Wart (Verruca) Treatment

CHAPTER 42 Wart (Verruca) Treatment*



Lori Oswald, John L. Pfenninger




Warts are a disease of antiquity. They have no regard for class or social status. They do not discriminate by race or color. There is an equal political distribution between Republicans and Democrats. They are annoying, sometimes disfiguring and painful, and to the angst of patient and physician, they frequently recur. With ardent attempts to rid the pest by heating, freezing, burning, cutting and electrifying, treatment has induced as much anxiety as the disease itself. But the physician persists.


William C. Everts, DO


Verrucae vulgaris (warts) are caused by the human papillomavirus (HPV). There are over 100 individual types and they are identified by numbers. Common warts are caused by types 1, 2, 4, 7, 27, 29, and 57; flat (planar) warts, by types 3, 10, 28, and 49; and plantar warts, by types 1, 2, and 4. Another series of HPV cause cervical dysplasia and condylomata. Most verruca vulgaris lesions form after a latent period of weeks to several months. The peak incidence occurs in late childhood and adolescence.


HPV causes numerous epithelial cancers. Cervical dysplasia and cervical cancer are the most commonly recognized types. However, 31% of squamous cell carcinomas and 36% of basal cell carcinomas of the skin contain HPV in nonimmunosuppressed patients. In immunosuppressed patients, 65% of squamous cell carcinomas and 60% of basal cell carcinomas contain HPV. As a result, treatment becomes more than just a cosmetic issue.


Warts have the following various presentations:


• Flat (planar)

• Filiform (small, fine, elongated lesions)

• Mosaic (a cluster of warts that fuse together)

• Verruca vulgaris, including periungual (“common wart”)

• Plantar

• Genital/anal wart (condylomata acuminata)

• Laryngeal papillomatosis


Differential Diagnosis



• Actinic keratosis

• Seborrheic keratosis

• Nevus

• Molluscum contagiosum

• Callus

• Corn

• Nonspecific papule

• Cutaneous dysplasia

It can be difficult to differentiate the true nature of a plantar lesion. Hypertrophic callus buildup makes identification confusing. The tell-tale sign of a plantar wart is that, as the callus is pared away, the practitioner sees small, punctate sites of bleeding. This is nearly pathognomonic for HPV disease. Biopsies can be obtained when the diagnosis remains unclear.



Indications for Treatment



• Pain

• Bleeding

• Recurrent trauma

• Lack of spontaneous resolution

• Psychosocial sequelae

• Employment repercussions (e.g., waitress)

• Rapid growth or multiplication

• Concerns regarding transmission

• Persistence as a possible cause of malignancy

A large number of verrucae do not resolve spontaneously. A longitudinal study concluded that only 40% of patients cleared their warts over a 2-year follow-up. HPV can remain dormant for long periods, then suddenly grow rapidly or multiply. With any treatment, the role of the immune system should not be underestimated. Induced inflammation from whatever treatment modality is used may finally trigger the immune system to recognize and then resolve the virus.


The virus itself is never totally eliminated. Rather, the immune system merely keeps it in remission, much like herpes. The virus can recur with any immunosuppressed state at any time during the patient’s life. The goal of treatment is to eradicate active disease, not to eliminate the virus itself.



Contraindications



• Lack of compliance

• Cellulitis

• Allergy to treatment modality

• Ambiguous diagnosis

• Bleomycin in the very young (relative)


Treatment


See Box 42-1 and Figure 42-1.



Box 42-1 Modalities for Treating Warts (Verruca Vulgaris)



General guidelines (maintaining healthy immune system)
Eating a diet high in fruits and vegetables

Taking vitamins with folic acid (may supplement folic acid up to 1 mg)

Avoiding smoking and secondhand smoke

Avoiding any immunosuppression when possible

Expectant observation

Hypnosis

Chemicals: topical
Over-the-counter medication (usually an acid preparation)

Topical salicylic acid 17%–40%

Formalin

Cantharidin (Cantharone) 0.7% collodion solution

Trichloroacetic acid

Bichloracetic acid

Tretinoin (Retin-A 0.05% solution, or 0.025%, 0.05%, or 0.1% cream)

