What is the recommended treatment for a patient with a filiform wart on the scalp?

Treatment of Filiform Warts on the Scalp

For filiform warts on the scalp, surgical removal by tangential scissor excision, shave excision, curettage, or electrosurgery is the most appropriate first-line treatment, as these pedunculated lesions are anatomically suited for immediate physical destruction rather than prolonged topical therapy. 1

Why Surgical Approaches Are Preferred for Filiform Warts

Filiform warts are finger-like, pedunculated projections that differ significantly from flat or common warts in their morphology. 2 The scalp location combined with the filiform morphology makes these lesions:

• Difficult to treat with topical agents - The hair-bearing scalp prevents effective application and occlusion of topical preparations like salicylic acid, which require daily application after paring and work best on flat surfaces 3
• Ideal candidates for immediate removal - Their pedunculated structure allows for simple tangential excision at the base with minimal tissue damage 1
• Best treated with single-visit destruction - Surgical therapy eliminates warts in one visit, avoiding the 3-6 month treatment courses required for topical agents 4, 5

Recommended Surgical Options (Provider-Administered)

Primary surgical methods include: 1

• Tangential scissor excision - Simple snipping at the base of the pedunculated lesion
• Tangential shave excision - Using a scalpel to shave the wart flush with the skin surface
• Curettage - Scraping after focal preparation
• Electrosurgery - Electrocautery provides simultaneous hemostasis, though depth must be controlled to prevent scarring 1

Alternative Provider-Administered Options

If surgical removal is not feasible or declined:

• Cryotherapy with liquid nitrogen applied every 1-2 weeks, though this requires multiple visits and proper training to avoid over- or under-treatment 1, 6
• Trichloroacetic acid (TCA) 80-90% applied sparingly only to the wart until white "frosting" develops, repeated weekly if necessary 1, 3

Critical Scalp-Specific Considerations

Important caveats for scalp treatment:

• Hair makes topical therapy impractical - Salicylic acid (the evidence-based first-line for most warts) requires daily application after paring, which is nearly impossible through hair 3, 7
• Avoid podophyllin on the scalp - This resin must air-dry before contact with clothing and has variable stability, making it unsuitable for hair-bearing areas 1
• Scarring risk is lower with controlled technique - Electrocautery depth must be controlled to prevent permanent alopecia or hypertrophic scarring 1
• Filiform warts respond poorly to cryotherapy without blister induction - One study specifically notes that filiform warts are treated with cryotherapy without blister induction, which may reduce efficacy 6

What NOT to Use

Contraindicated or impractical options:

• Patient-applied therapies (podofilox, imiquimod) - These require the patient to identify and reach warts, apply precisely, and maintain treatment schedules that are impractical on the scalp 1
• Salicylic acid paints - While first-line for most warts, the scalp location with hair makes application and the required paring/debridement extremely difficult 3, 4

Expected Outcomes

• Surgical removal typically eliminates warts in a single visit with proper technique 1
• Recurrence rates are 21-39% regardless of modality because treatment removes visible warts but does not eradicate HPV 4
• Scarring and hypopigmentation are possible with any ablative treatment, though uncommon with proper technique 1