Is surgical excision (cutting out) of plantar warts more effective than cryotherapy for a patient, considering potential complications and underlying medical conditions such as diabetes or impaired circulation?

Surgical Excision vs. Cryotherapy for Plantar Warts

Surgical excision (cutting out) of plantar warts is NOT recommended and should be avoided—cryotherapy is the preferred destructive treatment option, though neither approach is particularly effective for plantar warts. 1

Why Surgery Should Be Avoided

The British Association of Dermatologists explicitly states there are no high-quality studies supporting surgical treatments such as curettage, cautery, or excision for plantar warts, despite their widespread use. 1 More critically:

• Surgical excision and cautery are very painful procedures that can leave permanent tender scars on weight-bearing surfaces 2
• Surgery frequently leads to relapse due to the Koebner phenomenon (viral spread to traumatized tissue) 2
• Scarring on the plantar surface creates long-term morbidity with painful weight-bearing that persists even after the wart is gone 2
• The British guidelines assign surgical interventions only Level 3 evidence with Strength D recommendation—the lowest possible rating 1

Cryotherapy Performance

While cryotherapy is considered a standard second-line treatment, its effectiveness for plantar warts is modest at best:

• Cure rates range from only 14-39% for plantar warts, significantly lower than for warts at other body sites 1, 3
• A 2022 meta-analysis found cryotherapy has lower cure rates than alternative treatments (OR 0.31,95% CI 0.12-0.78) 4
• The thick cornified layer of plantar skin prevents adequate treatment penetration 3, 5
• More aggressive cryotherapy regimens (double freeze-thaw cycles, longer freeze times) may improve efficacy to 65% but increase pain, blistering, and scarring risk 1, 2

Critical Safety Considerations for High-Risk Patients

Cryotherapy must be used with extreme caution—or avoided entirely—in patients with diabetes or impaired circulation. 1 The British guidelines specifically warn:

• Avoid cryotherapy near cutaneous nerves, tendons, and in patients with impaired arterial or venous circulation 1
• Salicylic acid can cause chemical burns and should not be used in areas of poor healing such as neuropathic feet 1

For diabetic patients or those with peripheral vascular disease, watchful waiting or referral to podiatry/dermatology is safer than attempting destructive treatments that could result in non-healing ulcers.

Recommended Treatment Algorithm

First-line (3-4 months trial):

• Salicylic acid 15-40% with proper paring/debridement before each application 3, 5
• Expected cure rate: approximately 33% for plantar warts 1

Second-line (if first-line fails):

• Cryotherapy every 2 weeks for 3-4 months 3, 5
• Expected cure rate: 30-39% 1, 5
• Consider combining with continued salicylic acid (may achieve 86% clearance in some studies, though data quality is limited) 1

Third-line (resistant cases):

• Monochloroacetic acid (46% cure rate, less painful than cryotherapy) 6
• Formaldehyde 3-4% soaks 3, 5
• Glutaraldehyde 10% solution 3, 5

Key Clinical Pitfalls

• Never damage surrounding normal skin during paring—this spreads HPV infection to adjacent areas 3, 5
• Treatment duration must be adequate (minimum 3-4 months) before declaring failure 5
• Patient compliance is often poor with topical treatments due to surrounding skin irritation and prolonged treatment courses 1, 5
• Spontaneous resolution occurs in approximately 30% of cases within 6 months, making watchful waiting reasonable for asymptomatic warts 5
• Plantar warts inherently have lower cure rates (14-33%) than warts elsewhere due to thick plantar skin—set realistic expectations 5