What is the best treatment approach for a 32-year-old male patient with multiple large colonies of plantar warts on the right foot and a single spot on the left foot, scheduled to undergo cryotherapy (cryosurgery) starting with the left foot?

From the Guidelines

For this 32-year-old male with multiple large plantar wart colonies on the right foot and a single wart on the left foot, a comprehensive treatment approach is recommended, starting with cryotherapy on the left foot and a combination of cryotherapy and salicylic acid for the right foot, as supported by the British Association of Dermatologists' guidelines 1. The patient's condition, with multiple large colonies of plantar warts on one foot and a single wart on the other, necessitates a treatment plan that addresses both the extent of the warts and the potential for recurrence.

• The initial step of starting cryotherapy on the left foot is appropriate because it targets the isolated lesion first, which typically responds better to treatment.
• For the right foot with multiple colonies, a combination approach would be most effective:
  • Continue cryotherapy sessions every 2-3 weeks (using liquid nitrogen applied for 10-15 seconds with a double freeze-thaw cycle) 1.
  • Supplement with daily at-home salicylic acid treatment (40% plasters or 17% gel) applied after gentle debridement of dead tissue, as recommended for plantar warts 1.
• Between treatments, the patient should keep feet clean and dry, avoid walking barefoot in public areas, and use separate towels for feet to prevent spread. This multi-modal approach is recommended because plantar warts often require persistent treatment, as the HPV virus that causes them embeds deeply in thick plantar skin. The combination of destructive therapy (cryotherapy), keratolytic agents (salicylic acid), addresses both the virus and the hyperkeratotic tissue while minimizing recurrence risk, as noted in the guidelines for the management of cutaneous warts 1.

From the Research

Treatment Approach for Plantar Warts

The patient presents with multiple large colonies of plantar warts on the right foot and a single spot on the left foot, scheduled to undergo cryotherapy starting with the left foot.

• The treatment plan involves cryotherapy, which is a common method for treating plantar warts, although its efficacy compared to other treatments is still being researched 2, 3.
• Studies have shown that cryotherapy may have lower cure rates than alternative treatments, such as topical formulations consisting of cantharidin, podophyllotoxin, and salicylic acid (CPS) 2.
• A systematic review and meta-analysis found that cryotherapy appears to have lower cure rates than other treatments, including physical treatment, antiviral, chemotherapy, and retinoid groups 3.
• However, another study suggests that cryotherapy can be effective, especially when used in combination with other treatments, such as salicylic acid 4.
• Other treatment options, such as imiquimod 5% cream combined with a keratolytic lotion, have shown promise in treating cutaneous warts, including plantar warts, and may be considered as an alternative or adjunct to cryotherapy 5, 6.

Considerations for Treatment

• The patient's treatment plan should take into account the potential for cryotherapy to have lower cure rates than other treatments, and the possibility of combining cryotherapy with other treatments to improve efficacy.
• The use of imiquimod 5% cream combined with a keratolytic lotion may be considered as an alternative or adjunct to cryotherapy, especially for plantar warts.
• The treatment plan should also consider the patient's individual needs and circumstances, including the size and location of the warts, as well as any potential side effects or interactions with other treatments.
• It is also important to note that the treatment of plantar warts may take several months to complete, as mentioned in the patient's treatment plan 2, 3, 4, 5, 6.