At a glance......
- 1 Types of Warts
- 2 Causes of Plantar Warts
- 3 Symptoms of Plantar Warts
- 4 Diagnosis of Plantar Warts
- 5 Treatment of Plantar Warts
- 5.1 Folk and Alternative Remedies
- 5.2 Folklore
- 5.3 Hypnosis/Suggestive Therapy
- 5.4 Duct Tape
- 5.5 Destructive Therapy
- 5.6 Surgical Removal by Curettage or Cautery
- 5.7 Chemical Cautery
- 5.8 Salicylic Acid
- 5.9 Cantharidin
- 5.10 Cryotherapy
- 5.11 Hot Water
- 5.12 Exothermic Patches
- 5.13 Ultrasound Hyperthermia
- 5.14 Radiofrequency Ablation
- 5.15 Microwave Treatment
- 5.16 Infrared Coagulation
- 5.17 Carbon Dioxide (CO2) Laser
- 5.18 Erbium:Yttrium/Aluminum/Garnet (Er:YAG) Laser
- 5.19 Neodymium: YAG (Nd: YAG) Laser
- 5.20 Pulsed Dye Laser
- 5.21 Potassium-Titanyl-Phosphate (KTP) Laser
- 5.22 Photodynamic Therapy
- 5.23 Virucidal Therapy
- 5.24 Glutaraldehyde
- 5.25 Formaldehyde
- 5.26 Formic Acid
- 5.27 Antiviral Drugs
- 5.28 Antimitotic Therapy
- 5.29 Bleomycin
- 5.30 Retinoids
- 5.31 Podophyllin
- 5.32 Podophyllotoxin
- 5.33 Immunotherapy
- 5.34 Oral Zinc Sulphate
- 5.35 Contact Sensitizers
- 5.36 Intralesional Injection of Interferon
- 5.37 Intralesional Injection of Mumps or Candida Antigen
- 5.38 5-Fluorouracil (5-FU)
- 5.39 Cimetidine
- 5.40 Levamisole
- 5.41 Imiquimod
- 5.42 Bacillus Calmette-Guérin Therapy
- 5.43 Vaccines
- 5.44 A sample of combination therapy outcomes in other studies follows
- 5.45 5% Imiquimod + Salicylic Acid
- 5.46 Cryotherapy + 5% Imiquimod + Salicylic Acid
- 5.47 5-FU + Salicylic Acid
- 5.48 Systemic Interferon-α2b + Isotretinoin
- 5.49 Intralesional Interferon-α2b + Podophyllin Resin
- 5.50 Podophyllin + Vidarabine
- 5.51 Cryotherapy + Podophyllotoxin
- 5.52 Er:YAG + Podophyllotoxin
- 5.53 Pulsed Dye Laser + Intralesional Bleomycin
- 5.54 Photoselective Dye Laser + Photosensitizer for Photodynamic Therapy
- 5.55 Combined Antigen Injection
- 5.56 Cimetidine + Levamisole
- 5.57 Electrocautery + Cidofovir
- 5.58 Antiretroviral Regimen + Protease Inhibitor
- 5.59 Surgery
- 5.60 Prevention
- 5.61 References
- 5.62 People Also Reading
Diet Prevention, Complication of Plantar Warts/Plantar warts caused by the human papillomavirus (HPV), are a commonly encountered condition presenting in the clinic. In adults, an array of various therapies exists, frequently with modest results particularly with plantar lesions. Microwaves have had limited uses for medical purposes. Recently a new portable microwave device has been approved for the treatment of skin lesions. Prior research has demonstrated immuno-stimulatory effects against HPV infection. We report the application of a novel portable medical microwave unit to treat a long-standing plantar wart which had failed to respond to other treatment modalities.
Warts are non-cancerous (benign) skin growths that develop in different parts of the body and can take on various forms. They are caused by viruses. Warts are contagious and very common. Most people will have one at some point in their lives. Although they can affect people of any age, warts are most common among children and teenagers.
A plantar wart is a wart occurring on the bottom of the foot or toes.[rx] Their color is typically similar to that of the skin.[rx] Small black dots often occur on the surface.[rx] One or more may occur in an area.[rx] They may result in pain with pressure such that walking is difficult.[rx]
Types of Warts
Warts may appear alone or in groups, which are capable of covering larger areas of skin. The main types of warts include:
- Common warts – are skin growths that range from the size of a pinhead to the size of a pea. They harden, making them scaly and rough to the touch. Common warts are often found on the back of the hands, the fingers, the skin around the nails, and on your feet.
