Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

common wart: immunocompetent

1st line – watch and wait approach

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ACUTE
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common wart: immunocompetent
1st line – 

watch and wait approach

Because many common warts will regress spontaneously in immunocompetent patients, the option of watchful waiting is reasonable in some cases and should be discussed with the patient.[5]​ This should be considered especially in children, because treatment is uncomfortable and may not be tolerated.

1st line – debridement + salicylic acid

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ACUTE
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common wart: immunocompetent
1st line – 

debridement + salicylic acid

For debridement and salicylic acid treatment, the affected area should be soaked in warm water for 5 minutes; the hyperkeratotic surface should be debrided with a clean knife, nail filer, pummel stone, or emery board until the first hint of either tenderness or bleeding.

The instruments used for debridement should not be used on any other parts of the body for other purposes, in order to prevent the spread of infection.

Salicylic acid applied daily may have similar efficacy to that of cryotherapy and has a cure rate of up to 75%.[5][10]​ Salicylic acid has been found to be superior to placebo, but a systematic review found that there was no clinically relevant difference in effectiveness between topical salicylic acid, cryotherapy, or a wait-and-see approach for plantar warts after 13 weeks.[11][12] One other study found that salicylic acid increased the clearance of warts from all sites, although it may be more effective for warts on the hands compared with warts on the feet.[9]

Adverse effects include local tenderness, skin erosion, and super-infection.

Primary options

salicylic acid topical: (17%) apply 1-2 drops onto affected area(s), then cover with occlusive bandage for 12-24 hours

Consider – duct tape occlusion

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ACUTE
|
common wart: immunocompetent
Consider – 

duct tape occlusion

Additional treatment recommended for SOME patients in selected patient group

Is usually used in conjunction with debridement and salicylic acid, although may be effective with debridement alone.

A popular regimen is to repeat a cycle of 6 days of tape occlusion without replacement followed by 1 day off, until the wart disappears.

Occlusion of the wart with impermeable duct tape may be a simple and effective method of eradication, with response rates as high as 85% by week 8 for cutaneous warts.[6][7] However, some authors have found no clear effectiveness for duct tape occlusion compared with placebo.[9][13]

1st line – cryotherapy

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ACUTE
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common wart: immunocompetent
1st line – 

cryotherapy

Using a spray gun filled with liquid nitrogen, the operator should treat the wart adequately to produce a blister in 24 to 48 hours. Cryotherapy can be a clinically-efficacious and cost-effective treatment for common warts.[6][8][10]​ However, only one trial has demonstrated cryotherapy to be more effective than both salicylic acid and placebo, and this trial only considered patients with hand warts. No significant differences in cure rates were reported at 2-, 3-, or 4-week intervals.[9] A meta-analysis of randomised controlled trials (mostly of low methodological quality) was unable to show that cryotherapy was statistically superior to placebo. It found that aggressive cryotherapy was significantly better than gentle cryotherapy for the treatment of cutaneous warts.[11] One randomised controlled trial, performing an intention-to-treat analysis, found cryotherapy to be the most effective therapy for common warts compared with topical salicylic acid or a wait-and-see approach, but it was unable to find a clinically relevant difference in effectiveness between the three approaches for patients with plantar warts.[12] A total of 49% of patients with common warts were cured with cryotherapy after 13 weeks compared with 15% of patients who used salicylic acid in petroleum jelly and 8% of patients who received no treatment, while 14% of patients with plantar warts were cured with cryotherapy after 12 weeks compared with 14% of patients who used salicylic acid.[14] From pooled evidence-based data, it is possible to conclude that significantly higher remission rates can be expected with cryotherapy when used in combination with salicylic acid.[15]

Warts in children, and on cosmetically sensitive areas such as facial skin, may be treated by dipping a cotton swab into liquid nitrogen for 5 seconds and then applying it to the lesion for 10 seconds.

Quick freeze for 10 seconds, followed by a slow thaw for 40 seconds is the optimal method to produce a blister. However, this can cause scarring, so some experts prefer to freeze with a narrow margin.

A single freeze-thaw cycle appears to be equally effective compared to 2 freeze-thaw cycles.[27]

For flat lesions, the application time should be decreased to only 1 to 2 seconds or until the entire lesion turns white.

Should be repeated every 2 to 3 weeks, ideally immediately after the scab from the healed blister has fallen off.

