eMedicine Specialties > Dermatology > Viral Infections
Warts, Nongenital: Treatment & Medication
Updated: May 5, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Multiple modalities are available for the treatment of warts, but none is uniformly effective.8,9 Start with the least painful, least expensive, and least time-consuming methods. Reserve the more expensive and invasive procedures for refractory extensive warts. Immunosuppressed individuals often are refractory to wart treatments. Treatment methods are as follows:
- Benign neglect: Providing no treatment at all is certainly safe and cost effective. Consider this as an option, since 65% of warts may regress spontaneously within 2 years. Without treatment, however, patients risk warts that may enlarge or spread to other areas. Treatment is recommended for patients with extensive, spreading, or symptomatic warts or warts that have been present for more than 2 years.
- Topical agents
- Salicylic acid is a first-line therapy used to treat warts. It is available without a prescription and can be applied by the patient at home. Cure rates from 70-80% are reported.
- Several topical agents are available that can be applied by trained personnel in a physician's office.
- Cantharidin is an extract of the blister beetle that causes epidermal necrosis and blistering.
- Dibutyl squaric acid, also known as squaric acid dibutyl ester (SADBE), and diphencyclopropenone (DCP) are contact sensitizers.
- Trichloroacetic acid is a caustic compound that causes tissue necrosis.
- Podophyllin is a cytotoxic compound used more commonly in the treatment of genital warts.
- Aminolevulinic acid (ALA) is a photosensitizer that has been successfully used topically in combination with blue light to treat flat warts.10
- Several prescription medications have proven beneficial in treating warts. These can be applied at home by the patient.
- Imiquimod is an immune response modifier approved for the treatment of genital warts. Reports indicate successful treatment of common warts.11
- Cidofovir is an antiviral agent used for the treatment of cytomegalovirus infection in HIV patients. Reportedly, in 2 patients with recurrent persistent common warts in whom multiple standard therapies were not responsive, the warts were resolved using topical cidofovir gel applied 1-2 times per day. This remains an investigational drug for warts.12
- Podophyllotoxin is a purified ingredient of podophyllin. Since it tends to work better on mucosal surfaces, it is used primarily to treat genital warts. Little information is available regarding treatment of nongenital warts with this medication.
- 5-Fluorouracil is a topical chemotherapeutic agent primarily used to treat actinic keratoses. It has been reported to be effective in treating warts when used under occlusion daily for up to 1 month.
- Tretinoin is a topical retinoic acid that primarily is used to treat acne. It has been successful in treating flat warts.
- Intralesional injections: When warts are persistent and refractory to topical agents, consider intralesional injections as an alternative.
- Intralesional immunotherapy using injections of Candida, mumps, or Trichophyton skin test antigens has been shown to be effective in the treatment of warts, with reports of success in up to 74% of patients.13 (A clinical trial recruiting as of May 5, 2009 is Study With Candida Antigen for Treatment of Warts.)
- Bleomycin is a chemotherapeutic agent that inhibits DNA synthesis in cells and viruses. Cure rates have ranged from 33-92%.14,15
- Interferon-alfa is a naturally occurring cytokine with antiviral, antibacterial, anticancer, and immunomodulatory effects. Cure rates of 36-63% have been reported.
- Systemic agents: Systemic agents that have been used to treat warts include cimetidine, retinoids, and intravenous cidofovir.
- Cimetidine is a type-2 histamine receptor antagonist commonly used to treat peptic ulcer disease. Because of its immunomodulatory effects at higher doses, cimetidine was considered a possible treatment for warts; however, results have varied. Double-blind placebo-controlled studies have shown no benefit.16
- Retinoids are synthetic vitamin A analogs that may help with extensive disabling hyperkeratotic warts in immunocompromised patients. They may help alleviate pain and facilitate the use of other treatments. Retinoids also have helped reduce the number of lesions in immunosuppressed renal transplant patients. The limiting side effects include liver function abnormalities, increased serum lipid levels, and teratogenicity. (A clinical trial recruiting as of May 5, 2009 is bLAC - Treatment of Cutaneous Warts in Immune Suppressed, Kidney Transplanted Patients.)