- Plantar warts – mostly occur on the ankles and soles of the feet. Those on the bottom of the feet and toes are sometimes referred to as verrucas. They can become quite large. Because the soles of your feet have to support your body weight, plantar warts do not grow outward like other kinds of warts. They are pushed inward when you stand or walk. This can cause pain or tenderness due to the pressure. It also makes it difficult to treat this kind of wart.
- Mosaic warts – are white and about the size of a pinhead. They are usually found on the balls of the feet or under the toes, but may also spread and cover larger areas on the entire sole of the foot. Unlike plantar warts, they do not hurt when you walk because they are flatter.
- Filiform warts – have a thread-like, spiky appearance, and sometimes look like tiny brushes. Because they often appear on the face, they are usually considered to be particularly bothersome.
- Flat warts – are small, slightly raised warts that are often just a few millimeters wide. Sometimes they are light brown in color. They are most commonly found on the face, particularly on the forehead and cheeks. Hands and lower arms are often affected too.
- Genital warts – are small hard nodules with rough surfaces. They are sexually transmitted and affect only the genital region. The treatment for genital warts is different from treatment for the other kinds of warts mentioned above, so genital warts are not included in this overview.
- Classic Plantar Wart
- Mosaic Wart (coalescence of multiple lesions)
- Myrmecia (refers to the anthill-like lesion)
- The epidermal lesion extends deeply under the skin surface
- Usually associated with HPV Type 1
Causes of Plantar Warts
- Warts are caused by human papillomaviruses (HPV) – of which there are more than 100 different types. These viruses can enter the skin through small cuts and cause extra cell growth. The outer layer of skin turns thicker and harder, forming a raised wart. Wart viruses are mainly spread by direct skin contact, but they may also be spread by touching objects like towels or razors. They are more likely to infect moist and soft or injured skin.
- Common wart (Verruca Vulgaris) – Histopathologic features include acanthosis, digitated epidermal hyperplasia, papillomatosis, compact orthokeratosis, hypergranulosis, tortuous capillaries within the dermal papillae, and vertical tiers of parakeratotic cells with red blood cells entrapped above the tips of the digitations. Elongated rete ridges may point radially toward the center of the lesion. In the granular layer, cells infected with HPV have coarse keratohyalin granules and vacuoles surrounding wrinkled-appearing nuclei. Koilocytic cells are pathognomonic.
- Butcher’s – Butcher’s warts have acanthosis, hyperkeratosis, and papillomatosis. Small vacuolized cells are seen, and centrally located shrunken nuclei may be identified in clusters within the granular layer rete ridges.
- Filiform – Filiform warts appear similar to common warts, but they may have prominent papillomatosis.
- Focal Epithelial Hyperplasia (Heck disease) – Focal epithelial hyperplasia is characterized by acanthosis, blunting, hyperplastic mucosa with thin parakeratotic stratum corneum, anastomosis of rete ridges, and whiteness of epidermal cells due to intracellular edema. Some may have prominent keratohyalin granules, and vacuolated cells may be present.
- Deep Palmoplantar – Deep palmoplantar warts are similar to common warts except the lesion lies deep to the plane of the skin surface. The endophytic epidermal growth has the distinctive feature of polygonal, refractile-appearing, eosinophilic, cytoplasmic inclusions made up of keratin filaments, forming ringlike structures. Basophilic parakeratotic cells loaded with virions and basophilic nuclear inclusions and maybe in the upper layers of the epidermis.
- Flat – Flat warts are similar to common warts in light microscopy. Cells with prominent perinuclear vacuolization around pyknotic, basophilic, centrally located nuclei can be in the granular layer. These are referred to as “owl’s eye cells.”
- Cystic – A cyst wart is filled with horny material. The wall is composed of basal, granular, and squamous cells. Many epithelial cells have large nuclei and clear cytoplasm with eosinophilic inclusion bodies. The cyst may rupture causing a foreign body granuloma.
Some people are at greater risk of developing warts. They include
- People who work with raw meat, for example at a butcher’s shop or slaughterhouse,
- Children and teenagers who often use communal showers, for instance after sports or at the swimming pool,
- People with family members who have warts,
- Children who share a classroom with a lot of children who have warts,
- People who have a weakened immune system: especially adults and children who have had an organ transplant or who have a serious disease like cancer or AIDS, and
- people with atopic conditions like eczema.
- The viruses multiply in the skin. If someone has a weakened immune system, their body isn’t always able to successfully fight
- The primary manifestations of HPV infection include Common warts, Genital warts, Flat warts, Deep palmoplantar warts (Myrmecia), focal epithelial hyperplasia, Epidermodysplasia verruciformis, and Plantar cysts. Warts may be transmitted by direct or indirect contact.
