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

From the Guidelines

Cryotherapy with liquid nitrogen is the most effective method for wart removal, with repeat applications every 1–2 weeks as needed. This method is recommended due to its high efficacy and relatively low risk of complications when performed by a trained healthcare provider 1.

Provider-Administered Treatments

Other provider-administered treatments include:

• Podophyllin resin 10%–25% in a compound tincture of benzoin
• Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%–90%
• Surgical removal either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery

Patient-Applied Treatments

Patient-applied treatments, such as podofilox, imiquimod, and sinecatechin ointment, are also available options.

• Podofilox solution should be applied with a cotton swab, or podofilox gel with a finger, to visible genital warts twice a day for 3 days, followed by 4 days of no therapy
• Imiquimod cream should be applied once daily at bedtime, three times a week for up to 16 weeks
• Sinecatechin ointment should be applied three times daily until complete clearance of warts, for a maximum of 16 weeks

It is essential to note that the choice of treatment depends on the location, size, and number of warts, as well as the patient's overall health and preferences. Cryotherapy remains the most effective and recommended treatment option, but patient-applied treatments can be a suitable alternative for some patients 1.

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. Lesions that do not respond to therapy should be carefully re-evaluated and management reconsidered; the safety and efficacy of a repeat course of Imiquimod Cream treatment have not been established 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.

The Imiquimod Cream can be used for wart removal.

• The cream should be applied to the wart area and rubbed in until the cream is no longer visible.
• Local skin reactions are common, and a rest period 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, a biopsy or other alternative intervention should be considered.
• The safety and efficacy of a repeat course of Imiquimod Cream treatment have not been established 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.

The Podofilox Topical Solution can also be used for wart removal.

• The solution should be applied to the wart area with an applicator, using the minimum amount necessary to cover the lesion.
• The treatment cycle can 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 3.

From the Research

Wart Removal Treatments

• There are various treatments available for wart removal, including medical and destructive therapeutic options 4.
• The effectiveness of these treatments varies, and none is uniformly effective or virucidal 4.
• First-line therapy includes medical treatments such as salicylic acid, silver nitrate, and glutaraldehyde, which are useful for treating a single wart or a few small common warts of short duration 4.

Cryotherapy and Salicylic Acid

• Cryotherapy and salicylic acid used in combination have been shown to have significantly higher remission rates than other treatments 4.
• Cryotherapy has been found to be effective in treating warts, particularly on the hands, with a risk ratio of 2.67 compared to placebo 5.
• Salicylic acid has also been shown to be effective, with a risk ratio of 1.56 compared to placebo, and is more effective for hands than feet 5.

Other Treatments

• Imiquimod 5% cream has been found to be effective in treating warts, particularly in combination with salicylic acid, with a cure rate of 81.1% in one study 6.
• Dinitrochlorobenzene has been found to be more than twice as effective as placebo in treating warts, with a risk ratio of 2.12 5.
• Clear duct tape has not been shown to be effective in treating warts, with a risk ratio of 1.43 compared to placebo 5.

Cost-Effectiveness

• Salicylic acid and cryotherapy have been found to be cost-effective treatments for warts, with incremental cost-effectiveness ratios of 2.20 pound/% cured and 1.95-7.06 pound/% cured, respectively 7.
• Over-the-counter treatments, such as salicylic acid and cryotherapy, have been found to be the most cost-effective options, with incremental cost-effectiveness ratios ranging from 0.22-1.12 pound/% cured 7.