Developing and validating the Cutaneous WARTS (CWARTS) diagnostic tool: a novel clinical assessment and classification system for cutaneous warts

Abstract

SummaryBackground The clinical appearance of cutaneous warts is highly variable and not standardized. Objectives To develop and validate a reproducible clinical tool for the standardized assessment of cutaneous warts to distinguish these lesions accurately. Methods Nine morphological characteristics were defined and validated regarding intra-and interobserver agreement. Based on literature and semistructured interviews, a systematic dichotomous assessment tool, the Cutaneous WARTS (CWARTS) diagnostic tool was developed. The validation consisted of two independent parts performed with photographs from the recent WARTS-2 trial. In part A, the CWARTS diagnostic tool was tested by 28 experienced physicians who assessed photographs of 10 different warts to investigate interobserver concordance. In part B, morphological characteristics were validated by masked and independent scoring of 299 photographs by six different observers. Part B also entailed reassessment of the photographs after at least 1 week. The primary outcome measurement was the intraclass correlation coefficient (ICC). Results Presence of black dots (capillary thrombosis) had the greatest ICC (0Á85) for interobserver agreement in part A, followed by arrangement (0Á65), presence of border erythema (0Á64) and sharpness of the border (0Á60). In part B, results were similar for interobserver agreement with presence of black dots having the highest ICC (0Á68), followed by border erythema (0Á64), arrangement (0Á58) and colour (0Á55). For intraobserver agreement, presence of black dots had the highest agreement (0Á70), followed by presence of border erythema (0Á694) and colour (0Á59). Conclusions Wart phenotype can be reliably assessed using the CWARTS diagnostic tool.

Morphological characteristics and human papillomavirus genotype predict the treatment response in cutaneous warts

“…A new clinical diagnostic tool for warts, the CWARTS tool, was developed and validated in an earlier study . In the current study this tool was implemented.…”

“…Photographs were taken by a trained research nurse using the Dino‐Lite digital microscope (AnMo Electronics Corporation, Hsinchu City, Taiwan), set to a fixed scale of ‘20’ resulting in a scale of 5·7 : 1 and using a standard object that assured a standard camera–wart distance from a selection of the patients who were included in the WARTS‐2 trial. At an earlier stage, a clinical assessment tool, the CWARTS tool, had been developed and validated for inter‐ and intraobserver agreement by respectively 18 and six physicians with a different set of pictures based on the score of nine dichotomized morphological characteristics: (i) arrangement (confluent/multiple or solitary); (ii) level (elevated or skin level); (iii) aspect (rough/lobed or smooth/not lobed); (iv) border (sharply or not sharply circumscribed); (v) colour (lighter/skin colour/yellow or red); (vi) presence of white skin flakes; (vii) presence of black dots (capillary thrombosis); (viii) border erythema; and (ix) callus . In short, inter‐ and intraobserver agreement for most characteristics was moderate to strong with average intraclass correlation coefficients of 0·51 and 0·42, respectively.…”

“…In a former study, morphological characteristics of warts were defined by a group of dermatologists and general practitioners and validated for inter‐ and intraobserver agreement. An assessment tool for diagnosing warts – the Cutaneous WARTS diagnostic tool (CWARTS tool) – was developed and was used in this study …”

A randomized controlled proof‐of‐concept trial of digoxin and furosemide in adults with cutaneous warts

“…Therefore, wart morphology was assessed to confirm or reject the hypothesis that wart size reduction could be predicted by the morphological aspects of all warts in this study. Standardized photographs of the primary wart were taken and wart morphology was assessed using the CWARTS diagnostic tool . Complete responders were defined as showing a reduction of 100% in size, partial responders a reduction of 25–100% and nonresponders < 25% reduction at the EOS compared with baseline.…”

Black dots in palmoplantar warts—challenging a concept: A histopathologic study

“…Clinically, many lesions have characteristic small black dots that are considered to represent thrombi in dermal vessels. 1 This concept has been taught by dermatologists over many decades and is found in the newest versions of our standard literature. 2,3 However, to our knowledge, this concept has not been sufficiently substantiated by morphologic studies.…”