What are the treatment options for common warts?

Treatment Options for Common Warts

Salicylic acid (15-40%) is the first-line treatment for common warts due to its proven efficacy, safety profile, and ease of use. 1

First-Line Treatments

Salicylic Acid

• Concentration: 15-40% topical paints or ointments
• Application: Apply daily after paring/debridement of the wart
• Duration: Continue for up to 6 months if needed
• Efficacy: Studies show 73% cure rate compared to 48% with placebo 2
• Advantages: Inexpensive, self-administered, minimal side effects
• Higher concentrations: 26% salicylic acid in polyacrylic vehicle showed 81% improvement in just two weeks 3

Cryotherapy

• Application: Applied by healthcare provider every 1-2 weeks for 3-4 months
• Mechanism: Destroys warts through thermal-induced cytolysis
• Considerations:
  • Requires proper training to avoid over/under-treatment
  • May cause pain, necrosis, and sometimes blistering
  • Not superior to salicylic acid in comparative studies 2

Treatment Algorithm Based on Wart Location

Plantar Warts (Feet)

1. First choice: Salicylic acid (15-40%)
2. Alternative: Cryotherapy every 2 weeks for 3-4 months
3. Combination approach: Combined cryotherapy/70% salicylic acid has shown 89.2% eradication rate 4
4. Important note: Paring before treatment improves penetration but avoid damaging surrounding skin

Hand Warts

1. First choice: Salicylic acid (15-40%)
2. Alternative: Cryotherapy with liquid nitrogen
3. For resistant warts: Consider TCA/BCA (80-90%)

Facial Warts

1. First choice: Gentle cryotherapy (milder freeze)
2. Alternative: Curettage or hyfrecation
3. Caution: Avoid aggressive treatments that may cause scarring

Plane Warts (Flat Warts)

1. First choice: Lower concentration salicylic acid (2-10%)
2. Alternative: Topical retinoid
3. Note: Often resolve spontaneously; destructive treatments may cause scarring

Second-Line Treatments

Trichloroacetic Acid (TCA) or Bichloroacetic Acid (BCA)

• Concentration: 80-90%
• Application: Apply small amount only to warts, allow to dry until white frosting develops
• Frequency: Weekly as needed
• Efficacy: 80% TCA showed significantly better response than 35% TCA (46.7% vs 12% good response) 5
• Caution: Can damage adjacent tissues if applied excessively

Patient-Applied Options

1. Podofilox 0.5% solution/gel:

   • Apply twice daily for 3 consecutive days
   • Rest for 4 days
   • Repeat cycle up to 4 times
   • Limit to <10 cm² of wart tissue and <0.5 mL per day 6

2. Imiquimod 5% cream:

   • Apply 3 times per week at bedtime
   • Leave on for 6-10 hours then wash off
   • Continue until clearance or for maximum of 16 weeks 7

Other Treatment Options

• Zinc oxide 20% ointment (50% cure rate in one study) 8
• Formaldehyde 3-4% solution (for plantar warts)
• Glutaraldehyde 10% solution
• Surgical removal (for isolated, resistant warts)

Special Considerations

For Children

• Warts often resolve spontaneously within 1-2 years
• Avoid painful treatments in young children
• Prefer salicylic acid as first-line treatment
• Use gentle cryotherapy if needed

Treatment Pitfalls to Avoid

1. Overtreatment: Can cause scarring, especially on face and hands
2. Damaging surrounding skin: Can spread infection
3. Inadequate duration: Most treatments require weeks to months for full effect
4. Unrealistic expectations: Even best treatments have failure rates
5. Ignoring spontaneous resolution: Many warts resolve without treatment within 2 years

Remember that the evidence base for wart treatments is limited 1, and no single treatment is universally effective. For resistant warts, combination therapy or sequential treatment approaches may be necessary.