What are the treatment options for plane flat warts?

Treatment Options for Plane Flat Warts

For plane flat warts, topical salicylic acid (2-10%) or topical retinoids are recommended as first-line treatments, with oral isotretinoin being highly effective for recalcitrant cases. 1, 2, 3

First-Line Treatment Options

Topical Treatments

• Salicylic acid (2-10%):

  • Apply cream/ointment daily without occlusion
  • For facial warts, use lower concentrations (2-10%) to avoid scarring
  • Can cautiously use salicylic acid paint (12-17%) without occlusion for more resistant lesions 1

• Topical retinoids:

  • Apply daily to affected areas
  • Effective for facial plane warts
  • May cause local irritation and photosensitivity 1, 4

Physical Treatments

• Cryotherapy:
  • Use milder freeze technique than for common warts
  • Apply every 2-4 weeks for up to 3-4 months
  • Caution: May cause hypopigmentation, especially in darker skin types 1, 2

Second-Line Treatment Options

Chemical Treatments

• Trichloroacetic acid (TCA) 30%:

  • Highly effective with 86% reduction in lesions after 12 weeks
  • Apply carefully to avoid surrounding skin
  • Caution: Higher risk of hyper/hypopigmentation compared to other treatments 4

• Glycolic acid 15%:

  • Particularly effective for facial plane warts
  • Can be combined with salicylic acid 2% for enhanced effect
  • Well-tolerated in children 1

Immunomodulators

• Imiquimod:
  • Recommended for plane warts in guidelines
  • Apply 3 times weekly for up to 16 weeks
  • May cause local inflammatory reactions 1, 2

Treatment for Recalcitrant Cases

Oral Treatments

• Oral isotretinoin:
  • Highly effective for recalcitrant facial flat warts
  • Dosage: 30mg daily for 12 weeks
  • Achieved 100% clearance in clinical trials of recalcitrant cases
  • Side effects include cheilitis and other typical retinoid side effects
  • Requires monitoring of lipids and liver function
  • Contraindicated in pregnancy 5, 3

Advanced Options

• Local hyperthermia:

  • Apply heat (43±1°C) for 30 minutes on three consecutive days
  • Repeat treatment 10 days later
  • Similar efficacy to cryotherapy (35.6% vs 31.3%) but with significantly lower recurrence rates (16.7% vs 53.3%)
  • Better tolerated with fewer adverse events than cryotherapy 6

• Hydrogen peroxide 40% solution:

  • Apply topically every 2 weeks for 4 sessions
  • 90% complete clearance rate with no recurrence after 3 months
  • Cost-effective and easy to use 7

Location-Specific Considerations

• Facial warts:

  • Use gentler treatments to avoid scarring
  • Topical retinoids, low-concentration salicylic acid, or glycolic acid are preferred
  • Avoid aggressive destructive methods 1, 2

• Hand warts:

  • May require more aggressive treatment than facial warts
  • Salicylic acid at higher concentrations or cryotherapy may be used 1

Treatment Algorithm

1. Start with topical salicylic acid (2-10%) or topical retinoid for 8-12 weeks
2. If inadequate response, try cryotherapy (milder freeze) every 2-4 weeks
3. For persistent lesions, consider TCA 30%, glycolic acid 15%, or imiquimod
4. For recalcitrant cases, oral isotretinoin 30mg daily for 12 weeks is highly effective
5. Alternative options for resistant cases include local hyperthermia or hydrogen peroxide 40%

Important Considerations

• Plane warts may spontaneously resolve, especially in children, so non-aggressive approaches are often appropriate
• Destructive treatments carry higher risk of scarring on the face and should be used cautiously
• Patient compliance is crucial for success with topical treatments
• Monitor for treatment-specific side effects, particularly pigmentary changes with TCA and systemic effects with oral isotretinoin

Remember that treatment may take several months for complete clearance, and recurrence is possible with any treatment modality due to persistent HPV infection.