Caution should be exercised in patients with a tendency to develop severe blisters, such as those with Fanconi anaemia, cryoglobulinaemia, poor peripheral circulation, and Raynaud's phenomenon.[1]​​

1st line – silver nitrate solution

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ACUTE
|
common wart: immunocompetent
1st line – 

silver nitrate solution

Silver nitrate 10% solution should be applied every other day for 3 to 6 weeks. Adverse effects include temporary brownish discolouration of the skin which resolves 1 week after treatment.[16]

Primary options

silver nitrate topical: (10%) apply to the affected area(s) every other day for 3-6 weeks

2nd line – debridement + salicylic acid + local immunotherapy

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ACUTE
|
common wart: immunocompetent
2nd line – 

debridement + salicylic acid + local immunotherapy

To debride, the affected area should be soaked in warm water for 5 minutes; the hyperkeratotic surface should be debrided with a clean knife, nail filer, pummel stone, or emery board until the first hint of either tenderness or bleeding.

If warts are resistant to destructive treatments alone, addition of local immune adjuvants may help stimulate a cellular immune response against the human papillomavirus-infected keratinocytes.

Candida antigen may be given intralesionally, administered by an experienced physician.

Imiquimod may be used topically. Daily application to some non-facial lesions may not be tolerated by some patients, so treatment should be modified to application every other day.

Primary options

salicylic acid topical: (17%) apply 1-2 drops onto affected area(s), then cover with occlusive bandage for 12-24 hours

-- AND --

Candida antigen: 0.3 mL intralesionally under surface of wart or wart cluster every 3 weeks, maximum 5 treatments

or

imiquimod topical: (5%) apply to the affected areas(s) once daily at bedtime for 4 weeks

2nd line – cryotherapy + local immuno- or chemotherapy

Back
ACUTE
|
common wart: immunocompetent
2nd line – 

cryotherapy + local immuno- or chemotherapy

Using a spray gun filled with liquid nitrogen, the wart should be treated adequately to produce a blister in 24 to 48 hours.

Warts in children, and on cosmetically sensitive areas like facial skin, may be treated by dipping a cotton swab into liquid nitrogen for 5 seconds and then applying it to the lesion for 10 seconds.

Quick freeze for 10 seconds, followed by a slow thaw for 40 seconds is the optimal method to produce a blister. However, it can cause scarring, so some experts prefer to freeze with a 2 to 3 mm margin of the lesion.

A single freeze-thaw cycle appears to be equally effective compared to 2 freeze-thaw cycles.[27]

For flat lesions, the application time should be decreased to only 1 to 2 seconds or until the entire lesion turns white.

Should be repeated every 2 to 3 weeks, ideally immediately after the scab from the healed blister has sloughed off. Caution should be exercised in patients with a tendency to develop severe blisters, such as those with Fanconi anaemia, cryoglobulinaemia, poor peripheral circulation, and Raynaud's phenomenon.[1]​​

Immune adjuvants should be applied immediately after the lesion has thawed.

Intralesional Candida antigen (administered by an experienced physician), topical imiquimod, or topical fluorouracil is used in conjunction with cryotherapy.

Daily application of imiquimod to some non-facial lesions may not be tolerated by some patients, so treatment should be modified to application every other day.

Primary options

Candida antigen: 0.3 mL intralesionally under surface of wart or wart cluster every 3 weeks, maximum 5 treatments

OR

imiquimod topical: (5%) apply to the affected areas(s) once daily at bedtime for 4 weeks

OR

fluorouracil topical: (2-5%) apply sparingly to the affected area(s) once daily at bedtime for 4 weeks after soaking and paring wart

3rd line – surgery (cold-scalpel or laser)

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ACUTE
|
common wart: immunocompetent
3rd line – 

surgery (cold-scalpel or laser)

Cold-scalpel surgery carries the risk of infection, scarring, bleeding, pain, and nerve damage, and should be carried out under sterile conditions with the use of local anaesthesia by an experienced physician.

CO2 laser produces complete ablation of the lesion, with 56% to 100% resolution reported in case series.[30][31] It also requires local anaesthesia, physician expertise, and proper vapour evacuation mechanisms. Adverse effects include scarring, nail dystrophy, and the generation of an infectious plume that may affect the patient, physician, and others present in the treatment room. A smoke evacuator is therefore mandatory for this procedure.[28]

Laser surgery with a pulsed-dye laser may produce responses of up to 95% wart clearance in immunocompetent individuals with recalcitrant lesions.[29] It usually requires no anaesthesia. Treatment is performed with a short pulse duration and high energies, in order to induce thrombosis and small vessel vasculitis of the vessels feeding the wart, and to induce non-specific heat trauma to the wart itself.[29]​ Treatment produces purple-grey purpura, which turns into an eschar in 1 to 2 weeks. Treatment also generates a potentially infectious plume, and evacuation with a vacuum is necessary.

