Wart Treatment in Children
Initial Management Strategy
For children under 5 years old, watchful waiting without treatment is the most appropriate approach, as warts typically resolve spontaneously in 65% by 2 years and 80% by 4 years regardless of treatment. 1, 2, 3 Treatment should only be initiated if the wart causes significant pain or functional impairment, as painful treatments are poorly tolerated in young children. 1, 2
For children 5 years and older with symptomatic warts, proceed with active treatment using the algorithmic approach below. 2
First-Line Treatment: Topical Salicylic Acid
Salicylic acid 15-26% applied daily for 3-4 months is the first-line treatment for warts in children, with the strongest evidence (Level A recommendation) for safety and efficacy. 1, 2, 4
Application Protocol:
- Soak the wart in warm water for 5-10 minutes to soften thickened skin before each treatment. 2, 5
- Pare down the wart using a disposable emery board, pumice stone, or callus file, removing only the white, thickened keratin layer—stop if pinpoint bleeding occurs. 2, 5
- Apply salicylic acid daily after paring and cover with occlusion (bandage or tape) to enhance penetration. 2, 4, 5
- Discard the paring tool after use or dedicate it solely to the wart to prevent spreading infection. 5
- Continue treatment for the full 3-4 months before declaring failure—premature discontinuation is a common pitfall. 2, 5
Critical Safety Precautions:
- Limit the treatment area to avoid excessive systemic absorption and salicylate toxicity, particularly in children under 12 years. 2, 4
- Monitor for signs of salicylate toxicity: tinnitus, nausea, vomiting, hyperventilation, and confusion. 2, 4
- Avoid use during chickenpox or influenza-like illnesses due to Reye syndrome risk. 2, 4
- If excessive drying or irritation occurs, apply a bland cream or lotion and reduce application frequency. 6
Second-Line Treatment: Cryotherapy
If salicylic acid shows no improvement after 3 months of proper use, switch to cryotherapy with liquid nitrogen. 2, 4, 5
Cryotherapy Protocol:
- Freeze the wart for 15-30 seconds per treatment using liquid nitrogen or cryoprobe. 2, 5
- Repeat every 2-4 weeks (fortnightly) for at least 3 months or up to six treatments before declaring failure. 1, 2, 4
- Use gentle freezing in young children to minimize pain and blistering risk. 1, 4
Evidence Comparison:
While cryotherapy is more effective than salicylic acid, it carries a higher risk of pain and blistering, particularly problematic in children. 7 Combination therapy with salicylic acid and cryotherapy may be more effective but increases adverse effects—reserve this for recalcitrant cases only. 1, 4
Third-Line Treatments for Resistant Warts
When both salicylic acid and cryotherapy fail after adequate trials, consider these options in order of preference:
Intralesional Immunotherapy (Preferred):
- Candida antigen injection has shown 72% complete clearance within 8 weeks and is increasingly favored for resistant warts. 2
Topical Immunotherapy:
- Diphencyprone (DPC) or squaric acid dibutyl ester (SADBE) applied at appropriate strength from twice weekly to every 3 weeks for 3-6 months (Level C evidence). 2, 5
Other Options:
- Intralesional bleomycin (0.1-1 mg/mL solution injected after local anesthesia, one to three treatments)—note this is painful during and after treatment (Level C evidence). 2, 5
- Pulsed dye laser (7-10 J/cm² after paring/salicylic acid pretreatment, two to four treatments typically needed, Level C evidence). 2, 5
- Additional alternatives include cidofovir, formaldehyde, glutaraldehyde, or silver nitrate. 1, 4
Special Considerations by Location
Plantar Warts:
- Cure rates are lower due to thicker cornified layer reducing treatment penetration. 1, 2
- Use higher concentrations of salicylic acid (15-40%) with more aggressive paring, but avoid damaging surrounding skin to prevent spreading infection. 1
Plane Warts (Face/Hands):
- Use lower concentrations of salicylic acid (2-10% cream/ointment or cautious 12-17% paint without occlusion) to avoid scarring. 1, 5
- Apply gentler cryotherapy with milder freeze. 1, 5
- Destructive and caustic agents should be used with extreme care at these cosmetically sensitive sites. 1
Facial/Filiform Warts:
- Cryotherapy, curettage, or hyfrecation may be more appropriate than topical treatments. 1, 5
- Avoid damaging adjacent skin in beard areas, as this spreads infection similar to shaving. 1
Common Pitfalls to Avoid
- Do not stop treatment prematurely—salicylic acid requires 3-4 months and cryotherapy needs at least 3 months or six treatments before declaring failure. 5
- Avoid aggressive paring that damages surrounding skin, as this spreads the viral infection. 1, 5
- Do not use multiple destructive modalities simultaneously in initial treatment—this increases scarring risk without proven benefit. 5
- Do not treat asymptomatic warts aggressively in children under 5—the natural history favors spontaneous resolution. 2, 4, 3
Prognostic Factors
- Warts with plantar location take longer to resolve due to thicker skin reducing treatment penetration. 1, 2
- Children with a history of childhood infections or warts at more than one anatomic site have significantly greater risk of longer time to resolution. 3
- Treatment is more successful for warts that are small and have been present less than 1 year. 1