From the Guidelines
Compounded topicals for warts in the USA should be based on salicylic acid (15-40%) as the primary treatment, as it has been shown to be effective in promoting exfoliation of epidermal cells and stimulating host immunity against warts, as supported by the British Association of Dermatologists' guidelines for the management of cutaneous warts 2014 1. The most commonly prescribed compounded topical for warts is a combination of salicylic acid (15-40%), lactic acid (10-20%), and 5-fluorouracil (0.5-5%) in a cream or gel base. This combination works by:
- Exfoliating the wart tissue (salicylic acid)
- Softening the keratin (lactic acid)
- Inhibiting DNA synthesis in rapidly dividing cells (5-fluorouracil) For treatment, apply a small amount directly to the wart once or twice daily using a cotton swab or gloved finger, avoiding healthy skin. Cover with a bandage after application and continue for 6-12 weeks or until the wart resolves. Other effective compounded formulations include:
- Imiquimod with tretinoin
- Cantharidin combined with podophyllin and salicylic acid These medications require a prescription and must be prepared by a compounding pharmacy. Patients should expect some local irritation, redness, or mild pain during treatment, which indicates the medication is working. If severe irritation occurs, temporarily discontinue use and consult your healthcare provider. The British Association of Dermatologists' guidelines for the management of cutaneous warts 2014 also provide recommendations for specific clinical situations, such as plantar warts, plane warts, facial warts, warts in children, and warts in the immunosuppressed 2. It is essential to note that the treatment of warts should be individualized, and the choice of treatment should be based on the patient's specific needs and circumstances, as well as the severity and location of the warts 1.
From the FDA Drug Label
For Dermatologic Use: Salicylic Acid 6% is a topical aid in the removal of excessive keratin in hyperkeratotic skin disorders including verrucae, and the various ichthyoses (vulgaris, sex-linked and lamellar), keratosis palmaris and plantaris keratosis pilaris, pityriasis rubra pilaris, and psoriasis (including body, scalp, palms and soles). For Podiatric Use: Salicylic Acid 6% is a topical aid in the removal of excessive keratin on dorsal and plantar hyperkeratotic lesions. Topical preparations of 6% salicylic acid have been reported to be useful adjunctive therapy for verrucae plantares.
Compounded topicals for warts in the USA may include salicylic acid, as it is indicated for the removal of excessive keratin in hyperkeratotic skin disorders, including verrucae.
- The FDA-approved indication for salicylic acid 6% includes verrucae.
- Salicylic acid 6% can be used as an adjunctive therapy for verrucae plantares 3.
From the Research
Compounded Topicals for Warts in the USA
- There is limited information available on compounded topicals for warts in the USA, but some studies suggest that salicylic acid and other topical treatments can be effective in treating cutaneous warts 4, 5.
- A study published in the Journal of the American Academy of Dermatology found that a combination of cryosurgery, imiquimod, and salicylic acid was effective in treating resistant common warts 6.
- Another study published in the Journal of the European Academy of Dermatology and Venereology found that a topical formulation consisting of cantharidin, podophyllotoxin, and salicylic acid was more effective than cryotherapy in treating plantar warts 7.
- A randomized controlled trial published in the Canadian Medical Association Journal found that cryotherapy with liquid nitrogen was more effective than topical salicylic acid application in treating common warts, but there was no significant difference in effectiveness between the two treatments for plantar warts 8.
Treatment Options
- Salicylic acid is a commonly used treatment for cutaneous warts, and can be used as a first-line therapy 4, 5.
- Cryotherapy with liquid nitrogen is also a widely used treatment for cutaneous warts, and can be used as a second-line therapy 4, 8.
- Other treatment options, such as cantharidin, podophyllotoxin, and imiquimod, may be used in combination with salicylic acid or cryotherapy to treat resistant or difficult-to-treat warts 6, 7.
Efficacy of Treatments
- The efficacy of treatments for cutaneous warts can vary depending on the type of wart, the duration of treatment, and the individual patient's response to treatment 4, 5, 8.
- Combination therapy, such as cryosurgery followed by imiquimod and salicylic acid, may be more effective than single treatments for resistant common warts 6.
- Topical formulations, such as cantharidin, podophyllotoxin, and salicylic acid, may be more effective than cryotherapy for plantar warts 7.