Consider – local immuno- or chemotherapy

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ACUTE
|
common wart: immunocompetent
Consider – 

local immuno- or chemotherapy

Additional treatment recommended for SOME patients in selected patient group

Warts have a tendency to recur when treated with surgery alone (up to 30% of recurrence in some studies).[1][2]​​​​ For this reason, the modality is best combined with a topical adjuvant modality, such as topical immunomodulation or topical chemotherapy, for increased efficacy.

Candida antigen may be given intralesionally, administered by an experienced physician.

Imiquimod may be used topically. Daily application to some non-facial lesions may not be tolerated by some patients, so treatment should be modified to application every other day.

Topical fluorouracil is another alternative.

Primary options

Candida antigen: 0.3 mL intralesionally under surface of wart or wart cluster every 3 weeks, maximum 5 treatments

OR

imiquimod topical: (5%) apply to the affected areas(s) once daily at bedtime for 4 weeks

OR

fluorouracil topical: (2-5%) apply sparingly to the affected area(s) once daily at bedtime for 4 weeks after soaking and paring wart

common wart: immunocompromised

1st line – debridement + salicylic acid + local immunotherapy

Back
ACUTE
|
common wart: immunocompromised
1st line – 

debridement + salicylic acid + local immunotherapy

Immunocompromised patients should receive adjuvant topical immunomodulation as a first-line treatment after debridement and salicylic acid.

To debride, the affected area should be soaked in warm water for 5 minutes; the hyperkeratotic surface should be debrided with a clean knife, nail filer, pummel stone, or emery board until the first hint of either tenderness or bleeding.

Candida antigen may be given intralesionally, administered by an experienced physician.

Imiquimod may be used topically. Daily application to some non-facial lesions may not be tolerated by some patients, so treatment should be modified to application every other day.

It is prudent to consult the patient's transplant immunologist, oncologist, or infectious disease physician before prescribing imiquimod and Candida antigen in these patients.

Primary options

salicylic acid topical: (17%) apply 1-2 drops onto affected area(s), then cover with occlusive bandage for 12-24 hours

-- AND --

Candida antigen: 0.3 mL intralesionally under surface of wart or wart cluster every 3 weeks, maximum 5 treatments

or

imiquimod topical: (5%) apply to the affected areas(s) once daily at bedtime for 4 weeks

1st line – cryotherapy + local immuno- or chemotherapy

Back
ACUTE
|
common wart: immunocompromised
1st line – 

cryotherapy + local immuno- or chemotherapy

Immunocompromised patients should receive adjuvant topical immunomodulation as a first-line treatment with cryotherapy.

Cryotherapy should be repeated every 2 to 3 weeks, ideally immediately after the scab from the healed blister has fallen off. Caution should be exercised in patients with a tendency to develop severe blisters, such as those with Fanconi anaemia, cryoglobulinaemia, poor peripheral circulation, and Raynaud's phenomenon.[1]​​

Candida antigen may be given intralesionally, administered by an experienced physician.

Imiquimod may be used topically. Daily application to some non-facial lesions may not be tolerated by some patients, so treatment should be modified to application every other day.

Topical fluorouracil is another alternative.

It is prudent to consult the patient's transplant immunologist, oncologist, or infectious disease physician before prescribing topical immuno- or chemotherapy in these patients.

Primary options

Candida antigen: 0.3 mL intralesionally under surface of wart or wart cluster every 3 weeks, maximum 5 treatments

OR

imiquimod topical: (5%) apply to the affected areas(s) once daily at bedtime for 4 weeks

OR

fluorouracil topical: (2-5%) apply sparingly to the affected area(s) once daily at bedtime for 4 weeks after soaking and paring wart

2nd line – surgery (cold-scalpel or laser) + local immunotherapy

Back
ACUTE
|
common wart: immunocompromised
2nd line – 

surgery (cold-scalpel or laser) + local immunotherapy

Cold-scalpel surgery carries the risk of infection, scarring, bleeding, pain, and nerve damage, and should be carried out under clean conditions with the use of local anaesthesia by an experienced physician.

