What are the treatment options for verruca (wart) removal?

From the Guidelines

Wart removal and treatment should be approached with the most effective and safest method, which is cryotherapy with liquid nitrogen or cryoprobe, repeated every 1-2 weeks, as recommended by the most recent guidelines 1.

Treatment Options

The treatment of warts depends on their type and location. For common warts, several treatment options are available, including:

• Cryotherapy with liquid nitrogen or cryoprobe, which is a highly effective method for removing warts, especially for genital warts 1
• Podophyllin resin 10%-25% in a compound tincture of benzoin, which is an antimitotic drug that destroys warts, but its safety during pregnancy has not been established 1
• Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%-90%, which can be used to treat warts, but may cause local irritation and other side effects 1
• Surgical removal, which can be used for persistent warts, but may cause scarring and other complications 1

Patient-Applied Treatments

For patient-applied treatments, podofilox 0.5% solution or gel is a relatively inexpensive, easy to use, and safe option, but its safety during pregnancy has not been established 1. Imiquimod is another option, which is a topically active immune enhancer that stimulates production of interferon and other cytokines, but may cause local inflammatory reactions and other side effects 1.

Recommendations

Based on the most recent guidelines, cryotherapy with liquid nitrogen or cryoprobe is the recommended treatment for warts, especially for genital warts, due to its high efficacy and safety profile 1. For common warts, salicylic acid products like Compound W or Dr. Scholl's Clear Away can be used, applied daily for several weeks until the wart disappears. For persistent warts, it is recommended to consult a healthcare provider who may use stronger cryotherapy, laser treatment, or prescription-strength medications. While treating warts, it is essential to avoid touching or picking at them to prevent spreading the virus to other body areas, cover warts with bandages during treatment, and wash hands thoroughly after contact.

From the FDA Drug Label

It is recommended that patients wash their hands before and after applying Imiquimod Cream. The patient should wash the treatment area with mild soap and water before applying the cream, and allow the area to dry thoroughly. The target tumor should have a maximum diameter of 2 cm and be located on the trunk (excluding anogenital skin), neck, or extremities (excluding hands and feet) Imiquimod Cream should be rubbed into the treatment area until the cream is no longer visible. Local skin reactions in the treatment area are common. A rest period of several days may be taken if required by the patient's discomfort or severity of the local skin reaction. If there is clinical evidence of persistent tumor at the post-treatment assessment for clinical clearance, a biopsy or other alternative intervention should be considered. Imiquimod Cream is packaged in single-use packets, with 12 or 24 packets supplied per box. Patients should be prescribed no more than 36 packets for the 6-week treatment period.

Wart Removal and Treatment with Imiquimod Cream:

• The treatment area should include a 1 cm margin of skin around the tumor.
• Sufficient cream should be applied to cover the treatment area.
• The cream should be rubbed into the treatment area until it is no longer visible.
• Local skin reactions are common, and a rest period may be taken if required by the patient's discomfort.
• If there is clinical evidence of persistent tumor, a biopsy or other alternative intervention should be considered 2.

Apply twice daily morning and evening (every 12 hours), for 3 consecutive days, then withhold use for 4 consecutive days This one week cycle of treatment may be repeated up to four times until there is no visible wart tissue. If there is incomplete response after four treatment weeks, alternative treatment should be considered. Podofilox Topical Solution 0. 5% is applied to the warts with an applicator supplied with the drug. The drug-dampened applicator should be touched to the wart to be treated, applying the minimum amount of solution necessary to cover the lesion.

Wart Removal and Treatment with Podofilox:

• Apply the solution twice daily for 3 consecutive days, then withhold use for 4 consecutive days.
• The treatment cycle may be repeated up to four times until there is no visible wart tissue.
• If there is incomplete response after four treatment weeks, alternative treatment should be considered.
• The solution should be applied with an applicator, using the minimum amount necessary to cover the lesion 3.

From the Research

Wart Removal and Treatment Options

• Cryotherapy with liquid nitrogen is a common treatment for cutaneous warts, with a cure rate of 39% after 13 weeks 4.
• Topical salicylic acid application is another treatment option, with a cure rate of 24% after 13 weeks 4.
• A wait-and-see approach can also be effective, with a cure rate of 16% after 13 weeks 4.

Comparison of Treatment Options

• For common warts, cryotherapy is the most effective therapy, with a cure rate of 49% after 13 weeks 4.
• For plantar warts, there is no significant difference in effectiveness between cryotherapy, topical salicylic acid application, and a wait-and-see approach after 13 weeks 4.
• Imiquimod 5% cream combined with a keratolytic lotion can be an effective treatment for cutaneous warts in children, with a cure rate of 81.1% after 3 months 5.

Imiquimod as a Treatment Option

• Imiquimod is an immune response modifier that can be used to treat cutaneous warts, with a combined rate of complete response to therapy of 44% in immunocompetent patients 6.
• The efficacy of imiquimod in treating cutaneous warts has not been well established, and further studies are needed to determine its effectiveness and optimal treatment regimen 6.
• Imiquimod can be used safely in children with warts and is equally effective as cryotherapy in plantar warts 5.