Kennebec Region Health Alliance

Authors: Jonathan Karnes, MD, Jill Colvin, MD, MDFMR Dermatology Services
2.12.16

Treatment Summary: Cutaneous warts are common in all age groups and often resolve spontaneously. There are many treatments for warts. No known treatment has greater than 60-70% clearance rate for a solitary wart over 6 months follow up. Some treatments can cause significant pain and morbidity. In general for the treatment of warts on non-facial and non-genital skin, we recommend a 4-6 month trial, of watchful waiting and expectant management may be a reasonable option for any wart not causing pain.

1. Discuss realistic expectations for treatment goals with patient before treatment.
   1. WARTS ARE STUBBORN AND NO TREATMENT RELIABLY MAKES A WART GO AWAY WITH ONE TREATMENT; MANY MONTHS OF TREATMENT ARE TYPICALLY NECESSARY. With no treatment an individual wart will resolve on average within 2 years.
2. Application of over the counter 17% salicylic acid applied every 24 hours with or without occlusion for at least 12 weeks should be considered and has as good or better efficacy than any other treatment reported. For acral thick skinned sites (palms and soles) 40% salicylic acid plaster under occlusion with duct tape nightly for at least 12 weeks may prove more efficacious than 17% salicylic acid products.
3. If salicylic acid therapies are unsuccessful, cryotherapy in the office with liquid nitrogen is a good second line therapy. A 10-30 second freeze time is often necessary to achieve reported efficacy. This can be done with either a spray canister or a cotton tipped applicator dipped in nitrogen. Two cycles of freezing separated by a thawing cycle increases the effectiveness slightly. This may be repeated every 2-3 weeks ideally until the wart is cleared. Cryotherapy is rarely appropriate for young children and may be poorly tolerated even by some adults because of the degree of post therapy pain which lasts for several minutes.
   
   1. The American Family Physician review article noted below is a good resource for more detail regarding cryotherapy. MDFMR Dermatology periodically offers a procedure teaching-lab for cryotherapy during the FMR Dermatology Teaching Blocks.
      
      Multiple other treatments have been tried in the medical literature but are not FDA approved including intralesional candida antigen, topical fluorouracil, imiquimod, cantharidin, podophyllin, PDT, LASER, curettage, excision, and many others have case reports in the literature.
   2. PDT, LASER, AND BLEOMYCIN ARE NOT OFFERED at MDFMR Dermatology at this time.

See attached patient educational handouts for the treatments outlined above.

We reviewed these resources in making this guideline:
Sterling JC, Gibbs S, Hussain SH. British Association of Dermatologists' guidelines for the management of cutaneous warts 2014. British Journal of Dermatology. 2014;171: 696-712.
Mulhem E, Pinelis S. Treatment of nongenital cutaneous warts. American family physician. 2011;84(3):288-293.

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