What are the treatment options for verruca (warts)?

From the Guidelines

Warts can be effectively treated with salicylic acid or cryotherapy, depending on their type and location, with the goal of minimizing morbidity, mortality, and improving quality of life. When considering treatment options, it's essential to prioritize the most recent and highest quality study, which in this case is the British Association of Dermatologists' guidelines for the management of cutaneous warts 2014 1. According to these guidelines, for plantar warts, salicylic acid (15–40%) topical paints or ointments, or cryotherapy, fortnightly for 3–4 months, are recommended treatment options. For plane warts, salicylic acid cream/ointment 2–10% or cautious use of salicylic acid paint, 12–17%, used without occlusion, and cryotherapy with a milder freeze, are suggested. In the case of facial warts, cryotherapy, curettage, or hyfrecation can be used, while for warts in children, salicylic acid (15–40%) topical paints or ointments and gentle cryotherapy are preferred. For immunosuppressed patients, standard treatments with paring, abrasive agents, salicylic acid, and destructive methods can help reduce wart bulk, but care must be taken to avoid damaging surrounding skin. It's also important to note that warts are caused by human papillomavirus (HPV) infections in the skin, and treatments focus on removing infected tissue or stimulating the immune system to fight the virus, as mentioned in the guidelines 1. In terms of specific treatment regimens, the guidelines recommend that combination treatments, such as salicylic acid and cryotherapy, can be undertaken, but care is needed with worse side-effects 1. Additionally, other treatments, such as dithranol, 5-FU, formaldehyde, glutaraldehyde, hyperthermia, laser, PDT, podophyllotoxin, and topical immunotherapy, may be considered, but their effectiveness and potential side-effects should be carefully evaluated 1. Overall, the treatment of warts should be individualized, taking into account the type and location of the wart, as well as the patient's overall health and preferences, with the goal of minimizing morbidity, mortality, and improving quality of life. Some key points to consider when treating warts include:

• The importance of avoiding damage to surrounding skin, particularly in sensitive areas such as the face and genital area
• The need for careful consideration of treatment options in immunosuppressed patients
• The potential for combination treatments to be more effective, but also more likely to cause side-effects
• The importance of patient education and follow-up to ensure effective treatment and minimize the risk of complications. It's worth noting that while the 1998 guidelines for treatment of sexually transmitted diseases 1 provide some information on the treatment of genital warts, the more recent British Association of Dermatologists' guidelines 1 provide more comprehensive and up-to-date recommendations for the treatment of cutaneous warts.

From the FDA Drug Label

For Dermatologic Use: Salicylic Acid 6% is a topical aid in the removal of excessive keratin in hyperkeratotic skin disorders including verrucae, and the various ichthyoses (vulgaris, sex-linked and lamellar), keratosis palmaris and plantaris keratosis pilaris, pityriasis rubra pilaris, and psoriasis (including body, scalp, palms and soles). For Podiatric Use: Salicylic Acid 6% is a topical aid in the removal of excessive keratin on dorsal and plantar hyperkeratotic lesions. Topical preparations of 6% salicylic acid have been reported to be useful adjunctive therapy for verrucae plantares.

Salicylic acid is used as a topical aid in the removal of warts (verrucae). The treatment is used for hyperkeratotic skin disorders, including verrucae plantares. 2

From the Research

Warts Treatment Options

• There are various treatment options available for warts, including medical and destructive therapies 3.
• Salicylic acid, silver nitrate, and glutaraldehyde are considered first-line therapies for treating single or few small common warts of short duration (less than 1 year) 3.
• Cryotherapy may be considered as second-line therapy if first-line treatments have failed or are contraindicated 3.
• For recurrent or difficult-to-treat lesions, third-line therapy includes alternative therapeutic options such as topical, intralesional, systemic, and physical destruction, which are generally off-label and have drawbacks or adverse effects 3.

Efficacy of Treatment Options

• Salicylic acid and cryotherapy have been shown to be effective in treating cutaneous warts, with significantly higher remission rates when used in combination 3, 4.
• Imiquimod 5% cream has been shown to be effective in treating cutaneous warts, especially when combined with salicylic acid, and may be a viable option for children 5, 6.
• Cryotherapy has been shown to be effective in treating hand warts, but its effectiveness for foot warts is less clear 4.
• Dinitrochlorobenzene has been shown to be more than twice as effective as placebo in treating cutaneous warts 4.

Treatment Considerations

• Spontaneous healing of warts should be considered, and patients should be followed up for at least six months to one year before initiating treatment 7.
• The choice of treatment should be based on the individual patient's needs and the specific type of wart being treated 3, 4.
• Adverse effects, such as pain, blistering, and scarring, should be considered when selecting a treatment option 4.