What are the treatment options for warts?

Wart Treatment Options

The most effective treatment for warts depends on their location, with provider-administered treatments like cryotherapy, TCA/BCA application, or surgical removal offering the highest clearance rates for most wart types. 1

Patient-Applied Treatments

• Podofilox 0.5% solution or gel: Applied by patients to external genital warts twice daily for 3 consecutive days, followed by 4 days without treatment for up to 4 cycles. The total wart area treated should not exceed 10 cm², and total volume limited to 0.5 mL per day 1
• Imiquimod 5% cream: Applied once daily at bedtime, three times weekly for up to 16 weeks. The treatment area should be washed with soap and water 6-10 hours after application 1, 2
  • Most patients experience mild to moderate local skin reactions 1, 3
  • Complete clearance rates differ by gender: approximately 72% in women vs. 33% in men 3
  • More frequent application does not improve clearance rates but increases adverse events 4

Provider-Administered Treatments

• Cryotherapy with liquid nitrogen: Applied by providers every 1-2 weeks until warts are cleared 1

  • Destroys warts through thermal-induced cytolysis 1
  • Common side effects include pain, necrosis, and sometimes blistering 1
  • Local anesthesia may be needed for large treatment areas 1

• Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80-90%:

  • Apply small amount only to warts until white "frosting" develops 1
  • If excess acid is applied, neutralize with talc, sodium bicarbonate, or liquid soap 1
  • Can be repeated weekly as necessary 1

• Podophyllin resin 10-25% in compound tincture of benzoin:

  • Applied to each wart and allowed to air dry 1
  • Application should be limited to <0.5 mL or area <10 cm² per session 1
  • Some specialists recommend washing off 1-4 hours after application 1
  • Not safe during pregnancy 1

• Surgical removal options:

  • Tangential scissor excision, tangential shave excision, curettage, or electrosurgery 1
  • Advantage of usually eliminating warts in a single visit 1
  • Requires clinical training, additional equipment, and longer office visits 1
  • Most beneficial for patients with large or numerous warts 1

Alternative Treatments for Resistant Cases

• Intralesional interferon: Used for warts resistant to standard therapies 1

  • Comparable efficacy to other treatment modalities but with more systemic side effects 1
  • Not recommended for routine use due to inconvenient administration and frequent office visits 1

• Laser surgery: Useful for extensive warts or intraurethral warts 1

  • Particularly beneficial for patients who have not responded to other treatments 1

• Extended imiquimod treatment: For resistant cutaneous warts, longer treatment periods (up to 24 weeks) may be effective 5

  • In one study of resistant warts (mean duration 6.3 years), 27% achieved total clearance with extended treatment 5

Treatment Selection Based on Wart Location

• Cervical warts: Require biopsy evaluation before treatment; management should include specialist consultation 1

• Vaginal warts: Use cryotherapy with liquid nitrogen (avoid cryoprobe due to perforation risk) or TCA/BCA 80-90% 1

• Urethral meatus warts: Use cryotherapy with liquid nitrogen or podophyllin 10-25% 1

• Anal warts: Use cryotherapy, TCA/BCA application, or surgical removal; intra-anal warts require specialist consultation 1

Important Considerations

• Wart recurrence rates vary by treatment method, with imiquimod showing favorable recurrence rates (13-19%) compared to other treatments 6

• Local skin reactions are common with most treatments and can be managed with rest periods if necessary 1, 3

• For extensive or treatment-resistant warts, combination therapy may be considered, though data on efficacy and complications are limited 1, 7

• Treatment selection should consider the location, number, and size of warts, as well as patient preference and ability to comply with treatment regimens 7

• Follow-up is recommended to assess treatment response and address any concerns, particularly for self-administered therapies 2