What are the treatment options for a wart?

Treatment Options for Warts

For non-genital cutaneous warts, start with salicylic acid after paring/debriding the wart, and if this fails after 3-4 months, proceed to cryotherapy with liquid nitrogen every 1-2 weeks; for genital warts, use patient-applied podofilox 0.5% or imiquimod 5% cream as first-line therapy, or provider-applied cryotherapy if patient-applied options are unsuitable. 1, 2, 3

Non-Genital Cutaneous Warts

First-Line: Salicylic Acid

• Always pare or debride the wart before each salicylic acid application to remove the thick keratin layer that blocks treatment penetration. 1
• Avoid damaging surrounding normal skin during paring to prevent spreading HPV infection to adjacent areas. 1
• Continue treatment for a minimum of 3-4 months before declaring treatment failure. 4
• Approximately 30% of warts resolve spontaneously within 6 months, making watchful waiting reasonable for new warts if the patient is not bothered by them. 4

Second-Line: Cryotherapy

• Apply cryotherapy with liquid nitrogen every 1-2 weeks, continuing for 3-4 months minimum before declaring treatment failure. 1, 4
• Cryotherapy achieves cure rates of 50-70% after three to four treatments. 4
• The combination of cryotherapy and salicylic acid produces the highest remission rates (89.2% eradication rate), significantly superior to either treatment alone. 4, 5
• Local anesthesia (topical or injected) may facilitate therapy when the area of warts is large. 1
• Proper training is essential—over-treatment or under-treatment leads to poor efficacy or increased complications. 6

Third-Line: Surgical Removal for Recalcitrant Cases

• Surgical removal via tangential excision, curettage, or electrosurgery offers 93% efficacy with 29% recurrence rate and eliminates warts in a single visit. 1, 7
• This approach is particularly beneficial for patients with a large number or area of warts. 1
• The procedure creates a wound extending only into the upper dermis since most warts are exophytic. 1
• Hemostasis can be achieved with an electrosurgical unit or chemical styptic (aluminum chloride solution). 6
• CO2 laser therapy should be reserved for extensive, recalcitrant cases that have failed first-line treatments, with clearance rates of 67-75% but significant side effects including bleeding, pain, reduced function lasting weeks, and risk of scarring. 1

Genital Warts

Patient-Applied First-Line Options

Podofilox 0.5% Solution or Gel:

• Apply twice daily (every 12 hours) for 3 consecutive days, then withhold for 4 consecutive days. 3
• This one-week cycle may be repeated up to four times until there is no visible wart tissue. 3
• Treatment should be limited to less than 10 cm² of wart tissue and no more than 0.5 mL per day. 3
• Patients must be able to identify and reach warts to be treated. 6
• Most patients experience mild to moderate pain or local irritation after treatment. 6

Imiquimod 5% Cream:

• Apply 3 times per week (e.g., Monday, Wednesday, Friday) prior to normal sleeping hours. 2
• Leave on skin for 6-10 hours, then remove by washing with mild soap and water. 2
• Continue treatment until total clearance of genital/perianal warts or for a maximum of 16 weeks. 2
• Complete clearance occurs in 37-50% of immunocompetent patients, with partial clearance (≥50% reduction) in 76% of recipients. 8
• Female patients experience higher rates of complete clearance than males. 8
• Recurrence occurs in 13-19% of patients who achieve complete clearance. 8
• Local inflammatory reactions are common but usually mild to moderate. 6

Provider-Applied First-Line Options

Cryotherapy with Liquid Nitrogen:

• Destroys warts by thermal-induced cytolysis. 6
• Pain after application, followed by necrosis and sometimes blistering, is common. 6
• Requires proper training to avoid over- or under-treatment. 6

Trichloroacetic Acid (TCA) or Bichloroacetic Acid (BCA) 80-90%:

• Apply sparingly only to warts and allow to dry until white "frosting" develops. 6
• TCA has low viscosity and can spread rapidly if applied excessively, damaging adjacent tissues. 6
• If pain is intense, neutralize with soap or sodium bicarbonate. 6
• Can be repeated weekly if necessary. 6

Podophyllin Resin 10-25%:

• Apply a thin layer to warts and allow to air dry before contact with clothing. 6
• Over-application or failure to air dry can result in local irritation. 6
• Preparations differ in concentration of active components and contaminants, with unknown shelf life and stability. 6

Second-Line: Surgical Therapy

• Eliminates warts at a single visit but requires substantial clinical training, additional equipment, and longer office visit. 6
• After local anesthesia, warts can be destroyed by electrocautery (no additional hemostasis required), tangential excision with scissors or scalpel, or curettage. 6
• Most beneficial for patients with a large number or area of genital warts. 6
• Carbon dioxide laser may be useful for extensive warts or intraurethral warts, particularly for those who have not responded to other treatments. 6

Alternative Regimens (Not Recommended for Routine Use)

• Intralesional interferon has efficacy and recurrence rates comparable to other modalities but is not recommended for routine use due to inconvenient routes of administration, frequent office visits, and high frequency of systemic adverse effects. 6
• Systemic interferon is not effective. 6

Location-Specific Considerations

Cervical Warts:

• For women with exophytic cervical warts, high-grade squamous intraepithelial lesions (SIL) must be excluded before treatment is initiated. 6
• Management should include consultation with a specialist. 6

Vaginal Warts:

• Cryotherapy with liquid nitrogen (cryoprobe not recommended due to risk of vaginal perforation and fistula formation). 6
• TCA or BCA 80-90% applied only to warts, repeated weekly if necessary. 6

Urethral Meatus Warts:

• Cryotherapy with liquid nitrogen or podophyllin 10-25% in compound tincture of benzoin applied weekly if necessary. 6

Anal Warts:

• Cryotherapy with liquid nitrogen, TCA or BCA 80-90%, or surgical removal. 6

Critical Pitfalls to Avoid

• Do not use treatments designed for genital warts on non-genital cutaneous warts, as these are specifically indicated for genital lesions only. 1
• Plantar warts consistently show the poorest outcomes compared to warts at other body sites due to thick cornified layer preventing adequate treatment penetration. 1, 4
• Ensure adequate treatment duration (3-4 months minimum) before declaring treatment failure—premature treatment changes reduce overall success rates. 1, 4
• Recurrence is common with all wart treatments (approximately 25-30%), likely due to reactivation of subclinical HPV infection rather than reinfection. 4
• More aggressive treatment regimens increase efficacy but also increase pain and risk of scarring. 1
• Combination therapy (simultaneous use of two or more modalities on the same wart) may increase complications without improving efficacy, though data are limited. 6