Treatment Options for Common Warts (Verruca Vulgaris)
Salicylic acid and cryotherapy are the first-line treatments for common warts, with salicylic acid being the most accessible and cryotherapy being the most effective provider-administered option. 1
First-Line Treatments
Salicylic Acid (Strength of recommendation: A)
- Apply topical preparations of 15-26% salicylic acid daily after removing the thick keratin layer
- Use occlusion when possible to enhance penetration
- Continue treatment for 3-4 months 1
- FDA-approved for verrucae and other hyperkeratotic skin disorders 2
- Most accessible and cost-effective first-line treatment
Cryotherapy (Strength of recommendation: B)
- Freeze wart for 15-30 seconds with liquid nitrogen
- Repeat every 2-4 weeks for at least 3 months or six treatments 1
- Often causes pain, blistering, and necrosis after application 1
- Local anesthesia (topical or injected) may facilitate therapy if warts are present in many areas 1
- Consider changing treatment if no improvement after three sessions 3
Second-Line Treatments
Combination Therapy
- Combined approach of cryotherapy and salicylic acid shows higher efficacy (89.2% eradication rate) 3
- In-office cryotherapy with daily patient application of salicylic acid between sessions
Bleomycin (Strength of recommendation: C)
- 0.1-1 U/mL solution injected or pricked into wart after local anesthesia
- One to three treatments may be sufficient
- Painful during and after treatment 1
5-Fluorouracil (Strength of recommendation: C)
- 5% cream applied daily with occlusion for 4-12 weeks 1
Laser Treatment (Strength of recommendation: C)
- Pulsed-dye laser after paring and/or salicylic acid pretreatment
- Two to four treatments at 7-10 J/cm² are usually needed 1
Third-Line/Alternative Treatments
Surgical Options
- Curettage, cautery, or hyfrecation for filiform warts 1
- Electrocautery, tangential excision with scissors or scalpel
- Most beneficial for patients with large number or area of warts 1
- Advantage of usually eliminating warts at a single visit 1
Other Options (Strength of recommendation: D)
- Imiquimod 5% cream twice daily for up to 6 months 1
- Cantharidin 0.7% solution applied every 3 weeks up to four times 1
- Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80-90% applied weekly for up to 8 weeks 1
- Duct tape occlusion therapy (applied directly to the wart for up to 2 months) 4
Treatment Considerations
Factors Affecting Treatment Choice
- Location of wart (plantar warts may require more aggressive treatment)
- Size and number of warts
- Duration (warts present ≤6 months have better clearance rates) 3
- Patient age (children may not tolerate painful treatments)
- Previous treatment history
Important Caveats
- No treatment has been shown to eradicate HPV completely 1
- Spontaneous resolution occurs in 20-30% of cases within 3 months 1
- Recurrence is common with all treatment methods (at least 25% within 3 months) 1
- Overtreatment can lead to scarring 3
- Hypopigmentation or hyperpigmentation commonly occurs with ablative treatments 3
Special Populations
- Pregnancy: Avoid podofilox, podophyllin, and imiquimod 3
- Children: Consider less painful treatments 3
- Immunocompromised patients: May require more aggressive or prolonged treatment 3
Treatment Algorithm
- Start with salicylic acid for 4-6 weeks
- If no response, add or switch to cryotherapy every 2-3 weeks
- If still no response after 3 months of combined therapy, consider second-line options
- For extensive or refractory warts, consider surgical options or referral to a specialist 1
Remember that common warts are benign and often resolve spontaneously, particularly in children. Treatment aims to relieve physical and psychological discomfort and prevent spread of infection 5.