What are the treatment options for warts?

Treatment Options for Warts

The first-line treatments for cutaneous warts are topical salicylic acid (15-40%) or cryotherapy with liquid nitrogen, with treatment selection based on wart location, patient age, and extent of lesions. 1

Treatment Approach by Wart Type and Location

Plantar Warts

• First-line options:
  • Salicylic acid (15-40%) topical paints or ointments
  • Cryotherapy, applied fortnightly for 3-4 months
• Note: Cure rates are lower at this site due to thicker skin and poorer penetration of treatments
• Technique: Paring excess skin before treatment improves efficacy but avoid damaging surrounding skin to prevent spread 1
• Alternative treatments: Dithranol, 5-fluorouracil, formaldehyde, glutaraldehyde, hyperthermia, laser, photodynamic therapy, podophyllotoxin, topical immunotherapy

Plane Warts (Flat Warts)

• First-line options:
  • Salicylic acid cream/ointment (2-10%) or cautious use of salicylic acid paint (12-17%) without occlusion
  • Cryotherapy with milder freeze
  • Topical retinoid
• Note: Often found on hands or face; mainly a cosmetic problem with good chance of spontaneous clearance
• Caution: Destructive agents may cause scarring at these sites 1

Facial Warts

• First-line options:
  • Cryotherapy, curettage, or hyfrecation
• For filiform warts in beard area: Avoid damaging adjacent skin to prevent spread
• Alternative treatments: Glycolic acid 15%, imiquimod, laser, photodynamic therapy, topical immunotherapy 1

Genital Warts

• Provider-administered options:
  • Cryotherapy with liquid nitrogen (63-88% efficacy, 21-39% recurrence)
  • Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80-90% (81% efficacy, 36% recurrence) - especially for moist surfaces 2
• Patient-applied options:
  • Podofilox 0.5% solution/gel: Apply twice daily for 3 days followed by 4 days off, for up to 4 cycles (45-88% clearance) 3
  • Imiquimod 5% cream: Apply three times weekly at bedtime for up to 16 weeks 4

Warts in Children

• First-line options:
  • Salicylic acid (15-40%) topical paints or ointments
  • Gentle cryotherapy, fortnightly for 3-4 months
• Note: Warts in children often resolve spontaneously within 1-2 years
• Caution: Avoid painful treatments in young children 1

Warts in Immunosuppressed Patients

• Approach: Treatment may not result in cure but can reduce wart size and functional/cosmetic problems
• Options:
  • Standard treatments with paring, abrasive agents, salicylic acid
  • Destructive methods (avoiding damage to surrounding skin)
• Alternative treatments: Cidofovir (systemic or topical), contact immunotherapy, imiquimod, laser therapy, systemic retinoids 1, 2

Specific Treatment Details

Salicylic Acid

• Concentration: 15-40% for plantar/common warts; 2-10% for plane warts
• Application: Apply after paring or rubbing down warts
• Efficacy: 89.2% when used in combination with cryotherapy 1, 2

Cryotherapy

• Technique: Liquid nitrogen application every 1-2 weeks
• Duration: Up to 3-4 months
• Efficacy: 63-88% with recurrence rate of 21-39% 2
• Note: Requires training to avoid over/under-treatment

Imiquimod 5% Cream

• Application: Apply three times weekly at bedtime for up to 16 weeks
• Mechanism: Immune enhancer that stimulates production of interferon and cytokines
• Efficacy: Approximately 35% complete clearance in men with penile warts
• Contraindication: Pregnancy
• Side effects: Local inflammatory reactions including redness and irritation
• Note: May weaken condoms and vaginal diaphragms 2, 4

Podofilox 0.5% Solution/Gel

• Application: Apply twice daily for 3 consecutive days, then withhold for 4 days; cycle may be repeated up to four times
• Limit: Treatment should be limited to less than 10 cm² of wart tissue and no more than 0.5 mL per day
• Mechanism: Antimitotic drug that destroys warts
• Contraindication: Pregnancy
• Side effects: Mild to moderate pain or local irritation 2, 3

Treatment Monitoring and Follow-up

• Change treatment if no substantial improvement after three provider-administered treatments or if warts haven't cleared after six treatments 2
• Early clinical clearance cannot be adequately assessed until resolution of local skin reactions (approximately 12 weeks post-treatment) 4
• All treatments have recurrence rates of at least 25% within 3 months 2

Important Considerations

• Spontaneous resolution occurs in 20-30% of cases within 3 months, making watchful waiting an acceptable alternative, especially in children 2
• Treatment removes warts but does not eradicate HPV infection or prevent transmission 2
• Extensive or refractory disease should be referred to a specialist
• For difficult-to-treat warts (large, deep, numerous, extensive, or treatment-resistant), alternative treatment options may be needed 5

Common Pitfalls to Avoid

1. Overtreatment: Evaluate risk-benefit ratio throughout therapy to avoid unnecessary side effects
2. Damaging surrounding skin: Particularly important when treating facial or genital warts to prevent spread
3. Inappropriate treatment selection: Consider wart location, patient age, and extent of lesions
4. Inadequate follow-up: Monitor for recurrence for at least 3-6 months after treatment
5. Unrealistic expectations: Inform patients that multiple treatments may be needed and recurrence is common