What is the recommended approach for treating and presenting a patient with a trunk wart to the attending?

Approach to Treating and Presenting a Patient with Trunk Wart

For trunk warts, cryotherapy with liquid nitrogen is the recommended first-line provider-administered treatment, with salicylic acid 15-26% as an alternative patient-applied option. 1

Clinical Assessment and Presentation to Attending

When presenting a trunk wart case to your attending, follow this structured approach:

1. Introduction

• "I evaluated a [age] [gender] patient presenting with a [size, number, appearance] wart(s) on the trunk that has been present for [duration]."
• Specify if there are any concerning features: bleeding, rapid growth, unusual pigmentation, or pain

2. Relevant History

• Duration of the wart(s)
• Previous treatments attempted and outcomes
• Immunocompromised status (if applicable)
• Impact on quality of life (pain, cosmetic concerns)

3. Physical Examination Findings

• Precise location on trunk
• Size and number of lesions
• Appearance (flat, raised, pigmented, etc.)
• Any surrounding skin changes

4. Treatment Plan

Present your treatment recommendation in this algorithmic approach:

First-Line Options:

• Provider-administered treatment: Cryotherapy with liquid nitrogen

  • Applied every 1-2 weeks
  • Efficacy rate: 63-88% 1
  • Continue for 3-4 months if needed

• Patient-applied alternative: Salicylic acid (15-26%)

  • Applied daily after paring for 3-4 months
  • Efficacy rate: comparable to cryotherapy for non-genital warts 1

Second-Line Options (if first-line fails):

• Trichloroacetic acid (TCA) 80-90%

  • Applied weekly until resolved
  • Efficacy rate: 81% 1

• Imiquimod 5% cream

  • Applied three times weekly at bedtime for up to 16 weeks
  • Efficacy rate: approximately 35% 1, 2

For Refractory Cases:

• Surgical removal (93% clearance rate, but 29% recurrence) 1
• Consider combination therapy (e.g., cryotherapy plus salicylic acid)

Key Points to Emphasize to Attending

1. Treatment Monitoring: Change treatment if no substantial improvement after three provider-administered treatments or if warts haven't cleared after six treatments 3

2. Patient Education:

   • Spontaneous resolution occurs in 20-30% of cases within 3 months 1
   • Recurrence rates range from 13-39% depending on treatment 1
   • Local skin reactions are common and expected

3. Treatment Considerations:

   • Pregnancy status (avoid podofilox, podophyllin, and imiquimod) 3
   • Immunocompromised status (may require more aggressive treatment)
   • Patient preference and compliance ability

Common Pitfalls to Avoid

1. Overtreatment: Aggressive cryotherapy can lead to scarring or hypopigmentation

2. Misdiagnosis: Ensure the lesion is truly a wart and not another condition (e.g., seborrheic keratosis, molluscum contagiosum)

3. Inadequate follow-up: Recurrence is common, especially in the first 3 months after treatment 3

4. Neglecting patient preferences: Treatment selection should consider the patient's ability to comply with the regimen and their tolerance for pain/discomfort

By following this structured approach, you will demonstrate clinical reasoning and evidence-based decision-making when presenting this case to your attending.