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Warts -management

No single Rx is 100 % effective Most warts would resolve without treatment and several papers quote a 2 year period for children PCDS website mentions that new warts often resolve spontaneously -30 % within 10 weeks Other papers quite that in adults they may persist for 5-10 yrs It is safe to say that most warts would resolve spontaneously and no treatment has a very high success rate of 60 % to 70 % Asymptomatic warts in non-cosmetically sensitive areas may be left alone Majority of warts can be treated in primary care HPV has no cure Recurrence rates with most methods used for treatment is high

 

Not harmful Most may resolve without treatment Not all warts need treatment Warts are contagious That they do not cause scarring when they resolve Consider treatment if
○ painful
○ interference with function
○ cosmetic embarrassment
○ risk of malignancy Advice that every single treatment for warts is associated with failures Consider providing written information for e,g BAD leaflets ( find it under links for patients ) about prevention and management

 

Warts on face – refer dermatology referral if treatment is indicated Genital warts – consider GUM clinic referral Diagnostic uncertainty Patient is immunosuppressed Patient with diabetes or peripheral arterial disease – salicylic acid preparation have a warning that it is not suitable for this group due to the risk of damage to skin , nerves and tendons -risk of developing neuropathic ulcer , consider a referral to chiropody Warts which start to spread Extensive and large warts particularly if they are symptomatic or causing functional problems (e.g mosaic warts of the hand or feet ) Failure to respond following 3 months / repeated treatments ie recalcitrant warts Unusually severe or prolonged warts ( may be the first indication of lymphoma , HIV infection , immunodeficiency ) Significant psychological distress

 

Salicylic acid -keratolytic – ablates epidermal cells infected with HPV and softens hyperkeratotic epidermis ( chemical ablation and irritation) also thought to initiate an immune response often used first line -inexpensive , easy to use amd relatively safe avoid using on face due to risk of hypo or hyperpigmentation also not to be used
○ intertriginous or anogenital areas
○ diabetics or patients with impaired peripheral circulation
○ on moles , birthmarks
○ warts that
○ sensitivity to any ingredients
○ areas with open wound , irritated or erythematous skin or available in various strengths ranging from 15 to 50 % in either collodion or polyacrylic base plasters containing 40 % SA and ointments with 50 % SA are also available often combined with lactic acid which enhances the availability of salicylic acid from the dried collodion , it also has antiseptic and caustic properties SA is often combined with cryotherapy , pulsed dye-laser therapy , 5-fluorouracil , podophyllotoxin and cantharidin SA is the still the best treatment with evidence base.

 

advice to use daily does not require prescription and can be used at home soak the wart in warm water for a few minutes each day , pair with a file and then apply salicylic acid under occlusion advise to protect the healthy skin with either petroleum jelly or a plaster with hole cut in it SA can cause chemical burns once a week – to gently rub away the treated surface using an emery board or pumice stone no set ideal duration of treatment and most papers state that treatment may be continued for up to 3 months stop / interrupt use if erythema , pain or bleeding happens ( a mild erythema is normal ) most OTC products are SA paints which contain SA from 10 % to 26 % in either collodion or a polyacrylic base Plasters containing 40 % SA and ointments with 50 % SA are also available.

 

Cryotherapy- uses liquid nitrogen at – 196° ( destructive therapy ) can be applied using a cryo gun or cotton swabs may cause simple necrotic destruction of HPV-infected keratinocytes or possibly induce local inflammation conducive to development of an effective cell-mediated response variation in practice in relation to freeze times , mode of application and intervals may vary considerably reported cure rate vary widely

aerosols containing dimethyl ether and propane ( DMEP ) are available OTC ( ease of use but efficacy may be low ) cryotherapy is painful and blistering may occur blistering , infection , scarring , hypo or hyperpigmentation may happen.