Symptoms of Plantar Warts
- The firm, warty (rough, bumpy, and spongy, some appear thick and scaly) lesions with tiny pinpoint dark spots in the body of the wart (not always apparent): These dark spots are minute, thrombosed (containing blood clots) capillaries in the deeper layers of the skin.
- A small, fleshy, rough, grainy growth (lesion) on the bottom of your foot, usually the base of the toes and forefoot or the heel
- Hard, thickened skin (callus) over a well-defined “spot” on the skin, where a wart has grown inward
- Black pinpoints, which are commonly called wart seeds but are actually small, clotted blood vessels
- A lesion that interrupts the normal lines and ridges in the skin of your foot
- Pain or tenderness when walking or standing
- Smooth surface with a gray-yellow or brown color
- Often located over areas of pressure or bony point such as the heel and ball of the foot
- Usually flat because of pressure
- Several warts may fuse to form “mosaic” warts.
Diagnosis of Plantar Warts
The diagnosis of a wart is usually made on a clinical examination of physical findings.
- Immunohistochemical detection of HPV structural proteins confirms the presence of a virus, but this has poor sensitivity. Viral DNA identification using Southern blot hybridization is more sensitive and specific for HPV type. Polymerase chain reaction amplifies viral DNA for testing. Although HPV can be detected in younger lesions, it is not always present in older lesions.
- A biopsy is obtained if doubt exists regarding the diagnosis. The paring of a wart often reveals tiny black dots which represent thrombosed capillaries.
Treatment of Plantar Warts
Some of the treatments are quite complex and have a number of side effects. In Germany, not all of them are covered by statutory health insurers. For these reasons, they are only considered in exceptional circumstances – and even then only if the warts are very persistent and do not go away. The treatments that have not yet been tested in high-quality studies include:
- Special ointments and solutions – Ointments and solutions containing other medications were tested too, including 5-fluorouracil (a substance that inhibits cell growth), aciclovir and imiquimod (antiviral medications) and zinc.
- Injections using different kinds of medicine – Various medicines can be injected into the wart. These include bleomycin and 5-fluorouracil (both drugs inhibit cell growth), interferons (drugs that affect the immune system) and specific antigens (substances that, like vaccines, trigger an immune response).
- Curettage – Curettage involves cutting or scraping warts off with a special instrument. The wart is often first treated with a salicylic acid plaster or solution.
- Laser surgery – Here the wart is heated and destroyed using a laser beam. This treatment can cause scarring.
- Pulsed dye laser treatment – This treatment involves using a laser beam to heat and destroy the narrow blood vessels that supply blood to the wart. The aim is to stop the skin cells from multiplying.
- Erbium YAG laser – This is a laser treatment that aims to destroy the wart cells by strongly heating the fluid in them for a short time.
- Photodynamic therapy – First, a gel is applied to the wart and left on for about three hours. The gel contains a special chemical substance that is then activated by light so that it can destroy the wart tissue.
- Topical keratolytic medications – including salicylic acid 12.6% to 40% as a pad or a solution, may be applied to the corns. Urea 20% to 50%, silver nitrate, and hydrocolloid dressings can also be used in this indication. These techniques are more effective for a few lesions of interest. Topical keratolytic agents may also facilitate lesion paring by softening the corns.
- Ablative laser therapy – may also be used to treat corns instead of paring them with a scalpel. The carbon dioxide laser has been reported to be efficient by some authors. The 2,940 nm erbium-doped yttrium aluminum garnet laser has been used to treat corns with minimal thermal tissue damage. However, recurrence of lesions may be observed in some patients, especially if the trigger factors are maintained.
- Any mechanical trouble – and/or deformity should be managed with appropriate conservative treatment. This involves proper footwear and soft cushions (silicon sheet, sheepskin) which reduce friction and improve comfort.
It used to be quite common to remove warts by simply cutting them out, but this is rarely done nowadays since it can cause infection or scarring. And new warts may grow back after surgery.
