- 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:
- In cosmetically sensitive areas, e.g. face.
- In immunocompromised patients.
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.