management

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Typically warts are benign infections that may persist for months, or even years, and then finally spontaneously resolve.

  • if the affected individual is immunocompetent, then an expectant approach to management is entirely acceptable (1)

Prevention

  • warts are contagious but the risk of transmission is low
  • children with warts should NOT be excluded from physical activities, but should take care to minimise transmission:
    • cover the wart with a waterproof plaster when swimming
    • wear flip-flops in communal showers
    • avoid sharing shoes, socks and towels
  • limit personal spread by:
    • avoiding scratching lesions
    • avoiding biting nails or sucking fingers that have warts
    • keeping feet dry and changing socks daily (2)

If the lesions are uncomfortable or interfere with function, or may be a major cosmetic bother and embarrassment (e.g. - when numerous or on sites such as the face) the following treatment modalities may be used:

  • topical treatment – intention is to physically or chemically ablate warts and to stimulate an immune response
    • salicylic acid (SA)
      • are the most common preparation used in the treatment of viral warts
        • SA paints 
          • most commonly used, over-the-counter product
          • contain SA at concentrations of between 10% and 26% in either a collodion or a polyacrylic base
          • it is recommended that lesions should be abraded or pared down and/or soaked prior to application. Care should be taken when paring to avoid abrading the surrounding normal skin, as this may spread the disease
        • plasters – contains 40% SA
        • ointments – contains 60% SA
      • at high concentrations it is an irritant and is thought to work by promoting exfoliation of epidermal cells
        • additionally, these effects may activate host immunity an induce an immune response against warts
      • patients should receive clear instruction on use since compliance is important
      • suitable for any cutaneous site except the face
      • optimum duration of treatment is unknown, at first instance, 12 weeks of treatment should be considered before considering other types of treatmnet 
    • cryotherapy
      • liquid nitrogen, delivered by cryospray or cotton bud, is the most commonly used method
      • usually carried out in the secondary care or specialist community clinics  due to the difficulty in obtaining and storing liquid nitrogen in a primary care setting
      • over the counter products (e.g. - dimethyl ether and propane) may be used for “freezing” warts, not effective when compared to liquid nitrogen since these can only achieve temperatures of around −57°C compared with −196°C
      • complications - pain, hypopigmentation or hyperpigmentation, and blistering. 
    • combination therapy - cryotherapy and SA (1,3)

Other treatments used in secondary care include:

  • immunomodulatory agents
    • Imiquimod
    • Diphencyprone 
  • anti mitotic agents - Bleomycin
  • curettage and cautery
  • laser abalation
  • photodynamic therapy (1,3)

The British Association of Dermatologists (BAD) guidelines do not recommend the following treatment methods due to insufficient evidence:

  • citric acid
  • formic acid
  • H2 receptor antagonists
  • herbal treatment
  • hypnotherapy
  • intralesional immunotherapy
  • occlusotherapy (e.g. duct tape)
  • retinoids, topical
  • silver nitrate
  • zinc oxide or Zinc sulphate (3)

Reference:

Last edited 11/2018

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