viral wartThis BMJ Review looks at management options (BMJ 2014;348:g3339). Here we are considering skin warts not oral/genital lesions.

Key points

  • Common condition, with 7-12% prevalence in general population, higher in children.
  • Majority resolve spontaneously, but can take years!
  • No treatments are guaranteed to work, therefore side effects and cost should be minimised.

Which warts need treatment?

Given the above, asymptomatic warts in non-cosmetically sensitive areas need not be treated; they will get better spontaneously.

Consider treatment if warts are:

  • Painful.
  • In cosmetically sensitive areas, e.g. face.
  • In immunocompromised patients.

Treatment options

A recent Cochrane review looked at the effectiveness of various topical treatments, and found that studies were generally poor quality and small (Cochrane 2012, CD001781). Their conclusions are summarised in the table.

Treatment Evidence How to use Availability
Salicylic acid More effective than placebo (RR 1.56 (CI 1.2-2.03)). May be more effective on hands than feet. Good compliance improves effectiveness. Daily use for 12w. Soak warts in warm water. File and apply salicylic acid under occlusion. Cannot be used on face. Available OTC or FP10.
Cryotherapy Meta-analysis showed no benefit over placebo! One trial showed superiority over salicylic acid but only on hands. May be more effective in combination with salicylic acid. Apply to wart using spray gun or cotton bud (children). Administered in surgery. No studies of OTC freezing treatments.
Duct tape Two trials showed no benefits of duct tape over placebo. One small RCT showed it to be superior to cryotherapy. Apply tape and leave for 6d. Remove and soak/file, leave uncovered overnight. Repeat for up to 2m. Widely available!

So, not overwhelming! Salicylic acid is a reasonable first-line option for warts that need treatment.

Who needs referral?

The vast majority can be managed in primary care (or self-managed!). The review suggests referring:

  • Immunocompromised patients.
  • Large extensive warts on cosmetically sensitive areas, not responding to primary care treatment after 3m.

Dermatologists may then consider imiquimod, intralesional bleomycin or sensitisation with diphencyprone (requiring monthly outpatient visits for 12m). However, the Cochrane review found no benefit of these treatments over salicylic acid/cryotherapy.

Curettage/cautery have no role because of scarring and high recurrence rates.

Aimee Lettis

Aimee Lettis from the GP Update team gives us short, sharp nuggets of clinical information for sessional GPs. The GP Update team run one-day courses, bringing GPs up to date with all the latest evidence and guidelines.

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1 Response

  1. See my 2010 blog <a href="https://www.nasgp.org.uk/wart-charming-on-the-nhs/" rel="nofollow">'Wart-charming on the NHS?'</a>. Cochrane or not, I back lasering troublesome plantar warts. OK, it can be painful and the wound has to heal and it will scar, but for me a one-off treatment which usually finishes the problem beats months of struggling with salicylic acid or cryo. Yes, if you can't mount an immune response you will get more warts in time, but that's true of any treatment.

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