What are common methods for wart removal?

Common Methods for Wart Removal

For cutaneous warts, start with salicylic acid 15-40% after debridement as first-line treatment, escalate to cryotherapy with liquid nitrogen if no improvement after 8 weeks, and reserve surgical excision for recalcitrant cases—with the critical caveat that combining cryotherapy plus daily salicylic acid achieves the highest cure rates (89%) for plantar warts. 1, 2, 3

First-Line Treatment: Salicylic Acid

Salicylic acid (15-40%) topical paints or ointments represent the cornerstone of wart treatment due to low cost, ease of use, and proven efficacy. 1, 4

• Debridement before each application is essential—pare down the wart to remove the thick keratin layer that blocks penetration of the medication. 2, 4
• Apply the salicylic acid preparation directly to the wart, avoiding surrounding normal skin to prevent HPV spread. 1
• Treatment duration should be at least 8 weeks before declaring failure, with most warts clearing in 1-3 months. 2, 5
• For plantar warts specifically, use stronger concentrations (20-30%) after adequate paring for up to 6 months, as these consistently show the poorest outcomes due to thick cornified layers. 1, 2

Second-Line Treatment: Cryotherapy

Cryotherapy with liquid nitrogen should be used when salicylic acid fails or for patients preferring office-based treatment. 2, 4

• Apply every 1-2 weeks for 3-4 months minimum before declaring treatment failure—cure rates reach 50-70% after three to four treatments. 2, 1
• The major drawback is that proper technique requires substantial training; improper use leads to overtreatment (complications) or undertreatment (poor efficacy). 1
• Patients commonly experience moderate pain during and after the procedure, followed by necrosis and sometimes blistering. 1
• Local anesthesia may facilitate treatment when the wart area is large. 1, 4

Combination Therapy: Highest Efficacy

The combination of cryotherapy plus daily patient-applied salicylic acid achieves the highest remission rates—89.2% eradication in one study—and should be considered for plantar warts or recalcitrant lesions. 2, 3

• This approach involves in-office cryotherapy applications combined with daily home application of salicylic acid by the patient. 3
• The British Association of Dermatologists notes that more aggressive combination regimens are probably more effective than standard single-agent approaches, though side effects increase. 1

Third-Line Treatment: Surgical Removal

For extensive or recalcitrant warts, surgical removal via tangential excision, curettage, or electrosurgery offers 93% efficacy in a single visit. 2, 4

• The procedure creates a wound extending only into the upper dermis since most warts are exophytic. 1, 6
• Hemostasis can be achieved with an electrosurgical unit or chemical styptic (aluminum chloride solution)—suturing is neither required nor indicated in most cases. 1
• This is particularly beneficial for patients with a large number or area of warts. 1, 6
• Recurrence rate is approximately 29%, similar to other modalities. 6

Alternative Treatments for Specific Situations

For Genital Warts (Different Approach)

• Patient-applied podofilox 0.5% solution/gel or imiquimod 5% cream are first-line for genital warts, applied 3 times per week until clearance or maximum 16 weeks. 6, 7
• Provider-administered cryotherapy, TCA/BCA 80-90%, or surgical removal are alternatives. 1, 6
• Critical warning: Treatments for genital warts should NOT be used on non-genital cutaneous warts, as these are specifically indicated for genital lesions only. 4

For Facial/Plane Warts

• Use lower concentrations of salicylic acid (2-10%) or cautious use of 12-17% paint without occlusion to minimize scarring risk. 1
• Cryotherapy should use a milder freeze at these cosmetically sensitive sites. 1
• Destructive and caustic agents are more likely to produce scarring on the face and should be used with extreme care. 1

For Warts in Children

• Warts in children are often short-lived and likely to clear within 1-2 years—watchful waiting is reasonable as approximately 30% resolve spontaneously within 6 months. 1, 2
• Painful treatments should be avoided in young children if possible. 1
• When treatment is necessary, use salicylic acid or gentle cryotherapy. 1

Critical Treatment Considerations

Change treatment if there is no substantial improvement after 3 provider-administered treatments or 8 weeks of patient-applied therapy. 2, 6

• Minimum treatment duration should be 3-4 months before declaring complete treatment failure. 2
• Recurrence is common with all wart treatments (25-30%), likely due to reactivation of subclinical HPV infection rather than reinfection. 2, 6

Common Pitfalls to Avoid

• Do not damage surrounding normal skin during paring or treatment—this spreads HPV infection to adjacent areas. 1, 4
• Avoid premature treatment changes—inadequate treatment duration reduces overall success rates. 4
• Do not use genital wart treatments on cutaneous warts—these are specifically contraindicated. 4
• For cryotherapy, ensure proper training to avoid overtreatment (complications) or undertreatment (poor efficacy). 1, 4