What is the recommended treatment for a wart on the trunk?

Treatment of Warts on the Trunk

Cryotherapy with liquid nitrogen is the recommended first-line treatment for warts on the trunk, with efficacy rates of 63-88%. 1

First-Line Treatment Options

Cryotherapy with Liquid Nitrogen

• Apply every 2 weeks for 3-4 months
• Use a gentle freeze-thaw cycle of 15-30 seconds per application
• Prior debulking of the wart is recommended
• Efficacy rate: 63-88% 1
• Most effective for common warts (49% cure rate at 13 weeks) 2
• Warn patients that:
  • Treatment is painful
  • Blistering may occur
  • Local skin reactions (erythema, edema) are common and expected

Salicylic Acid (Alternative First-Line)

• 15-40% concentration
• Apply daily after paring for 3-4 months
• Efficacy rate: When combined with cryotherapy, 89.2% clearance 3
• Patient self-application option
• Less painful during application than cryotherapy 4

Second-Line Treatment Options

Trichloroacetic Acid (TCA) or Bichloroacetic Acid (BCA)

• 80-90% concentration
• Applied weekly as needed
• Apply until white "frosting" develops
• Neutralize excess with talc/sodium bicarbonate
• Efficacy rate: 81% 1
• Lower efficacy than cryotherapy for common warts (21.3% vs 83.1% complete cure) 5
• Fewer side effects than cryotherapy 5

Imiquimod 5% Cream

• Apply three times weekly at bedtime for up to 16 weeks
• Efficacy rate: approximately 35% 1
• Application instructions 6:
  • Wash hands before and after applying
  • Wash treatment area with mild soap and water before application
  • Apply to cover treatment area including 1 cm margin around the wart
  • Rub until cream is no longer visible
  • Leave on for 6-10 hours (typically overnight)
  • Avoid contact with eyes, lips, and nostrils

Surgical Removal

• Efficacy rate: 93% 1
• Recurrence rate: 29% 1
• Consider for resistant warts that don't respond to other treatments

Treatment Algorithm

1. Start with cryotherapy with liquid nitrogen

   • Apply every 2 weeks
   • Continue for up to 3-4 months

2. If no improvement after three treatments or if warts haven't cleared after six treatments:

   • Consider combination therapy with salicylic acid (89.2% efficacy) 1, 3
   • OR switch to TCA/BCA 80-90% 1

3. For patients who cannot tolerate cryotherapy pain:

   • Consider salicylic acid as monotherapy 1
   • OR TCA/BCA which has fewer side effects than cryotherapy 5

4. For resistant warts:

   • Consider surgical removal (93% clearance rate) 1
   • OR imiquimod 5% cream for immunomodulation 1, 6

Important Considerations

• Treatment Monitoring: Change treatment if no substantial improvement after three provider-administered treatments or if warts haven't cleared after six treatments 1

• Recurrence Rates:

  • Cryotherapy: 21-39% 1
  • TCA/BCA: 36% 1
  • Surgical removal: 29% 1

• Spontaneous Resolution: Occurs in 20-30% of cases within 3 months, making watchful waiting an acceptable alternative for some patients, especially children 1

• Cautions:

  • Use caution when applying cryotherapy near cutaneous nerves and tendons 1
  • Avoid overtreatment with caustic agents like TCA/BCA to prevent damage to surrounding healthy tissue 1
  • Scarring is uncommon but possible, especially with insufficient healing time between treatments 1

• Combination Therapy: Combined cryotherapy with salicylic acid shows higher efficacy (89.2%) than either treatment alone and may be particularly effective for resistant warts 3