What are the treatment options for warts?

Treatment Options for Warts

The most effective treatment options for warts include salicylic acid (15-40%) for most cutaneous warts and cryotherapy with liquid nitrogen for genital warts, with treatment selection based on wart location, patient age, and wart type. 1

Treatment Selection Based on Wart Location

Plantar Warts (Feet)

• First-line: Salicylic acid (15-40%) topical paints or ointments, applied after paring excess skin 1
• Second-line: Cryotherapy with liquid nitrogen, applied fortnightly for 3-4 months 1
• Combination therapy: Using salicylic acid and cryotherapy together may be more effective than either treatment alone, though side effects may be more pronounced 1
• Alternative options: Formaldehyde, glutaraldehyde, hyperthermia, laser, photodynamic therapy (PDT), or topical immunotherapy 1
• Combined approach: A regimen of cryotherapy with 70% salicylic acid has shown 89.2% success rate in eradicating plantar warts 2

Common Hand Warts

• First-line: Salicylic acid (15-40%) topical preparations 1
• Second-line: Cryotherapy with liquid nitrogen 1
• Most warts respond to treatment within 1-3 months with salicylic acid products 3

Plane Warts (Flat Warts)

• First-line: Salicylic acid cream/ointment (2-10%) or cautious use of salicylic acid paint (12-17%) without occlusion 1
• Second-line: Mild cryotherapy freeze 1
• Alternative: Topical retinoids 1
• Other options: Glycolic acid 15%, imiquimod, 5-FU cream, topical immunotherapy, zinc preparations 1
• Note: Plane warts on hands or face are mainly a cosmetic problem and spontaneous clearance can often be awaited 1

Facial Warts

• First-line: Cryotherapy, curettage, or hyfrecation 1
• Caution: Destructive treatments may cause scarring on facial skin 1
• For filiform warts in beard area: Avoid damaging adjacent skin which can spread infection 1

Genital Warts

• Patient-applied treatments:

  • Podofilox 0.5% solution or gel - applied 3 times weekly for up to 16 weeks 1
  • Imiquimod cream - applied 3 times weekly for up to 16 weeks 1

• Provider-administered treatments:

  • Cryotherapy with liquid nitrogen 1
  • Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80-90% 1
  • Surgical removal (tangential scissor excision, shave excision, curettage, or electrosurgery) 1

Special Populations

Children with Warts

• First-line: Salicylic acid (15-40%) topical preparations 1
• Second-line: Gentle cryotherapy, applied fortnightly for 3-4 months 1
• Important consideration: Warts in children often resolve spontaneously within 1-2 years; painful treatments should be avoided in young children 1

Immunosuppressed Patients

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

Treatment Administration Tips

Salicylic Acid Application

• Prior to application: Pare or rub down (debride) warts 1
• For plantar warts: Use stronger preparations (20-30%) after adequate paring 1
• Duration: Treatment may need to continue for up to 6 months 1
• Approximately 4 out of 5 warts heal within 1-3 months with proper application 3

Cryotherapy Administration

• Technique: Healthcare providers must be properly trained to avoid over- or under-treatment 1
• Common side effects: Pain, necrosis, and sometimes blistering 1
• Local anesthesia may be needed for extensive treatment areas 1
• For genital warts: Avoid using cryoprobe in vagina due to risk of perforation 1

TCA/BCA Application

• Apply sparingly only to warts and allow to dry 1
• A white "frosting" develops when properly applied 1
• If excess acid is applied: Neutralize with talc, sodium bicarbonate, or liquid soap 1
• Caution: TCA solutions have low viscosity and can spread rapidly if applied excessively 1

Imiquimod Use

• Application: Apply 3 times per week for genital warts for up to 16 weeks 4
• Timing: Apply prior to normal sleeping hours and leave on for 6-10 hours 4
• Removal: Wash area with mild soap and water after treatment period 4
• Side effects: Local inflammatory reactions are common but usually mild to moderate 4

Treatment Efficacy and Expectations

• Spontaneous resolution: Consider following warts for at least 6 months before treatment, as many resolve on their own 3
• Placebo effect: Average cure rate with placebo preparations is 27% (range 0-73%) after 15 weeks 5
• Salicylic acid efficacy: Meta-analysis shows 73% cure rate compared to 48% with placebo 5
• Recurrence: All treatment strategies are associated with some recurrence, but most successfully treated warts do not recur 6

Common Pitfalls and Caveats

• Avoid damaging surrounding skin during treatment, which can spread infection 1
• For genital warts, biopsy may be needed to exclude high-grade lesions before treatment 1
• Pregnancy considerations: Avoid podofilox, imiquimod, and sinecatechins during pregnancy 6
• Treatment resistance: Large, deep, numerous warts may require alternative or combination approaches 7
• Evidence limitations: There is considerable lack of evidence for many wart treatments, with high variability in trial methods and quality 5