Should verrucas be covered while swimming?
Date First Published:
February 28, 2003
Last Updated:
February 28, 2003
Report by:
L Vaile, F Finlay and S Sharma, - (Department of Community Paediatrics, Bath)
Three-Part Question:
In [a child with a verruca (plantar wart)] does [wearing an occlusive dressing or sock while swimming] reduce [transmission]?
Clinical Scenario:
The son of one of the authors came home from school with a letter explaining that prior to swimming each term, children would have their feet checked for verrucas. School policy stated that if a verruca was discovered a protective sock must be worn. Many public swimming pools have no restrictions on children swimming with verrucas, and in view of conflicting policies we wondered whether verrucas were transmitted during swimming and if wearing verruca socks was a necessary intervention.
Search Strategy:
Cochrane, Medline and Embase.
Search Details:
Secondary sources: Cochrane—none. Primary sources: Medline 1966 to present (verruca OR plantar wart) AND swim LIMIT to English language. Embase: same search strategy—no additional papers.
Outcome:
Altogether 7 articles found, 2 relevant plus 3 from manual search.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| The problem of verrucae. Allen WH, Dickinson VA. 1968, | 14,075 pupils from 40 primary and secondary schools | Random sample of 40 schools in Hertfordshire (level 4) | Prevalence of plantar warts | Prevalence of 2.9% for secondary schools and 1.8% for primary schools | Prevalence appeared greater in those using heated covered pools (4.02%), compared to those using pools, which were not covered and heated either at school (2.91%) or public pools (2.10%). Authors concluded that difference may be due to differing periods of exposure. No statistically significant difference was found between the groups that did gymnastics in barefoot compared to plimsolls |
| A scheme for the prevention of plantar warts. Tranter AW. 1969 | Pupils from 6 junior schools | Junior schools chosen at random (level 4) | Incidence of plantar warts and the amount of swimming undertaken | Correlation coefficient was calculated giving a significant positive value at the 5% level suggesting a positive relationship between the amount of swimming and the incidence of warts | Evidence suggested that if a school has its own pool, used only by its pupils and if they were examined twice/term and children with plantar warts excluded the incidence of warts will decline. If the school uses a communal pool the incidence will not decline |
| Prevention of plantar warts by the use of protective footwear in swimming pools. Bunney MH. 1972, | 68 matched pairs of swimmers. One of the pair wore "Plastsocks" and the other bare feet (control group) | Paired (level 2b) | Incidence of new plantar warts in the "Plastsocks" group versus the control group | During the study period the sock group was entirely free from plantar warts, while the control group developed 9 new plantar warts (p<0.01) | The study did not look at the effectiveness of "Plastsocks" in preventing the transmission of infection |
| Foot infections in swimming baths. Gentles JC, Evans EGV. 1973, | 773 bathers at a public swimming bath | Random sample: 9.3% of bathers (level 2c) | Incidence of verrucas | Overall incidence of verrucas was 4.8%, with 0.76% in adults, 6.9% in juveniles. Incidence of 10.2% during school swimming sessions and 5.1% during public swimming sessions (p<0.05) | The incidence of veruccas was noted to be higher than previously recorded. Authors conclude swimming baths are involved in the "vicious circle" of infection and floor contamination |
| Communal showers and the risk of plantar warts. Johnson LW. 1995 | 146 adolescents aged 10–18 who used locker rooms | Comparison of 80 pupils who only used locker rooms, with 66 members of a swim club who used locker rooms plus communal showers (level 4) | Incidence of plantar warts | Significant difference in prevalence between those who used public shower rooms and locker rooms (27%) compared to those who used only locker rooms (1.25%) (2=15.46, df=1, p=0.001) | Shower rooms proposed as a risk factor, with the warm, moist environment important for viral transmission. Author states that he is conducting a follow up study to determine whether the incidence of plantar warts among shower room users (swimmers) can be reduced by limiting foot-to-floor contact, but subsequent paper not found in search |
Author Commentary:
The Department of Health Guidance on infection control in schools and nurseries (1) suggests that affected children may go swimming but that verrucas should be covered.
Our search revealed little up to date information on the prevalence of verrucas in schoolchildren, or the effectiveness of preventive measures. One paper studied protective footwear, but this study looked at the role of protective footwear in preventing the acquisition of plantar warts in unaffected individuals. It did not examine the prevention of spread by affected individuals wearing footwear (4). There were no studies looking at the effectiveness of simply covering a plantar lesion with an adhesive dressing in the prevention of spread.
Only one study looked at the prevalence of plantar warts in swimmers compared to non-swimmers (6). This study found that adolescents who used locker rooms plus communal showers at a swim club had a significantly higher prevalence of warts than young people using only locker rooms.
Three studies looked at the prevalence of verrucas in swimmers. One (2) found a greater prevalence of warts in those swimming in heated covered pools compared to uncovered pools, concluding that this difference may be accounted for by a differing period of exposure. Another (3) found a positive correlation between the amount of swimming and the incidence of warts. The third (5) found a higher incidence of verrucas in those swimming during a school session than during a free-swimming session.
Our search revealed little up to date information on the prevalence of verrucas in schoolchildren, or the effectiveness of preventive measures. One paper studied protective footwear, but this study looked at the role of protective footwear in preventing the acquisition of plantar warts in unaffected individuals. It did not examine the prevention of spread by affected individuals wearing footwear (4). There were no studies looking at the effectiveness of simply covering a plantar lesion with an adhesive dressing in the prevention of spread.
Only one study looked at the prevalence of plantar warts in swimmers compared to non-swimmers (6). This study found that adolescents who used locker rooms plus communal showers at a swim club had a significantly higher prevalence of warts than young people using only locker rooms.
Three studies looked at the prevalence of verrucas in swimmers. One (2) found a greater prevalence of warts in those swimming in heated covered pools compared to uncovered pools, concluding that this difference may be accounted for by a differing period of exposure. Another (3) found a positive correlation between the amount of swimming and the incidence of warts. The third (5) found a higher incidence of verrucas in those swimming during a school session than during a free-swimming session.
Bottom Line:
Swimming is part of the national curriculum up until the end of key stage 2, by which time children are expected to be able to swim 25 metres. Although studies have shown an association between verrucas and swimming, none have looked at the increased risk of verruca acquisition with swimming. No studies have considered the effectiveness of protective socks/dressings in preventing transmission. Expecting children to wear protective socks, without evidence of their effectiveness, may stigmatise children and put them off swimming altogether.
References:
- Allen WH, Dickinson VA.. The problem of verrucae.
- Tranter AW.. A scheme for the prevention of plantar warts.
- Bunney MH.. Prevention of plantar warts by the use of protective footwear in swimming pools.
- Gentles JC, Evans EGV.. Foot infections in swimming baths.
- Johnson LW.. Communal showers and the risk of plantar warts.
- Department of Health.. Guidance on infection control in schools and nurseries.