5-Fluorouracil (Efudex, Fluoroplex) 5% cream

Imiquimod (Aldara)

Podofilox (Condylox)

Silver nitrate

Chemicals: oral
Cimetidine (Tagamet) 20–40 mg/kg/day (especially in pediatric patients)

Zinc sulfate 10 mg/kg to maximum of 600 mg/day (three divided doses, 2 mo maximum)

Chemicals: injection
Candida antigen (Candin) 1 : 500 solution or generic 1 : 1000 solution

Bleomycin (Blenoxane) 15-U vial

Interferon

Mechanical
Tape occlusion

Cryotherapy
Liquid nitrogen (−196° C)

Nitrous oxide (−89° C)

Carbon dioxide (−78° C)

Tetrafluoroethane (−47° C/−70° C): MediFrig, Verruca Freeze

Dimethyl ether/propane (−29° C/−55° C): Histofreezer, Compound-W, Wartner, Dr. Scholl’s

Electrodesiccation and curettage

Electrocautery (ball electrode)

Laser

Infrared coagulator (IRC)

Radiofrequency loop removal

Excision (discouraged)

Also see Chapter 155, Treatment of Noncervical Condylomata Acuminata.


image

Figure 42-1 Selection of modalities for treating verrucae. At each visit, reinforce general guidelines. At times, especially with extensive lesions, bleomycin and Candida antigen can be injected at the same visit (use separate syringes). Candida and bleomycin may need to be used more than three times. As long as progress is being made, there is no need to change treatment. OTC, over the counter.



General


Transmission of HPV occurs by direct person-to-person contact or, possibly (and rarely), from fomites. The patient may also cause autoinoculation of verruca vulgaris by scratching, shaving, or traumatizing the skin. It is important to enhance the immune system as much as possible during the treatment of all wart manifestations. Smoking is known to increase the growth potential and the persistence of warts on the cervix. Smoking reduces the cells of Langerhans in the skin in general and subsequently decreases all immunity. The patient must be advised to stop smoking (if applicable). Illicit drugs have been known to suppress the immune system and they, too, should be avoided. On the other hand, various vitamins (e.g., folic acid) have been shown to play a beneficial role in suppressing HPV. Subsequently, consider using a good multivitamin with minerals to maximize immune system capabilities. The patient should also be instructed to eat a diet that includes five helpings of fruits and vegetables a day to optimize immune function. Medications such as steroids that suppress immunity should be limited, if at all possible.


Treatment of verrucae in patients who are pregnant, have had organ transplants, are immunosuppressed as a result of diseases such as acquired immunodeficiency syndrome, or are taking immunosuppressants of any sort is difficult. Patients should be made aware that the success rate in such cases is poor.


Research into the efficacy of various treatments for warts is difficult. Some studies have shown that even hypnosis can resolve warts. Many folktales carry the belief that banana peels, raw potatoes, cerumen, spider webs, and other items resolve warts. Spontaneous resolution is always possible and often occurs for no apparent reason.


Many physicians recommend expectant observation. An old maxim states that “wart” patients should not be referred to a physician friend for treatment because it will generally make the physician look bad! Anyone who has treated warts can become frustrated in dealing with them. Not only can they persist, but they may indeed multiply. Frequently, treatment of a single wart with a modality such as cryotherapy or cautery will result in a ring of warts around the area that was frozen or burned. The simple common wart has indeed humbled the best clinicians. Subsequently, many again recommend simple observation.


Warts have no “roots” and are completely epidermal lesions. Treatment ideally should not cause scarring. There is no communication between warts—no “mother wart!” However, treatment of a single wart or some of the warts can lead to resolution of all the warts because of immune activation. Obtaining patient compliance for any regimen is often difficult, and home remedies frequently fail owing to lack of consistency in applying the treatment. It is not uncommon for a physician to have to treat a lesion(s) four or more times to resolve it.



