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Management

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

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:


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