What are the treatment options for a wart?

Treatment Options for Warts

Salicylic acid (15-40%) is the first-line treatment for most cutaneous warts, with cryotherapy as an effective alternative, while genital warts should be treated with patient-applied podofilox 0.5% or imiquimod 5% cream, or provider-administered cryotherapy. 1, 2, 3

Cutaneous (Non-Genital) Warts

First-Line Treatment: Salicylic Acid

• Salicylic acid 15-40% topical paints or ointments should be applied after paring/debridement of the wart, ideally with occlusion overnight, then washed off in the morning. 1, 4
• The skin should be hydrated for at least 5 minutes before application to enhance penetration. 4
• For plantar warts specifically, concentrations of 20-30% may be used after adequate paring, continued for up to 6 months. 1
• Cure rates with salicylic acid reach approximately 80% when used consistently for 1-3 months. 5
• This is the most cost-effective, well-tolerated option with the strongest evidence base. 1, 6

Second-Line Treatment: Cryotherapy

• Cryotherapy with liquid nitrogen should be applied every 1-2 weeks (fortnightly) for 3-4 months if salicylic acid fails. 1, 2
• For plantar warts, cure rates are lower (63-88%) due to thicker cornified layers requiring more aggressive treatment. 1, 2
• Pain, necrosis, and blistering are common side effects. 2
• Proper training is essential—over-treatment causes scarring while under-treatment reduces efficacy. 2

Combination Therapy for Resistant Cases

• Combined cryotherapy plus 70% salicylic acid achieves 89.2% eradication rates for plantar warts, significantly higher than either treatment alone. 7, 6
• Apply cryotherapy in-office with daily patient application of salicylic acid between visits. 7

Location-Specific Considerations

Plantar Warts:

• Require more aggressive regimens due to thick skin. 1
• Paring before each treatment is critical but must avoid damaging surrounding skin to prevent viral spread. 1

Plane Warts (face/hands):

• Use lower concentrations (2-10% salicylic acid cream) or cautious 12-17% paint without occlusion to minimize scarring risk. 1
• Milder cryotherapy freeze recommended. 1

Warts in Children:

• Often spontaneously resolve within 1-2 years, so watchful waiting is reasonable. 1
• If treatment needed, use salicylic acid 15-40% or gentle cryotherapy—avoid painful treatments in young children. 1

Third-Line Options for Refractory Warts

• Consider formaldehyde, glutaraldehyde 10%, imiquimod, 5-fluorouracil, laser therapy, or photodynamic therapy only after first and second-line failures. 1
• Surgical removal (curettage, electrosurgery) may be appropriate for large or numerous warts. 1

Genital Warts

Patient-Applied Options (Preferred Initial Treatment)

Podofilox 0.5% solution or gel:

• Apply twice daily for 3 consecutive days, then 4 days off, repeating cycles up to 4 times. 1, 3
• Limit to ≤10 cm² treatment area and ≤0.5 mL volume per day. 1, 2
• Contraindicated in pregnancy. 1

Imiquimod 5% cream:

• Apply at bedtime 3 times weekly for up to 16 weeks. 1, 8
• Wash off with soap and water 6-10 hours after application. 8
• Many patients achieve clearance by 8-10 weeks. 3, 8
• Contraindicated in pregnancy; may weaken condoms and diaphragms. 2, 8

Sinecatechins 15% ointment:

• Apply 3 times daily until clearance, maximum 16 weeks. 2, 3
• Contraindicated in pregnancy and immunocompromised patients. 2

Provider-Administered Options

Cryotherapy with liquid nitrogen:

• Repeat every 1-2 weeks as needed. 1, 3
• Efficacy 63-88%, relatively inexpensive, no anesthesia required. 2, 3

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

• Apply sparingly to warts only, allow to dry until white "frosting" develops. 1
• Can neutralize with soap or sodium bicarbonate if pain is intense. 1
• Repeat weekly if necessary. 1

Podophyllin resin 10-25%:

• Apply to warts, allow to air dry, wash off after 1-4 hours. 1
• Limit to ≤0.5 mL or ≤10 cm² per session due to systemic toxicity risk. 1
• Contraindicated in pregnancy. 1

When to Change Treatment

• Switch therapy if no substantial improvement after 3 provider-administered treatments or 8 weeks of patient-applied therapy. 2, 3
• Discontinue if no complete clearance after 6 provider-administered treatments. 2, 3

Critical Warnings and Limitations

Treatment Does Not Cure HPV

• All treatments remove visible warts but do not eradicate HPV infection or affect its natural history. 2, 3
• Recurrence rates are 25-30% with all modalities. 3
• Effect on future transmission is unclear. 3

Natural History Without Treatment

• Untreated warts may spontaneously resolve, remain unchanged, or increase in size/number. 2, 3
• For cutaneous warts in children, spontaneous resolution within 1-2 years is common. 1

Potential Complications

• Persistent hypopigmentation or hyperpigmentation is common. 2, 3
• Depressed or hypertrophic scars may occur. 2, 3
• Rare but serious chronic pain syndromes have been reported. 2, 3
• Avoid damaging surrounding skin during treatment to prevent viral spread. 1

Special Populations

Immunosuppressed patients:

• Treatment may not result in cure but can reduce wart bulk and functional/cosmetic problems. 1
• Standard treatments with careful avoidance of surrounding skin damage are recommended. 1

Pregnancy:

• Salicylic acid, cryotherapy, and TCA/BCA are acceptable options. 1
• Podofilox, podophyllin, imiquimod, and sinecatechins are contraindicated. 1, 2