Chemicals: Over-the-Counter Medications


Numerous over-the-counter (OTC) medications, usually mild acids in liquid form, are available for the treatment of warts. These include Compound-W, Mediplast, Trans-Ver-Sal, Occlusal, Duofilm, Premier, Salactic Film, Sal-Plant gel, Tinamed, Wart Off, and Duoplant. Forty percent salicylic acid treatments (Compound-W maximum-strength pads, Dr. Scholl’s clear-away maximum-strength pads and invisible strips) may also be used and applied every 48 hours. (See also the discussion of “Tape Occlusion” in the section on “Mechanical Methods.”)


Method: Pare away callus after soaking lesions in warm water. Hydrating the keratin allows better penetration of the liquid or agent being applied. Apply medication as directed by supplier and occlude the area. Repeat every other day, being sure to remove the dead tissue with paring or with a pumice stone. Treatment is nonscarring and generally effective but requires compulsive persistence with daily treatments, often for 4 to 6 weeks.



Chemicals: Physician Applied



Bichloracetic or Trichloroacetic Acid (50% to 85%)


These are potent chemicals and should not be provided for home treatment.


Method: Prepare the lesion as described for OTC medications. Apply the acid, being careful to avoid normal skin. If the lesion is raised and convoluted, work the acid into the lesion with a toothpick. Cover. Repeat weekly until the wart has resolved.



Cantharidin (Cantharone, Verr-Canth)


Cantharidin causes blistering at the dermoepidermal junction.


Method: Apply the chemical directly on the wart and cover it with tape for 48 hours. Evaluate the patient weekly and remove any residual blister, then reapply the cantharidin. Repeat until the wart has resolved.



Silver Nitrate


Method: Silver nitrate is available on the ends of sticks. Apply after paring as for OTC medications. Repeat weekly. Unfortunately, this method can leave a dark chemical “tattoo” that usually resolves but may last for months or years.



Prescription Creams



Tretinoin Cream (Retin A)


Method: Cream or solution at a concentration of 0.025%, 0.05%, or 0.1% is rubbed in thoroughly at bedtime. This is frequently used with diffuse flat warts on the legs or face, so it is rubbed over the entire area. The application may be repeated daily. The goal is to have a mild erythema with fine scaling. It is not uncommon to take months to resolve the warts. It can be used in combination with 5-fluorouracil or imiquimod.



5-Fluorouracil (Efudex, Fluoroplex)


5-Fluorouracil (5-FU) is a second-line treatment for truly resistant warts, and it has not been approved by the U.S. Food and Drug Administration (FDA) for this indication.


Method: A 2% solution or 5% cream is applied similarly to tretinoin cream. It is important to rub in thoroughly. 5-FU can also be used for condylomata (see Chapter 155, Treatment of Noncervical Condylomata Acuminata). 5-FU can cause significant inflammation in intertriginous areas and in areas with actinic skin change.



Imiquimod (Aldara)


Imiquimod is not a caustic agent but rather an immune enhancer. It is supplied in boxes of 12 or 24 packets. It is not approved by the FDA for verrucae (only for condylomata in those 12 years of age and older), but is frequently used as the sole treatment or as an adjunct in combination with other treatment therapies. It is essential to pare down the callus (especially on a plantar wart) and to rub in the imiquimod thoroughly. For verruca, it is applied daily, usually in the evening before sleep, and removed after 8 hours. It is not necessary to discard a packet if only a portion is used.



Podofilox (Condylox) Liquid


Refer to Chapter 155, Treatment of Noncervical Condylomata Acuminata.



Chemicals: Oral



Oral Cimetidine (Tagamet)


Method: Although controlled studies in children included small numbers, cimetidine appears to resolve verruca in some cases with dosages of 20 to 40 mg/kg/day for 2 months maximum. It can be used in addition to other caustic modalities to accentuate efforts. One study showed that adults with recalcitrant warts could be treated successfully with doses of 30 to 40 mg/kg (maximum dose of 3.5 g/day).



Oral Zinc


Zinc sulfate taken orally at 10 mg/kg/day to a maximum of 600 mg in three divided doses has been reported to result in complete resolution of resistant warts in 60.9% after 1 month and in 86.9% after 2 months. However, patients generally become nauseated and 20% experienced vomiting, which limits its overall acceptance.

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Wart (Verruca) Treatment

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