 

Silver nitrate -inorganic salt classified as a caustic , anti-septic and astringent agent aim is to achieve biochemical and physical destruction of the virus , application instigates localised tissue irritation hence initiating an immune response to the virus available as stick/ pencil which needs to be moistened with water and applied directly to the wart for 1-2 minutes strengths from 75 % to 95 % are frequently used in clinical practice chemical cautery evidence based of use is not robust. 3-6 applications are usually enough evidence based of use is not robust can stain surrounding skin or clothing , chemical burns available OTC occasionally pigmented scars may develop.

 

Formaldehyde-virucidal and available commercially as a 0.7 % gel or a 3 % solution disrupts the upper layer of epidermal cells and possibly damaging the virions , can cause sensitization and should be avoided in patients with eczema and allergies for secondary care use.

 

Duct tape -involves application of duct tape the size of the wart and removal after a few days ( occlusive treatment ) mechanism how it works is unclear lacks evidence base ( Cochrane review did not find any evidence ) and cannot be recommended as sole treatment , may be tried in children for e.g who cannot tolerate SA or cryotherapy

 

Other topical-Retinoids -disrupt epidermal growth and differentiation affecting wart growth/ bulk- also potent immunomodulators ( skin dryness and irritation can 
happen ) , for use in secondary care. Both oral and topical have been employed for treatment of warts. Podophyllin – from plant Podophyllum peltatum ,used for anogenital warts ( can cause painful necrosis particularly of normal skin adjacent to the wart ) mechanism- antimitotic by binding to spindle during mitosis blocking cellular division. Less effective when used for skin warts ( secondary care use ) 5-Fluorouracil chemotherapeutic agent used in various cancers ( blocks DNA synthesis and damages dividing basal layer cells ) , available as 5 % cream for use up to 12 weeks ( can cause local irritation , moderate to severe pain during application , blistering and onycholysis in periungual regions ) Topical zinc cream ( Zinc sulfate )- can augment immune function and / or assist in skin repair via the polyclonal activation of lymphocytes , limited evidence available as 15 % to 40 % cream Glutaraldehyde -10 % solution or gel , it hardens the skin and makes pairing easy but can stain the skin brown and risk of cutaneous necrosis Cantharidin -blistering agent causes acantholysis . Blistering can cause mild discomfort and happens 24 hr following application ( secondary care ) Trichloracetic acid and monochloroacetic acid – caustic agents used to treat genital warts Cidofovir – nucleoside analogue of deoxycytidine monophosphate that inhibits DNA synthesis , induces DNA fragmentation , reduces epithelialization and enhances excoriation Imiquimod – exact mechanism not known but it is likely that topical 5 % works as an immunomodulator that may stimulate cytokines and modulate the immune response.

 

Treatment methods discussed are not exhaustive but described as you may be questioned about available methods , as a general rule Salicylic Acid remains the agent of choice with evidence base and established safety profile for use in primary care.

 

 

Plantar warts -evidence base is weak and although a wide variety of treatments are available none has been shown to be effective for all patients wait and watch approach can be successful in 30 % and it is widely quoted that in immunocompetent individuals most plantar warts would clear by 2 yrs plantar warts can grow deep into the tissue due to the constant pressure application to the sole ie they can cause local pain symptom a plantar wart is considered recalcitrant if it has lasted more than 6 months – they are usually more resistant to treatment ( definition of duration when a wart becomes recalcitrant can vary from few months to 2 yrs ) salicylic acid ( SA ) and cryotherapy with liquid nitrogen are the standard first line interventions epidermis of the plantar skin is thick -debridement of hyperkeratosis is important at home using an emery board or by a podiatrist other options include low level laser and surgical techniques as curettage and electrosurgery.