CO2 laser produces complete ablation of the lesion. It also requires local anaesthesia, physician expertise, and proper vapour evacuation mechanisms. Adverse effects include scarring, nail dystrophy, and the generation of an infectious plume that may affect the patient, physician and others present in the treatment room. Therefore a smoke evacuator is mandatory for this procedure.[28]

Laser surgery with a pulsed-dye laser usually requires no anaesthesia. Treatment is performed with a short pulse duration and high energies, in order to induce thrombosis and small vessel vasculitis of the vessels feeding the wart, and to induce non-specific heat trauma to the wart itself.[29]​ Treatment produces purple-grey purpura, which turns into an eschar in 1 to 2 weeks. Treatment also generates a potentially infectious plume, and evacuation with a vacuum is necessary.

Candida antigen may be given intralesionally, administered by an experienced physician.

Imiquimod may be used topically. Daily application to some non-facial lesions may not be tolerated by some patients, so treatment should be modified to application every other day.

It is prudent to consult the patient's transplant immunologist, oncologist, or infectious disease physician before prescribing imiquimod or Candida antigen in these patients.

Primary options

Candida antigen: 0.3 mL intralesionally under surface of wart or wart cluster every 3 weeks, maximum 5 treatments

OR

imiquimod topical: (5%) apply to the affected areas(s) once daily at bedtime for 4 weeks

Consider – oral retinoids

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ACUTE
|
common wart: immunocompromised
|
with multiple lesions
Consider – 

oral retinoids

Additional treatment recommended for SOME patients in selected patient group

Indicated for immunocompromised patients with multiple resistant warts. These medicines should be prescribed by a physician familiar with their various adverse effects, and with the management of possible serious adverse events.

Primary options

isotretinoin: 0.5 to 1 mg/kg/day orally given in 2 divided doses

OR

acitretin: 10-25 mg orally once daily

filiform wart

1st line – cryotherapy

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ACUTE
|
filiform wart
1st line – 

cryotherapy

Metal forceps dipped into liquid nitrogen for 5 seconds and applied to the base of the stalk until the entire lesion is frozen may be the best approach.

A single freeze-thaw cycle appears to be equally effective compared with two freeze-thaw cycles.[27]

Cryotherapy should be repeated every 2 to 3 weeks, ideally immediately after the scab from the healed blister has sloughed off.

Caution should be exercised in patients with a tendency to develop severe blisters, such as those with Fanconi anaemia, cryoglobulinaemia, poor peripheral circulation, and Raynaud's phenomenon.[1]​​

Consider – topical imiquimod

Back
ACUTE
|
filiform wart
Consider – 

topical imiquimod

Additional treatment recommended for SOME patients in selected patient group

Topical imiquimod may be used as an adjunctive treatment to reduce the risk of recurrence.

Daily application to some non-facial lesions may not be tolerated by some patients, so treatment should be modified to application every other day.

Primary options

imiquimod topical: (5%) apply to the affected areas(s) once daily at bedtime for 4 weeks

2nd line – surgery

Back
ACUTE
|
filiform wart
2nd line – 

surgery

May be considered as first-line treatment, in place of cryotherapy, if the patient presents with a single facial lesion.

Cold-scalpel surgery carries the risk of infection, scarring, bleeding, pain, and nerve damage, and should be carried out under sterile conditions with the use of local anaesthesia by an experienced physician.

CO2 laser produces complete ablation of the lesion. It also requires local anaesthesia, physician expertise, and proper vapour evacuation mechanisms. Side effects include scarring, nail dystrophy, and the generation of an infectious plume that may affect the patient, physician and others present in the treatment room. A smoke evacuator is mandatory for this procedure.[28]

Laser surgery with a pulsed-dye laser usually requires no anaesthesia. Treatment is performed with a short pulse duration and high energies, in order to induce thrombosis and small vessel vasculitis of the vessels feeding the wart, and to induce non-specific heat trauma to the wart itself.[29]​ Treatment produces purple-grey purpura, which turns into an eschar in 1 to 2 weeks. Treatment also generates a potentially infectious plume, and evacuation with a vacuum is necessary.

Consider – topical imiquimod

Back
ACUTE
|
filiform wart
Consider – 

topical imiquimod

Additional treatment recommended for SOME patients in selected patient group

Topical imiquimod may be used as an adjunctive treatment to reduce the risk of recurrence.

Daily application to some non-facial lesions may not be tolerated by some patients, so treatment should be modified to application every other day.

Primary options

imiquimod topical: (5%) apply to the affected areas(s) once daily at bedtime for 4 weeks

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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