Folk and Alternative Remedies
- Historic folk remedies have included many variants: Rub a dusty, dry toad on warts, and they will disappear or the advice of Tom Sawyer to back up against the stump and jam your hand in and say, ‘Barley-corn, barley-corn, Injun-meal shorts, / Spunk water, spunk water, smaller these warts.[rx] Before these remedies are scoffed at, they serve as a reminder that many warts resolve spontaneously regardless of the treatment or lack thereof.[rx]
- For many years there have been sporadic reports of wart cures in both adults and children through hypnosis or autosuggestive therapy.[rx]–rx] These largely case reports or small case series with no controls for comparison with spontaneous regression rates. It is feasible that if hypnosis or suggestion could stimulate the immune system during therapy for wart treatment, as has been suggested in cancer cases, then there could be a basis for hypnotic benefits. However, this remains untested.[rx–rx]Garlic Extracts
- Components of garlic (Allium sativum) have been shown to have antiviral activity and to inhibit cellular proliferation of virally infected cells.[rx,rx] In one placebo-controlled trial, the application of chloroform extracts of garlic was reported to result in the complete resolution of cutaneous warts with no recurrence after 3–4 months.[x]
- Occlusive duct tape treatment was championed by Dr. Jerome Litt in a 1978 article.[rx] This treatment has become popular again due
Destructive therapy should not be confused with virucidal therapy. Destructive therapies are designed to damage or remove the lesion, rather than to kill the virus. These range from surgical curettage to cautery to caustic chemical ablation, and from cryotherapy to hyperthermic therapy. Many of the following approaches may be used with most warts. However, some warn against using destructive approaches for flat warts due to their tendency to Koebnerize.[rx]
Surgical Removal by Curettage or Cautery
- Surgical removal of warts by curettage followed by cautery was an early and still widely practiced method of treatment. Success rates of 65% to 85% have been reported, but scarring and recurrence occur in up to 30% of patients.[rx–rx] Scarring can be particularly problematic on the sole of the foot, so this technique is most commonly used for filiform warts on the limbs and face.
- Silver nitrate is probably most widely recognized in its historical use to prevent conjunctivitis in newborns,[rx] but in recent times it has largely been supplanted by antibiotic eye drops. The use of silver nitrate has also been used to chemically cauterize epithelial tissues in the treatment of pyogenic and umbilical granulomas, epistaxis, corns and warts.[rx–rx]
- Salicylic acid is a first-line therapy that many patients choose since it is available over the counter. It is a keratolytic therapy with a mechanism of action that slowly destroys the virus-infected epidermis and may cause an immune response from the mild irritation caused by the salicylic acid.[rx]
- It is prepared in concentrations from 10% to 60%.[rx] Over-the-counter preparations are available as 17% salicylic acid combined in a base of flexible collodion or as a 40% salicylic acid plaster patch.[rx] The advantages of over-the-counter salicylic acid include convenience, minimal expense, negligible pain, and reasonable effectiveness.[rx,rx]
- Cantharidin is derived from the blister beetle, Cantharis vesicatoria.[rx] It causes epidermal cell death, acantholysis, and clinical blister formation by interacting with mitochondria.[rx] Since 1992, the drug is no longer available in the United States but can be purchased in Canada.[rx]
- Cantharidin should be applied to the pared wart and covered with a nonporous occlusive tape for 24 hours. A blister will form and heal in 1 to 2 weeks.[rx] This process should be repeated in 1 to 3 weeks.[rx]
- Cryotherapy is available for the treatment of verruca Vulgaris in primary care and dermatology offices. It is considered second-line therapy.[rx] The most commonly used cryogen is liquid nitrogen with a temperature of -196°C.[rx] The effect on wart clearance may be through necrotic destruction of HPV-infected keratinocytes or by inducing local inflammation that triggers an effective cell-mediated response.[rx]
- Small patches containing chemicals that produce heat through oxidation upon exposure to air have been applied to warts with anecdotal success.[rx]
- In vitro treatment of excised warts by applying microwave energy has been shown to produce more HPV DNA damage than CO2 laser treatment, but there has been no reported clinical application of microwave treatment.[rx]
- Direct application of infrared contact coagulators has been reported as a cheaper, safer and more easily handled alternative to CO2 laser treatment. The instrument allows adjustable tissue necrosis without tissue adhesion and has yielded remissions with a 10.8% recurrence rate.[rx] In comparison to electrocoagulation, infrared coagulation produces similar outcomes.[rx]
Carbon Dioxide (CO2) Laser
- The CO2 lasers emit infrared light (10,600 nm) that is absorbed by water. Nonselective thermal tissue destruction results. A focused CO2 laser beam can be used as a scalpel to excise the wart down to the subcutaneous tissue after which the base of the wart is vaporized by a defocused beam until a clean surgical field is obtained.[rx]