- Two reports have described intravenous cidofovir used for the treatment of extensive, disfiguring, and refractory warts. This should be used with caution because of the risk of nephrotoxicity.17,18
- Alternative treatments: Several alternative treatments have been reported as successful in treating warts, including adhesiotherapy, hypnosis, hyperthermia, garlic, and vaccines.19,20
- Adhesiotherapy is performed by applying duct tape to the wart daily. This method is painless and inexpensive and has reports of good success.
- Hypnosis has been used to treat refractory warts.21 Several published studies have documented the success of hypnotherapy. Cure rates have been reported from 27-55%, with prepubertal children more likely to respond than adults. Patients in whom hypnotherapy fails may respond to hypnoanalysis for warts.
- Hyperthermia involves immersing the involved surface in hot water (113 º F) for 30-45 minutes, 2-3 times per week.
- Raw garlic cloves have been demonstrated to have antiviral activity. This can be rubbed onto the wart nightly, followed by occlusion.22
- Tea tree oil applied topically has also been reported as successful.23
- Vaccines currently are in development.
Surgical Care
- Cryosurgery24 : Liquid nitrogen (-196ºC) is the most effective method of cryosurgery.
- Apply liquid nitrogen using a cotton bud applicator or cryospray to the recommended 1-2 mm rim of normal skin tissue around the wart.
- Repeat every 1-4 weeks for approximately 3 months, as needed.
- Warn patients about pain and possible blistering after treatment.
- Use with caution on the sides of fingers, since it can injure underlying structures and nerves.
- Other side effects may include scarring, ulceration, or pigment alteration.
- Cure rates of 50-80% have been reported.
- Paring the wart, in addition to 2 freeze-thaw cycles, has been a valuable adjunct to cryosurgery for plantar warts.25
- Lasers: This is an expensive treatment, and is reserved only for large or refractory warts. Multiple treatments may be required. Local or general anesthesia may be necessary. A potential risk of nosocomial infection also exists in health care workers, since HPV can be isolated in the plume and can be inhaled.26
- Carbon dioxide lasers have successfully treated resistant warts; however, the procedure can be painful and leave scarring. One retrospective study revealed a cure rate of 64% at 12 months with carbon dioxide lasers.27
- The flashlamp-pumped pulse dye laser has shown mixed results in treating warts, with decreased risk of scarring and transmission of HPV in the smoke plume.28
- Nd:YAG laser may be used for deeper, larger warts.
- Electrodesiccation and curettage: Although electrodesiccation and curettage may be more effective than cryosurgery, it is painful, more likely to scar, and HPV can be isolated from the plume.
- Surgical excision: Avoid using surgical excision in most circumstances because of the risks of scarring and recurrence.
Medication
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Keratolytic agents
Cause cornified epithelium to swell, soften, macerate, and then desquamate.
Salicylic acid (Compound W)
Available OTC in 5-40% concentration and in a variety of vehicles, including creams, paints, gels, karaya gum, impregnated plasters, collodion, or sodium carboxycellulose tape. Lactic acid may be a second ingredient in some wart varnishes. By dissolving the intercellular cement substance, salicylic acid desquamates the horny layer of skin. Therapeutic effect may be enhanced by removal of surface keratin prior to application.
Adult
Apply topically qd/bid for several wk
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; prolonged use in diabetic persons and those with impaired circulation; do not use on moles, birthmarks, or lesions with hair growing from them; do not use on genital area, face, or mucous membranes; do not use on irritated skin or infected skin
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid contact with normal skin surrounding warts; immediately flush with water for 15 min if contact with eyes or mucous membranes occurs; avoid inhaling vapors; side effects may include irritation and maceration of surrounding normal skin or contact dermatitis to colophony in collodion bases
Podophyllum resin (Podocon-25)
Resin extract derived from May Apple plant that contains several cytotoxic compounds. Has a powerful irritant effect and must be used with caution. Works better on mucosal surfaces than keratinized surfaces and is therefore more commonly used for treatment of genital warts.
