recommendations

• Camouflage thinning hair
  • Wigs or hair weaves
  • Hair sprays, gels, colorants, topical hair fibers, powder cakes, hair crayons may create an illusion of fullness
• Surgical transplantation
• Avoid hairstyles that pull on hair, such as tight braids or weaves
• Avoid heat from hair dryers, curling/flat irons
• Avoid chemical processing, such as hair dyes, hair weaving, or hair straightening
• Comb / brush hair when dry & avoid excess brushing
• Hair conditioners may help
• Low-level laser light therapy (LLLT) is available for home use – stimulates vasodilation

5-Alpha Reductase Inhibitors

• The 5 alpha reductase enzyme converts testosterone to DHT; blocking it with an inhibitor reduces DHT
• Daily use for >3 months is necessary for results
• Originally used for BPH
• Side effects: orthostatic hypotension, dizziness, decreased libido, and impotence
• Highly teratogenic – crushed or broken tablets should not be handled by pregnant patients or patients seeking to become pregnant
• Finasteride – brand name: Propecia 1mg daily approved for androgenic alopecia; not approved for use in women
• Dutasteride – brand name: Avodart, only approved for BPH, used off-label for AGA

Other Agents

• Ketoconazole shampoo (brand name Nizoral)
  • Inhibits DHT pathway
  • Data in combo with oral finasteride
• Prostaglandin analogues: latanoprost (brand Xalatan) and bimatoprost (Alphagan)
  • Latisse (bimatoprost) is approved to increase eyelash growth
  • Studies underway
• Oral minoxidil may be an option for patients unresponsive to topical
• Spironolactone – has anti-androgen activity; used off-label for Female Pattern Hair Loss (FPHL)

Agents for Alopecia Areata

• Alopecia areata is an autoimmune condition
• Treatment options:
  • Corticosteroids: intralesional, topical, or systemic
  • Dupilumab
  • Methotrexate
  • Azathioprine