- Two case series described a 64% to 71% cure rate at 12 months.[rx] No randomized, controlled trials have been published on the efficacy of CO2 laser.[rx] Lost skin heals by secondary intention.[rx] This treatment may be useful for periungual and subungual warts that are recalcitrant to other treatments.[rx]
Erbium:Yttrium/Aluminum/Garnet (Er:YAG) Laser
- YAG laser emits a shorter wavelength infrared radiation (2940 nm) that is absorbed 12 to 18 times more efficiently by water-containing superficial cutaneous tissues than is the 10,600 nm wavelengths emitted by the CO2 laser.[rx]
- The YAG laser has a smaller zone of thermal damage, thereby allowing more precise thermal ablation with minimal scarring. Warts in a variety of locations have been successfully eliminated in 75% of patients after a single treatment, with a 25% relapse rate within 1 year after treatment.[rx] Approximately 14% of patients are non-responders.[rx]
Neodymium: YAG (Nd: YAG) Laser
- The Nd: YAG laser’s principal emission wavelength is at 1064 nm, still in the infrared range. Hyperthermic treatment with this laser has been reported to cause remission with no recurrence in several case reports and case series.[rx,rx] In biopsied tissues, pre- and post-treatment with either cryotherapy or Nd: YAG hyperthermic therapy, HPV DNA was reduced from 100% to 96% after cryotherapy and from 100% to 0% after laser treatment.[rx]
Pulsed Dye Laser
- The mechanism of action of the pulsed dye laser is through selective microvascular destruction of dilated capillaries in warts. This happens as a result of thermal damage occurring upon yellow light absorption (585 nm) by oxyhemoglobin. Thermal damage, removal of the blood supply, and a cell-mediated immune response are believed to contribute to wart healing.[rx] The treatment sensation has been compared to being snapped by a rubber band and is considered relatively painless.[rx]
Potassium-Titanyl-Phosphate (KTP) Laser
- The KTP laser has been utilized in the treatment of recalcitrant cutaneous warts and when treated to complete clearance, no recurrence occurred.[rx]
- Rather than using endogenous target absorbers (i.e., water for the CO2 laser and oxyhemoglobin for the 585 nm pulsed dye laser), photodynamic therapy uses the light of a wavelength absorbed by specific photosensitizing molecules that are exogenously administered to the target tissue.[rx]
- One agent commonly used is 5-aminolaevulinic acid (ALA), which is a prodrug that stimulates porphyrin accumulation in the tissue.[rx,rx] Porphyrins then act as the photosensitizing agent.
- Glutaraldehyde is virucidal and available as a 10% water-miscible gel or alcohol solution.[rx] Application of glutaraldehyde is typically applied twice a day and can stain the skin brown, as well as cause contact sensitivity.1 The treatment has been reported to be as effective as with salicylic acid with cure rates over 70%.[rx]No randomized, controlled trials for glutaraldehyde treatment of warts have been published.[rx]
- Formaldehyde is also virucidal and works by disrupting the upper layer of epidermal cells and possibly damaging the virions.[rx]
- Available 0.7% gels or 3% solutions are used to soak pared plantar warts to speed resolution.[rx] Formaldehyde, widely used as a preservative in many products such as lotions and shampoos, can cause sensitization and should be avoided in patients with eczema and allergies.[rx]
- Formic acid is the chemical irritant found in the stings and bites of many hymenopteran insects, including bees and ants, and was first isolated from red ants, hence the name from the Latin for ant, Formica.
- It is also the irritant in the leaves of stinging nettles. In a nonrandomized, placebo-controlled, open trial in 100 patients, a topical 85% formic acid/needle puncture technique resulted in a 92% complete clearance rate as compared with 6% in the placebo (water) group.[rx]
- Cidofovir is a nucleoside analog of deoxycytidine monophosphate that inhibits DNA synthesis, induces DNA fragmentation, reduces epithelialization and enhances excoriation.[rx–rx] It has been used successfully in HIV-positive patients for the topical treatment of genital warts.[rx–rx]
- Bleomycin, an antibiotic derived from Streptomyces verticillus, is reserved for recalcitrant warts that have failed other types of treatment.[rx] It selectively affects squamous cell and reticuloendothelial tissue.[rx]DNA and protein synthesis are inhibited, and apoptosis is triggered. Bleomycin is not thought to bind directly to HPV.[rx]
- Bleomycin causes acute tissue necrosis that may stimulate an immune response, as evidenced by the fact that it is less effective as a wart treatment in immunosuppressed renal transplant patients.[rx,rx,rx,rx] Bleomycin treatment of warts results in significant systemic drug exposure and should not be used on pregnant women, children, immunosuppressed patients or patients with vascular disease.[rx,rx]
- Epidermal growth and differentiation are disrupted by retinoids, so wart growth is affected. Retinoids are also potent immunomodulators.[rx] There is some evidence that retinoids can downregulate HPV transcription in affected cells as well.[rx,rx] Retinoids can be administered topically or systemically. Treatment of warts with a tretinoin cream resulted in 85% clearance in a series of children as compared to 32% spontaneous clearance in controls.[rx]
