What is the recommended treatment protocol for warts?

Wart Treatment Procedure Note

The most effective first-line treatments for warts are salicylic acid (15-26%) for patient self-application or cryotherapy with liquid nitrogen for provider-administered treatment, with efficacy rates of 45-88% and 63-88% respectively. 1, 2

Patient Assessment

• Location and type of warts (common, plantar, anogenital)
• Number, size, and distribution of lesions
• Previous treatments and response
• Contraindications (pregnancy status, immunosuppression)
• Patient preference for self-administered vs. provider-administered treatment

Treatment Options by Wart Type

Common/Hand Warts

1. First-line treatments:

   • Salicylic acid (15-26%): Applied daily after removing thick keratin layer, with occlusion if possible, for 3-4 months 1
   • Cryotherapy: Freeze wart for 15-30 seconds, repeating every 2-4 weeks for at least 3 months 1

2. Second-line treatments:

   • Bleomycin (intralesional)
   • Contact immunotherapy
   • 5-Fluorouracil
   • Pulsed-dye laser

Plantar Warts

1. First-line treatments:

   • Salicylic acid (15-26%): Daily application after paring down the wart
   • Combination therapy: Cryotherapy plus 70% salicylic acid shows 89.2% efficacy 3

2. Second-line treatments:

   • Monochloroacetic acid: Comparable efficacy to cryotherapy with less treatment pain 4
   • Bleomycin (intralesional)
   • Surgical removal for resistant cases

Anogenital Warts

1. Patient-applied treatments:

   • Podofilox 0.5% solution/gel: Apply twice daily for 3 days, followed by 4 days without treatment, for up to 4 cycles 1, 2
   • Imiquimod 5% cream: Apply once daily at bedtime, three times weekly for up to 16 weeks 1, 5

2. Provider-administered treatments:

   • Cryotherapy: Apply every 1-2 weeks 1
   • TCA/BCA 80-90%: Apply weekly as needed 1, 2
   • Surgical removal: For extensive or resistant warts 2

Procedure Documentation for Cryotherapy

Pre-procedure

1. Obtain informed consent
2. Cleanse treatment area with alcohol
3. Pare down hyperkeratotic warts with #15 blade or curette
4. Protect surrounding skin with petroleum jelly if needed

Procedure

1. Apply liquid nitrogen using spray or cotton-tipped applicator
2. Freeze wart for 15-30 seconds until a 1-2mm white halo forms around the wart
3. Allow complete thawing before considering a second freeze cycle for thicker lesions
4. Document number and location of warts treated

Post-procedure

1. Apply antiseptic ointment if needed
2. Cover with adhesive bandage if necessary
3. Instruct patient:
   • Mild pain, redness, and swelling are expected
   • Blister formation is normal and should not be punctured
   • Keep area clean and dry
   • Return in 2-4 weeks for follow-up treatment
4. Document expected follow-up interval

Procedure Documentation for Chemical Treatment (TCA/BCA)

Pre-procedure

1. Obtain informed consent
2. Cleanse treatment area with alcohol
3. Pare down hyperkeratotic warts if needed

Procedure

1. Apply small amount of TCA/BCA 80-90% only to warts using wooden applicator
2. Allow to dry until white "frosting" develops
3. Neutralize excess acid with talc, sodium bicarbonate, or liquid soap
4. Document number and location of warts treated

Post-procedure

1. Apply petroleum jelly if needed
2. Instruct patient:
   • Mild burning sensation is normal for 2-24 hours
   • Keep area clean and dry
   • Return weekly for repeat treatment if necessary
3. Document expected follow-up interval

Treatment Monitoring and Follow-up

• Change treatment if no substantial improvement after three provider-administered treatments 2
• Consider alternative approach if warts haven't cleared after six treatments 2
• For patient-applied treatments, reassess after completing recommended cycles 1
• Recurrence rates vary by treatment: cryotherapy (21-39%), TCA/BCA (36%), surgical removal (29%) 2

Special Considerations

• Pregnancy: Avoid podofilox, podophyllin, imiquimod; prefer TCA/BCA or cryotherapy 1, 2
• Immunocompromised patients: May require more aggressive or prolonged therapy 2
• Children: Consider watchful waiting as spontaneous resolution occurs in 20-30% of cases within 3 months 2
• Persistent hypopigmentation or hyperpigmentation: Common with ablative treatments 1
• Pain management: Local anesthesia may be needed for extensive treatments 1

Treatment Complications

• Local skin reactions (erythema, edema, blistering) are common and expected
• Scarring is uncommon but possible, especially with insufficient healing time between treatments 1
• Rarely, chronic pain syndromes may develop at treatment sites 1