Podophyllotoxin (Podofilox) is a purified ingredient of podophyllin and, therefore, is less irritating. Available by prescription and can be applied by patient at home.
Adult
Podophyllin: Trained personnel must apply topically because of adverse effects; may be left on skin for 1-6 h before washing
Podophyllotoxin: 0.5% purified solution may be applied topically bid for 3 consecutive d, repeat qwk, not exceed 4 wk
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; prolonged use in diabetic persons and those with impaired circulation; do not use on moles, birthmarks, or lesions with hair growing from them; do not use on genital area, face, or mucous membranes; do not use on irritated skin or infected skin
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Podophyllin may cause significant irritation, local erosion, ulceration, and scarring; systemic side effects may include fever, nausea, vomiting, confusion, coma, ileus, renal failure, paresthesias, polyneuritis, and leukopenia; avoid extensive application because of risk of systemic absorption; avoid in pregnancy because of teratogenicity
Cantharidin (Verr-Canth)
Dried extract of blister beetle (also termed Spanish fly). Causes epidermal necrosis and blistering.
Adult
0.7% solution: Apply sparingly with wooden end of cotton-tipped applicator in physician's office, and allow area to completely dry; do not cover area with bandage after application; repeat applications at 3- to 4-wk intervals may be required.
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; do not use near eyes, mucous membranes, or anogenital areas; use with caution in intertriginous areas (may lead to more intense painful reactions due to problems with spreading and body occlusion); do not use on lesions with other agents or if surrounding tissue is swollen or irritated
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Strong vesicant; adverse effects include blistering, epidermal necrosis at site of application, and possible "ring wart phenomenon" in which virus is spread circumferentially
Trichloroacetic acid (Tri-Chlor)
Caustic compound that causes immediate superficial tissue necrosis.
Adult
Available as 80% solution that is painted onto lesions in physician's office; apply after excess keratotic debris is pared; repeat therapy qwk prn until wart is cured
Pediatric
Not established
None reported
Documented hypersensitivity; prolonged use in diabetic persons and those with impaired circulation; do not use on moles, birthmarks, or lesions with hair growing from them; do not use on genital area, face, or mucous membranes; do not use on irritated skin or infected skin
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Application may cause pain, burning, and ulceration; if not applied carefully, destruction with resultant scarring of normal surrounding skin may occur
Immunomodulators
Stimulate the release of key factors that regulate the immune system.29
Imiquimod (Aldara)
Induces secretion of interferon alpha and other cytokines; FDA approved for treatment of genital warts in adults; reports indicate success in treatment of common warts in children.
Adult
5% gel applied qd for 3 d/wk; may apply hs and wash off after 6-10 h; twice-daily administration for nongenital warts reported, but irritation may be increased
Pediatric
>12 years: Administer as in adults
None reported
Documented hypersensitivity; breastfeeding; prolonged use in diabetic persons and patients with impaired circulation; do not use on irritated skin or infected skin; avoid sun exposure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Local irritation including redness, itching, and burning may occur at application sites
Dibutyl squaric acid/diphencyclopropenone
Contact sensitizers that induce allergic contact dermatitis, causing a localized inflammation and immune response.
Adult
Apply solution in light-shielded accessible location (eg, arm) to achieve initial sensitization; repeat until reaction occurs; apply to warts q1-2wk
Pediatric
>12 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Erythema and pruritus occur at treated sites; occasionally, allergic contact dermatitis may be severe (blistering) or become disseminated (unusual); recall dermatitis may occur at initial sensitization site (common); regional lymphadenopathy may occur
5-Fluorouracil (Efudex, Adrucil, Fluoroplex)
Topical chemotherapeutic agent that is approved to treat actinic keratoses and superficial BCC; has been found more successful in treatment of flat warts than plantar and common warts.
Adult
Apply 5% solution or cream daily for up to 1 mo; may be used under occlusion, but risk of irritation increases
Pediatric
Not established
None reported
Documented hypersensitivity; breastfeeding
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Moderate-to-severe irritation may occur
Antineoplastic agents
Inhibit cell growth and proliferation.