- The rhizomes of the mayapple plant (Podophyllum peltatum) that grows throughout eastern and midwestern North America are the source of podophyllin resin, the crude alcohol extracts containing podophyllotoxin, 4-demethylpodophyllotoxin, α-peltate, and β-peltatin.[rx]
- The Penobscot Indians of the northeastern United States used poultices of mayapple for the treatment of warts.[rx]
- Podophyllum hexandrum grows in the mountainous regions of India and contains a higher content of podophyllotoxin, the active component.[rx] Podophyllotoxin binds to microtubules and causes mitotic arrest in the metaphase of cell division.[rx]
- In a small, double-blind, randomized clinical trial of self-administered podophyllotoxin solution versus vehicle in the treatment of genital warts, patients were instructed to administer 0.5% solution or vehicle at home twice daily for 3 consecutive days of each week for 4 weeks.[rx]
Oral Zinc Sulphate
- Dietary zinc has profound effects on the human immune system, and deficiency leads to reduced immune capacity.[rx,rx] Based on this, a placebo-controlled clinical trial was attempted using oral zinc sulfate (10 mg/kg daily) to treat recalcitrant warts. Complete clearance was reported in 87% of the treatment group versus no clearance in the placebo group.[rx]
- The mechanism of action for topical immunotherapy with contact sensitizers is proposed to be a type IV hypersensitivity reaction.[rx] The immune response is purported to be directed against a complex of contact agent hapten bound to the protein of viral or human origin that enhances wart regression.1 An effective topical immunotherapy contact sensitizer should ideally be readily available, able to sensitize at least 95% of the normal population, chemically stable, economical, free of significant adverse effects and rarely occurring in the human environment.[rx]
- Diphencyprone (DCP) – the standard sensitizer used for topical immunotherapy, is nonmutagenic and is available in an acetone solution.[rx] It has a shelf life of 3–6 months at room temperature if stored in an amber glass bottle to prevent light degradation.[rx] Another nonmutagenic contact sensitizer, squaric acid dibutyl ester (SADBE), has been used in the treatment of recalcitrant warts. SADBE is more expensive and less stable in solution than DCP.[rx[,rx]
Intralesional Injection of Interferon
- For genital warts that are recurrent or recalcitrant to other treatments, intralesional injection of interferon-α has been tested in a randomized, double-blind, placebo-controlled, multicenter trial. Leukocytic interferon can both kill viruses and stimulate the immune system. The interferon or placebo was injected twice weekly for up to 8 weeks. Complete clearance was seen in 62% of interferon-α patients compared to 21% of placebo-treated patients.[rx] Intralesional interferon-α has also been used successfully in the treatment of recurrent oral warts in AIDS patients.[rx]
Intralesional Injection of Mumps or Candida Antigen
- Intralesional injection of mumps or Candida may be a treatment option for recalcitrant warts that have not resolved with other therapies. One trial compared the intralesional injection of one wart with Candida or mumps antigen to cryotherapy of all warts.[rx]
- Excluded were patients with a prior allergic response to mumps or Candida antisera, pregnancy, HIV infection, iatrogenic immunosuppression, primary immunosuppression or any generalized dermatitis. Intradermal injection of 0.1 ml of mumps and Candida antigen was placed in the right and left forearms, respectively.
- Fluorouracil has been used topically as an antiproliferative agent for warts.[rx,rx] In one prospective placebo-controlled, single-blind, randomized trial, up to 70% of warts underwent complete response when treated with 5-FU combined with lidocaine to reduce pain and epinephrine to induce vasoconstriction in order to sustain high local drug concentrations.[rx]
- Daily doses of 20 to 40 mg/kg cimetidine, an H2-receptor antagonist, cleared up to 82% of recalcitrant warts in open-label studies.[rx] Cimetidine is postulated to act as an immunomodulating agent at high doses by inhibiting suppressor T-cell function while increasing lymphocyte proliferation, thereby enhancing cell-mediated immune responses.[rx,rx] Others found insufficient evidence of efficacy in three small randomized, controlled trials between cimetidine and placebo.[rx]
- Levamisole is another immunomodulating drug that has been used effectively in the treatment of flat and common warts with moderate success.[rx]
- Imiquimod 5% cream is an immunomodulator that may stimulate cytokines, including interferon-α, interleukin-1, interleukin-6, tumor necrosis factor-α, granulocyte-macrophage colony-stimulating factor, and granulocyte colony-stimulating factor.[rx] Absorption of imiquimod through intact skin is minimal.[rx] Its use in the treatment of external anogenital warts was approved by the United States Federal Drug Administration in 1997, and it has more recently been approved for the treatment of nonhyperkeratotic, nonhypertrophic actinic keratoses and superficial basal cell carcinomas.
