What are the treatment options for a large hand verruca (wart)?

From the Guidelines

For large hand warts, I strongly recommend starting with topical salicylic acid (SA) preparations of 15–26% applied daily after removing the thick keratin layer, with occlusion if possible, as this has the highest strength of recommendation (A) according to the British Association of Dermatologists' guidelines 1. This approach is supported by the guidelines, which suggest continuing treatment for 3–4 months. Other treatment options, such as cryotherapy, can be considered if salicylic acid is not effective, but they have a lower strength of recommendation (B) and may be more painful during and after treatment 1. Some key points to consider when treating large hand warts include:

• Removing the thick keratin layer before applying topical treatments
• Using occlusion to enhance the effectiveness of treatments like salicylic acid
• Avoiding picking or scratching the wart to prevent spreading the virus
• Washing hands thoroughly after touching the wart
• Being patient, as large warts often require multiple treatments over several weeks or months It's also important to note that some treatments, such as bleomycin, 5-fluorouracil, and laser therapy, may be considered for particularly stubborn large warts, but these should be discussed with a dermatologist due to potential side effects and the need for proper application 1.

From the FDA Drug Label

For Dermatologic Use: Salicylic Acid 6% is a topical aid in the removal of excessive keratin in hyperkeratotic skin disorders including verrucae, and the various ichthyoses (vulgaris, sex-linked and lamellar), keratosis palmaris and plantaris keratosis pilaris, pityriasis rubra pilaris, and psoriasis (including body, scalp, palms and soles). For Podiatric Use: Salicylic Acid 6% is a topical aid in the removal of excessive keratin on dorsal and plantar hyperkeratotic lesions. Topical preparations of 6% salicylic acid have been reported to be useful adjunctive therapy for verrucae plantares.

Treatment options for large hand warts include:

• Topical application of salicylic acid 6% as an aid in the removal of excessive keratin in hyperkeratotic skin disorders, including verrucae 2 Note that the FDA label does not provide specific guidance on the treatment of large hand warts, but salicylic acid 6% may be useful as an adjunctive therapy.

From the Research

Treatment Options for Large Hand Warts

• Medical treatments, such as salicylic acid, silver nitrate, and glutaraldehyde, are considered first-line therapy for treating single or few small common warts of short duration (less than 1 year) 3
• Cryotherapy may be considered as second-line therapy if first-line treatments have failed or are contraindicated 3
• For recurrent or difficult-to-treat lesions, third-line therapy includes alternative therapeutic options, such as topical, intralesional, systemic, and physical destruction, which are generally off-label and have drawbacks or adverse effects 3
• Salicylic acid and cryotherapy combined may be more effective than salicylic acid alone for treating hand warts 3, 4
• Imiquimod 5% cream has been shown to be effective in treating non-genital warts, including hand warts, with a success rate of 90% in one study 5
• A study comparing cryotherapy with imiquimod 5% cream combined with a keratolytic lotion found no significant difference in effectiveness between the two treatments for cutaneous warts in children, but imiquimod 5% cream was more effective for plantar warts 6
• Another study found that a topical formulation consisting of cantharidin, podophyllotoxin, and salicylic acid was more effective than cryotherapy in treating plantar warts 7

Efficacy of Different Treatments

• Salicylic acid has been shown to be effective in treating hand warts, with a risk ratio of 2.67 compared to placebo 4
• Cryotherapy has been shown to be effective in treating hand warts, but its effectiveness may be limited by adverse effects such as pain, blistering, and scarring 4
• Imiquimod 5% cream has been shown to be effective in treating hand warts, with a success rate of 90% in one study 5
• Dinitrochlorobenzene has been shown to be more than twice as effective as placebo in treating warts, but its use is limited by potential adverse effects 4

Considerations for Treatment

• The choice of treatment for large hand warts should be based on the individual patient's needs and medical history 3
• Patients should be informed of the potential risks and benefits of each treatment option, including the risk of adverse effects and the potential for recurrence 3
• Treatment should be tailored to the individual patient's response, with adjustments made as needed to achieve optimal results 3