Cutaneous warts treatment

Treatment options

Tips

• Warts are benign and self-limited in nature, scarring treatments should be avoided.
• Whatever method is used there will be failures and recurrences.
• It should be explained to patients that warts often require several treatment sessions.
• To avoid scarring, treatment should be conservative.
• Precautions should be taken to avoid inhalation of virus particles in the aerosol plume when laser or electrosurgical procedures are performed.

First line

• Duct tape occlusion
  • Continuous duct tape occlusion of common warts for up to 2 months.
• Topical 5-fluorouracil
  • 5‐fluorouracil (5‐FU) 5% cream carefully applied daily under occlusion for a month.
  • If use for periungual warts it may cause onycholysis.
  • A combination of 5% 5‐FU and 10% salicylic acid may be used with success.
  • 4 ml of 50 mg/mL 5FU + 1 ml mixture of 20 mg/mL (2%) lidocaine and 0.0125 mg/mL epinephrine mixed in a 5ml syringe injected weekly for up to 4 weeks.
  • The solution is injected intralesionally in multiple warts until blanching of the lesion occurred with insulin syringe.
  • Side effects inculde erythema, edema, hyperpigmentation, hypopigmentation, ulceration, necrosis, onycholysis, or scarring.
  • Pain and burning sensations also occurs at the site of injection.

• Retinoic acid
  • Tretinoin cream 0.05% used for plane warts.

• Cantharidin
  • Topical cantharidin application is painless , bloodless, and rapid, making it suitable for pediatric use. 
  • It can be reapplied every three weeks.
  • Used as montherapy or in combination with podophyllotoxin, and salicylic acid.
  • Cantharidin is applied to individual warts and then covered with tape. Blistering will occur within 2 to 24 hours, after which time the tape should be removed and the medication washed off with soap and water.

• Trichloroacetic acid
  • once-weekly application of 80% TCA solution with once-weekly.

• Vitamin D analogues
  • Maxacalcitol.
  • Combiantion of Maxacalcitol and salicylic acid.

• BCG vaccine paste
  • Once weekly for eight consecutive weeks.[link] 

Second line

• Cryotherapy
  • Cryotherapy is mainly used for warts in older children and adults and often avoided in young children.
  • Firstly, A surgical blade is used to debulk the wart before freezing..
  • Cryotherapy is applied until a rim of iced tissue (white discoloration) about 1 mm in width is seen in the normal skin surrounding the wart.
  • The freeze is continued for 5–30 s depending on the size and site of the wart.
  • Continuous or pulsed spray for between 5 and 20 s, depending on the size and thickness of the wart.
  • Continuous freezing over 25 s is more likely to leave scarring.
  • Treatment should be repeated every 3 weeks.
  • Excessive freezing times should be avoided over nerves, e.g on the sides of the fingers.
  • Pain is variable between patients( persist for many hours or even a few days).
  • Depigmentation may be a cosmetic concern in dark skinned patients.
  • If no response was detected after six sessions, try another modality.

• Laser
  • Pulsed dye laser.
  • Er : YAG
  • Nd : YAG
  • Carbon dioxide laser: for periungual and subungual warts unresponsive to other modalities.
• Local hyperthermia: 44°C/111°F for 30 minutes on days 1, 2, 3, 17 and 18.

• Surgery
  • It should be avoided since scarring may occurs and recurrences are frequent.
• Photodynamic therapy.

Third line (severe and recalcitrant)

• Podophyllotoxin
  • Mainly used for the treatment of ano‐genital warts.
  • Self-applied podophyllotoxin 0.5% solution twice a day for 3 days repeated weekly
  • Not to be used in children
  • Contraindicated in pregnancy
  • Side effects include: erythema and erosions.

• Imiquimod
  • Imiquimod 5% cream is used mainly for genital warts treatment.
  • Side effects include irritation, discomfort and occasionally erosion at the point of application with a small risk of causing vitiligo‐like depigmentation

• Topical immunotherapy
  • performed by clinicians
  • 0.5–4% DPCP at 3-week intervals

• Intralesional immunotherapy
  • Candida antigen: 0.3 ml candida antigen is injected into the largest wart at first visit and then every 3 weeks
  • MMR vaccine:
    • Prior sensitivity testing was done using a dose of 0.1mL via injection intradermally into the volar aspect of the left forearm.
    • The injected sites were examined after two weeks for immune response in the form of erythema or nodule formation. 
    • In sensitized patients, 0.5mL of MMR vaccine after reconstitution with distilled water was injected intradermally into their single largest wart.
    • Injections were given every two weeks for a total of five sessions.
  • PPD : 0.1-0.3 mL injected into the oldest and/or largest wart with 1-3 week intervals between sessions for a total of 6 injections.

• Interferon
• H2 receptor antagonists
  • Cimetidine :30–40 mg/kg/day for 3–4 months
  • Ranitidine: 300 mg twice daily.
• Zinc
  • Oral zinc sulphate :10 mg/kg/day.
  • Topical zinc sulphate 10% aqueous solution applied three times daily for 4 weeks for plane warts.

• Levamisole
  • 2.5–5 mg/kg/day for 3 consecutive days every 2 weeks for 4–5 months.

• Oral retinoids
  • Isotretinoin 0.5 mg/kg/day for 2 months used for treatment of plane warts.
  • low‐dose acitretin.
• Intralesional bleomycin
  • Bleomycin sulphate 0.25–1 mg/mL is injected up to three times to a maximum total dose of 4 mg.
  • Pain may persist for up to 2 days and is followed by tissue necrosis.
  • Reported complications include nail loss or dystrophy following periungual injections, Raynaud phenomenon in treated fingers and local pigmentation.
  • Treatment with bleomycin is not recommended for children, pregnant women, immunosuppressed patients, or patients with vascular disease because of systemic absorption.

• Cidofovir
  • intravenously (3–5 mg/kg as a single dose given every 1–2 weeks) for very severe warts and can also be injected intralesionally, diluted from 375 mg/mL to 15 mg/mL and injected monthly [193] or applied as a 1% cream.
  • Side effects, mainly seen with systemic administration, include nephrotoxicity, metabolic acidosis and bone marrow suppression.
  • Local application especially on mucosal surfaces can produce erosion and pain

• Psychological methods
  • Hypnosis

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