 

Warts in children-most would resolve spontaneously -are short lived and clear within a year or two Salicylic acid in concentrations from 15 % to 40 % as topical paints or ointments 
( BAD ) Salicylic acid with petrolatum Cryotherapy – poorly tolerated by children , needs frequent visit ( leading to absence from school ) Curettage and electrodessication with LA-warrants the patient to remain still which can be a problem with young patients


Anogenital warts ( AGW ) in children○ high risk of child sexual abuse
○ RCPCH quotes an estimated 31 % to 58 % risk of child sexual abuse in a child with genital warts , for children aged 4-8 yrs with AGW’s the positive predictive value for sexual abuse is 50 % and those > 8 yrs is 70 % ( Sinclair 2006 )
○ please be mindful that viral warts cannot be swabbed and the diagnosis is clinical unless histology is available
○ if in doubt seek help / discuss -same day
○ consider following child protection pathway to ensure safety / welfare – same day.

 

Management of anogenital warts in adults is not discussed here as most patients would seek help from specialized GUM clinics

  1. Lipke, Michelle M. “An armamentarium of wart treatments.” Clinical medicine & research vol. 4,4 (2006): 273-93. doi:10.3121/cmr.4.4.273
  2. Plantar warts: a persistently perplexing problem BPAC NZ https://bpac.org.nz/bpj/2014/december/plantar-warts.aspx

  3. Ockenfels, H.M. (2016), Therapeutic management of cutaneous and genital warts. JDDG: Journal der Deutschen Dermatologischen Gesellschaft, 14: 892-899. https://doi.org/10.1111/ddg.12838
  4. Plantar Warts: Epidemiology, Pathophysiology, and Clinical Management Dexter Jordan Witchey, MPAS, PA-C; Nichole Brianne Witchey, MPAS, PA-C;
    Michele Marie Roth-Kauffman, JD, MPAS, PA-C; Mark Kevin Kauffman, DO, MS  The Journal of the American Osteopathic Association February 2018 | Vol 118 | No. 2
  5. Warts and verrucae https://cks.nice.org.uk/topics/warts-verrucae/
  6. Guidelines for the management of cutaneous warts J.C.STERLING,* S.HANDFIELD-JONES,² P.M.HUDSON³ *Department of Dermatology, Addenbrooke’s Hospital. Cambridge, U.K.
    ²West Suffolk Hospital, Bury St Edmunds, U.K. ³Peterborough District Hospital, Peterborough, U.K. Accepted for publication DD MONTH 2000 British Journal of Dermatology 2001; 144: 4±11. https://www.bad.org.uk/library-media/documents/Warts_2001.pdf
  7. Al Aboud AM, Nigam PK. Wart. [Updated 2020 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431047/
  8. Viral warts DermNet NZ https://dermnetnz.org/topics/viral-wart/
  9. The management of plantar warts – a podiatric perspective Ivan Bristow, Jane Greenwood  Dermatological Nursing, 2009, Vol 8, No 3
  10. VerbovHow to manage warts 
  11. Warts and All: A Treatment Update for Verruca Vulgaris Peter A. Lio, MD 

  12. British Association of Dermatologists’ guidelines for the management of cutaneous warts 2014 J.C. Sterling,1 S. Gibbs,2 S.S. Haque Hussain,1 M.F. Mohd Mustapa3 and S.E. Handfield-Jones4 British Journal of Dermatology (2014) 171, pp696–712 https://www.bad.org.uk/library-media/documents/Warts_2014.pdf
  13. Salactol medicine compendium https://www.medicines.org.uk/emc/product/3766
  14. Paediatric Clinical Practice Guideline Royal Alexandria Children’s Hospital Ano-genital warts https://www.bsuh.nhs.uk/library/wp-content/uploads/sites/8/2020/10/Paediatric-guidelines-anogenital-warts-2020.pdf
  15. Treatment of Warts in Children: An Update JO – Actas Dermo-Sifiliográficas (English Edition) AU – Gerlero,P. AU – Hernández-Martín,Á. https://www.actasdermo.org/en-treatment-warts-in-children-an-articulo-S1578219016301329

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