What is the treatment for Verruca vulgaris?

Treatment for Verruca Vulgaris

Most cases of verruca vulgaris (common warts) can be treated with chemical or physical destruction methods, with salicylic acid being a first-line treatment option. 1, 2

Understanding Verruca Vulgaris

• Verruca vulgaris (common warts) are benign epithelial proliferations caused by human papillomaviruses 1
• They typically appear as painless, multiple lesions on any epithelial surface, most commonly on hands, feet, and around/under nails 1
• Most warts will eventually resolve spontaneously, with 30% regressing within 6 months and approximately 60% within 2 years 1

First-Line Treatment Options

Salicylic Acid

• FDA-approved for verrucae as a topical aid in removing excessive keratin 2
• Available in various concentrations (typically 6-70%) 2, 3
• Mechanism: causes keratolysis of infected epithelium 1
• Can be used as a standalone treatment or in combination with other modalities 3

Cryotherapy

• Involves freezing the wart with liquid nitrogen 1
• Often requires multiple treatment sessions 1
• May cause pain that could limit athletic activity 1
• Side effects include burning (100%), irritation (96.7%), erythema (93.7%), blister formation (93.7%), and pain (76.7%) 4

Combination Therapy

• Combined cryotherapy with 70% salicylic acid shows high efficacy (89.2% eradication rate) 3
• Patient applies salicylic acid daily after in-office cryotherapy 3
• Combination therapy may be more effective than either treatment alone 3

Alternative Treatment Options

Topical Agents

• Tretinoin (retinoic acid) cream 1
• Formaldehyde soaks (3-10%) - reported 80% cure rate in children with plantar warts 1
• Glutaraldehyde 10% paint - reported as equivalent to salicylic acid for plantar warts 1
• 5-Fluorouracil 5% ointment - effective for flat warts resistant to other treatments 5

Physical Destruction Methods

• Surgical (paring) or laser removal 1
• Electrowave "electrosection" - 67% success rate reported for solitary plantar warts 1
• Photodynamic therapy (PDT) - 75% resolution reported when combined with pre-treatment using urea 10% and salicylic acid 10% 1

Immunotherapy

• Topical immunomodulating agents 1
• Intralesional Candida antigen - reported success even in immunocompromised patients 6

Treatment Selection Algorithm

1. Initial Treatment: Start with salicylic acid-based products (6-40%) for 2-3 months 2, 1
2. If Limited Response: Consider combination therapy with cryotherapy and salicylic acid 3
3. For Resistant Warts: Progress to more aggressive options such as:
   • Higher concentration salicylic acid (70%) 3
   • Cantharidin combined with podophyllotoxin-salicylic acid (note: may cause pain and blistering) 1
   • Intralesional immunotherapy for recalcitrant cases 6

Special Considerations

• Treatment may be more challenging in immunocompromised patients 6
• Warts in weight-bearing areas may have higher relapse rates 1
• Risk factors for transmission include sharing equipment and exposure of unshod feet in common shower areas 1
• In a study of adolescents using locker rooms, 27% of those using communal showers regularly had plantar warts versus only 1.25% of those only using locker rooms 1

Safety Considerations

• Salicylic acid with lactic acid combination shows fewer side effects than cryotherapy 4
• More destructive methods may cause pain that could limit activity 1
• Consider location of warts when selecting treatment (e.g., periungual warts may require different approaches than plantar warts) 1