What are the treatment options for warts?

Wart Treatment Options

The most effective approach to wart treatment is to use salicylic acid (15-40%) for common warts and cryotherapy with liquid nitrogen for genital warts, with treatment selection based on wart location, size, and number. 1

Treatment Algorithm by Wart Type

Common Cutaneous Warts

1. First-line therapy:

   • Salicylic acid (15-40%) topical paints or ointments
   • Apply after paring/debridement of the wart
   • Continue treatment for up to 3-4 months

2. Second-line therapy (if first-line fails):

   • Cryotherapy with liquid nitrogen
   • Apply every 1-2 weeks for 3-4 months
   • Use 10-second freeze cycles for better efficacy
   • Consider changing treatment if no improvement after three sessions

3. Third-line therapy (for resistant cases):

   • Surgical removal (curettage, electrodesiccation)
   • Carbon dioxide laser
   • Combination therapy (cryotherapy plus salicylic acid)

Plantar Warts

1. First-line:

   • Salicylic acid (15-40%) with paring before application
   • Avoid damaging surrounding skin to prevent spread

2. Second-line:

   • Cryotherapy with more aggressive regimens
   • Combination of salicylic acid and cryotherapy

3. Alternative options:

   • Formaldehyde or glutaraldehyde solutions
   • Laser therapy
   • Photodynamic therapy

Facial/Plane Warts

1. First-line:

   • Lower concentration salicylic acid (2-10%)
   • Gentle cryotherapy with milder freeze

2. Second-line:

   • Topical retinoids
   • Imiquimod 5% cream (apply once daily at bedtime, three times weekly for up to 16 weeks) 2

3. Alternative options:

   • Glycolic acid 15%
   • Photodynamic therapy

Genital Warts

1. First-line:

   • Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80-90%
   • Apply sparingly only to warts and allow to dry
   • Powder with talc or sodium bicarbonate to remove unreacted acid
   • Repeat weekly if necessary 3

2. Second-line:

   • Cryotherapy with liquid nitrogen
   • Podofilox 0.5% solution (patient-applied)
     • Apply twice daily for 3 days, followed by 4 days of no therapy
     • Repeat for up to 4 cycles
     • Contraindicated in pregnancy 3

3. Third-line:

   • Surgical removal (for large or numerous warts)
   • Imiquimod 5% cream (3 times per week for up to 16 weeks) 2
   • Electrosurgery (contraindicated for patients with cardiac pacemakers) 3

Special Considerations

Treatment Selection Factors

• Wart location: Facial warts require gentler treatment to avoid scarring
• Wart size and number: Surgical approaches better for large or numerous warts
• Duration: Warts present less than 6 months respond better to treatment
• Patient age: Children may need less aggressive approaches
• Pregnancy status: Avoid podofilox, podophyllin, and imiquimod 3, 1

Important Caveats

• Recurrence is common: At least 25% recurrence within 3 months with all treatment methods 3
• Spontaneous resolution: 20-30% of untreated warts resolve within 3 months 3
• Potential complications:
  • Hypopigmentation or hyperpigmentation with ablative treatments
  • Scarring with aggressive treatments, especially on face and hands 1
  • Pain and blistering with cryotherapy

Treatment Monitoring

• Change treatment modality if no substantial improvement after three provider-administered treatments 1
• For genital warts, continue treatment until total clearance or for maximum of 16 weeks 2
• For superficial warts, assess clinical outcome after resolution of local skin reactions (approximately 12 weeks post-treatment) 2

Efficacy Comparison

• Surgical removal: 93% efficacy, 29% recurrence rate 3
• Cryotherapy: 63-88% efficacy 3
• Combined cryotherapy and salicylic acid: 89.2% eradication rate 1
• TCA/BCA: 21.3% complete cure rate with fewer side effects than cryotherapy 1

Remember that no treatment completely eradicates HPV, and the goal is to remove the wart while minimizing complications and recurrence. Treatment should be adjusted based on response, with consideration for changing approaches if no improvement is seen after three sessions.