Bacillus Calmette-Guérin Therapy
- Intravesical instillation of viable bacillus Calumette-Guérin is a standard adjuvant treatment for recurrent superficial bladder cancer.[rx] The mode of action is based on the stimulation of the local immune response.[rx,rx] The immune responses to malignant and virally transformed cells are similar
- Early attempts at vaccination for the treatment of persistent or recurrent anal and perianal venereal warts utilized an autologous vaccine prepared from wart extracts obtained from individual patients that were injected subcutaneously weekly for six weeks. Excellent results were obtained in 84% of patients with only 5% not responding, and all complete remissions that were followed remained disease-free for an average of 46 months.[rx]
A sample of combination therapy outcomes in other studies follows
5% Imiquimod + Salicylic Acid
Cryotherapy + 5% Imiquimod + Salicylic Acid
- A 50% to 100% clearance rate after 6 to 9 weeks has been reported after treatment with liquid nitrogen cryotherapy followed by 17% salicylic acid at bedtime and 5% imiquimod each morning.[rx]
5-FU + Salicylic Acid
- In an uncontrolled, retrospective study, twice-daily topical application of 5-FU (0.5% or 5.0%) was combined with salicylic acid (17% or 40%) to treat plantar warts with complete clinical resolution in all patients.[rx] Recurrence occurred in 15% of lesions, but these subsequently resolved upon repeated treatment.
Systemic Interferon-α2b + Isotretinoin
- In the treatment of venereal warts, statistically significant higher remission rates and lower recurrence rates with shorter treatment durations were achieved with systemic interferon-α2b plus isotretinoin versus the retinoid alone.[rx–rx] This combination therapy has also been used to successfully treat cases of epidermodysplasia verruciformis, a genetically determined susceptibility to widespread and persistent HPV infection.[rx,rx]
Intralesional Interferon-α2b + Podophyllin Resin
- In a medium-sized (49 combination therapy, 48 monotherapy) randomized trial, patients received either a combination intralesional interferon-α2b (1.5 x 106 IU) plus topical 25% podophyllin resin or topical podophyllin resin alone.[rx]
- Complete clearance of treated warts was seen in 67% of those receiving combination therapy versus 42% in those receiving monotherapy with podophyllin. The maximal response was exhibited after 2 weeks of therapy.
- Additionally, 18% of warts persisted despite either treatment, and after 11 weeks of follow-up in those who had seen complete clearance, a 67% recurrence occurred in the combination arm, and 65% recurrence was seen in the podophyllin-only arm.
Podophyllin + Vidarabine
- CIN is considered to be the precursor to cervical cancer.[rx] The co-application of vidarabine and podophyllin over six treatments resulted in the cytological and histological regression of lesions and the disappearance of HPV 16 and 18 DNA in 17 of 21 (81%) of women with CIN I-II.[rx]
- Vidarabine is a DNA polymerase inhibitor that suppresses HPV gene expression in immortalized human cervical keratinocytes and cervical cancer cell lines in vitro.
Cryotherapy + Podophyllotoxin
- In the treatment of anogenital warts in the United Kingdom, a combination of cryotherapy and podophyllotoxin is the most common first-line treatment, regardless of site.[rx]
Er:YAG + Podophyllotoxin
- Recalcitrant palmoplantar warts have been treated with an ablative Er: YAG laser followed by 0.5% podophyllotoxin solution after wound healing to yield an 88.6% complete response rate with a 5.7% relapse rate.[rx]
Pulsed Dye Laser + Intralesional Bleomycin
- A pulsed dye laser has been used to pretreat or “prepare” recalcitrant warts immediately prior to intralesional bleomycin injection to help assure basal drug delivery.[rx] This treatment resulted in 100% clearance in immunocompetent patients and 89% clearance in subjects on long-term immunosuppressant drugs.
Photoselective Dye Laser + Photosensitizer for Photodynamic Therapy
- In a sizable comparison trial, 81% (91/112) of warts were cured in an average of 3.34 sessions by photoselective laser destruction using a pulsed dye laser alone. Ninety-six percent (73/76) of warts were cured in 2.54 sessions using photodynamic therapy with aminolevulinic acid-induced protoporphyrin as a photosensitizer,[rx] and 100% (86/86) of warts were cured when the therapeutic modalities were combined.[rx] Warts in a variety of locations were treated. These cure rates are very promising, but no information on recurrence was provided.
