Treatment for Hand Warts
Start with topical salicylic acid 15-26% applied daily after paring down the wart, continuing for 3-4 months before considering treatment failure. 1, 2, 3
First-Line Treatment: Salicylic Acid
Salicylic acid receives the strongest "A" level recommendation from the British Association of Dermatologists for hand warts, based on robust evidence and the best safety profile among all available treatments. 1, 2, 3
Apply 15-26% salicylic acid preparations daily after carefully debriding or paring down the wart to remove the thick keratin layer that blocks penetration. 1, 3
Use occlusion (covering the treated area) if possible to enhance efficacy, and continue treatment for a full 3-4 months before declaring failure. 1, 3
The mechanism works through promoting exfoliation of infected epidermal cells and stimulating host immunity against the human papillomavirus. 3
Second-Line Treatment: Cryotherapy
If salicylic acid fails after 3 months, switch to cryotherapy with liquid nitrogen, which has a "B" strength recommendation for hand warts. 1, 2, 3
Freeze each wart for 15-30 seconds and repeat treatments every 2-4 weeks (fortnightly). 1, 2
Continue cryotherapy for at least 3 months or six treatment sessions before considering alternative approaches. 1, 2
Cryotherapy is relatively inexpensive, does not require anesthesia, and does not cause scarring when performed properly, though patients experience moderate pain during and after treatment. 1
Combination Therapy for Resistant Cases
For warts not responding to monotherapy, combine salicylic acid with cryotherapy, which demonstrates superior efficacy compared to either treatment alone. 3, 4
This combined approach achieved 89.2% eradication rates in clinical studies, significantly higher than single-agent therapy. 5, 4
Third-Line Options for Refractory Warts
Intralesional bleomycin (0.1-1 U/mL solution) receives a "C" strength recommendation, injected or pricked into the wart after local anesthesia, requiring one to three treatments. 1, 3
Contact immunotherapy with diphenylcyclopropenone (DPC) or squaric acid dibutylester (SADBE) can be applied from twice weekly to every 3 weeks for 3-6 months after initial sensitization. 1, 3
Other third-line options include 5-fluorouracil 5% cream applied daily with occlusion for 4-12 weeks, pulsed-dye laser therapy, or photodynamic therapy. 1
Critical Pitfalls to Avoid
Never damage surrounding skin during paring or treatment, as this spreads the viral infection through autoinoculation to adjacent areas. 3
Change treatment modality if no substantial improvement occurs after 3 provider-administered treatments or if warts haven't cleared after 6 treatments, rather than persisting with an ineffective approach. 3
Avoid overtreatment with ablative modalities, as scarring (persistent hypopigmentation, hyperpigmentation, or depressed/hypertrophic scars) commonly occurs without sufficient healing time between treatments. 3
Ensure adequate treatment duration (minimum 3-4 months) before declaring failure, as patient compliance is often poor due to the prolonged course required. 6
Special Considerations
For plane warts on the backs of hands, use lower concentrations of salicylic acid (2-10% cream/ointment or cautious use of 12-17% paint without occlusion) and milder cryotherapy freezes, as destructive agents are more likely to produce scarring at these sites. 1
For periungual warts (around the nails), the same treatment algorithm applies, with salicylic acid as first-line and cryotherapy as second-line therapy. 2
Surgical removal by curettage, electrosurgery, or CO2 laser should be reserved only for extensive or refractory disease that has failed multiple medical therapies, as these methods have only level 3 evidence and "D" strength recommendations. 2