Combined Antigen Injection
- Injection of a combination of Candida albicans, mumps and Trichophyton has been shown to be more effective than and as safe as single antigen injection in the treatment of cutaneous warts.[rx]
Cimetidine + Levamisole
Electrocautery + Cidofovir
- In a series of HIV patients with genital warts, surgical treatment by electrocautery resulted in a 93% clearance rate but a 74% relapse rate. Topical 1% cidofovir gel resulted in a 76% clearance rate with a 35% relapse rate. Using electrocautery followed by cidofovir gel application, the clearance rate was 100% with 27% relapse.[rx]
- In HIV patients with recalcitrant hand warts, resolution has been observed when antiretroviral nucleoside analogue reverse transcriptase inhibitors [azidothymidine (AZT, zidovudine), dideoxyinosine (ddI, didanosine) dideoxycytidine (ddC, zalcitabine), (−)2′,3′-dideoxy, 3′-thiacytidine (3TC, lamivudine), 2′,3′-didehydro-3′-deoxythymidine (d4T, stavudine)] or non-nucleoside reverse transcriptase inhibitor (nevirapine, loviride, delavirdine) drug therapies were combined with potent protease inhibitors (i.e., ritonavir, indinavir and/or saquinavir).[rx,rx]
- For facial warts in HIV patients, combined reverse transcriptase inhibitors and protease inhibitors have been used in addition to ablative treatment with a pulsed dye laser with good results.[rx]
- Liquid nitrogen – This, and similar cryosurgery methods is a common surgical treatment which acts by freezing the external cell structure of warts, destroying the live tissue.
- Electrodesiccation and surgical excision – which may produce scarring.
- Laser surgery – This is generally a last resort treatment, as it is expensive and painful, but may be necessary for large, hard-to-cure warts.[rx]
- Cauterization – This may be effective as a prolonged treatment. As a short-term treatment, cauterization of the base with anesthetic can be effective, but this method risks scarring or keloids. Subsequent surgical removal if necessary, also risks keloids and/or recurrence in the operative scar.[rx]
- Other acids – Your doctor shaves the surface of the wart and applies trichloroacetic acid with a wooden toothpick. You’ll need to return to the doctor’s office for repeat treatments every week or so. Side effects include burning and stinging. Between visits, you may be asked to apply salicylic acid to the wart.
- Immune therapy – This method uses medications or solutions to stimulate your immune system to fight viral warts. Your doctor may inject your warts with a foreign substance (antigen) or apply a solution or cream to warts.
- Minor surgery – Your doctor cuts away the wart or destroys it by using an electric needle (electrodesiccation and curettage). This procedure can be painful, so your doctor will numb your skin first. Because surgery has a risk of scarring, this method usually isn’t used to treat plantar warts unless other treatments have failed.
- Laser treatment – Pulsed-dye laser treatment burns closed (cauterizes) tiny blood vessels. The infected tissue eventually dies, and the wart falls off. This method requires repeat treatments every three to four weeks. The evidence for the effectiveness of this method is limited, and it can cause pain and potentially scarring.
- Vaccine – The HPV vaccine has been used with success to treat warts even though this vaccine is not specifically targeted toward the wart virus that causes the majority of plantar warts.
If you have warts, there are a few precautions you can take to avoid spreading them. These precautions may also help to prevent warts from spreading to other areas of your own skin.
You can do the following things to avoid infecting others
- Wearing shoes or sandals in locker rooms, swimming pool areas, and communal showers
- Keeping the feet clean and dry
- Avoiding contact with warts on other people
- Avoiding using a pumice stone or emery board that has been in contact with a wart
- Wearing clean, dry socks when wearing shoes
- Avoiding going barefoot in communal areas
- Cover warts with a waterproof plaster when you go swimming.
- Do not share towels, shoes, gloves or socks with others.
- Do not go barefoot at swimming pools, or in communal showers or changing rooms.
- Do not touch warts.
- Avoid direct contact with warts. This includes your own warts. Wash your hands carefully after touching a wart.
- Keep your feet clean and dry. Change your shoes and socks daily.
- Avoid walking barefoot around swimming pools and locker rooms.
- Don’t pick at or scratch warts.
- Don’t use the same emery board, pumice stone or nail clipper on your warts as you use on your healthy skin and nails.
In addition, the following things are recommended in order to stop warts from spreading to other areas of your own skin
- Do not scratch warts, otherwise, the viruses might spread.
- Keep your feet dry.
- Change your socks every day