Bleomycin (Blenoxane)
Cytotoxic polypeptide that inhibits DNA synthesis in cells and viruses. Has affinity for HPV-infected tissue and induces vascular changes that result in epidermal necrosis. Has been beneficial in treating resistant warts. Reserve as a third-line treatment when standard therapies have failed.
Adult
Inject 0.5-1 U/mL solution directly into wart; not to exceed 1.5 U/treatment; less painful administration involves placing 1 mg/mL gtt onto wart and pricking it into wart with needle
Pediatric
Not established
May decrease plasma levels of digoxin and phenytoin; cisplatin may increase toxicity of bleomycin when administered systemically
Documented hypersensitivity; significant renal function impairment; compromised pulmonary function; breastfeeding
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause pain with injection, local urticaria, vaso-occlusive phenomenon (Raynaud phenomenon) with distal necrosis of digit; permanent damage to nail matrix may occur when used periungually; may cause mutagenesis and pulmonary toxicity (10%); idiosyncratic reactions similar to anaphylaxis (1%) may occur; monitor for adverse effects during and after treatment
Interferons
Interferon alfa-2a and alfa-2b (Roferon and Intron A)
Naturally occurring cytokine with antiviral, antitumor, and immunomodulatory actions; intralesional administration more effective than systemic administration and associated only with mild flulike symptoms. Treatments may be required for several weeks to months before beneficial results are seen. Consider this treatment as third line, and reserve it for warts resistant to standard treatments.
Adult
Inject directly into warts up to 3 times/wk for 3-6 wk
Pediatric
Not established
Theophylline may increase toxicity; cimetidine may increase antitumor effects; zidovudine and vinblastine may increase toxicity
Documented hypersensitivity; use with caution in patients with brain metastases, severe hepatic or renal insufficiencies, seizure disorders, multiple sclerosis, or compromised CNS
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Transient flulike symptoms may occur after initial injections; however, tolerance usually develops; pain at injection sites may occur
Histamine H2 receptor antagonists
Cimetidine (Tagamet)
Type 2 histamine receptor antagonist commonly used to treat peptic ulcer disease; due to immunomodulatory effects at higher doses, has been used as treatment for warts. Results have been variable, and double-blinded, placebo-controlled studies have shown no benefit.
Adult
20-40 mg/kg PO qd divided q6h; not to exceed 2400 mg/d
Pediatric
20-40 mg/kg/d divided q6h
Can increase blood levels of theophylline, warfarin, tricyclic antidepressants, triamterene, phenytoin, quinidine, propranolol, metronidazole, procainamide, and lidocaine. Multiple potential drug interactions exist (see full prescribing information for more details).
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Serious reactions may include neutropenia, thrombocytopenia, agranulocytosis, and anemia; common reactions include headache, nausea, vomiting, diarrhea, and rash; older patients may experience confusional states; may cause impotence and gynecomastia in young males; may increase levels of many drugs; adjust dose or discontinue treatment if changes in renal function occur
Retinoids
May be helpful in immunocompromised patients with extensive disabling hyperkeratotic warts. May help alleviate pain and facilitate use of other treatments. In addition, retinoids have helped reduce the number of lesions in immunosuppressed renal transplant patients. Topical retinoids may be useful in treating flat warts.
Isotretinoin (Accutane)
Synthetic 13-cis isomer of the naturally occurring tretinoin (trans -retinoic acid); structurally related to vitamin A. Approved for severe nodular acne but has also been helpful in certain keratinization disorders.
A US Food and Drug Administration–mandated registry is now in place for all individuals prescribing, dispensing, or taking isotretinoin. For more information on this registry, see iPLEDGE. This registry aims to further decrease the risk of pregnancy and other unwanted and potentially dangerous adverse effects during a course of isotretinoin therapy
Adult
0.5-2 mg/kg/d PO divided bid with food
Pediatric
>12 years: 0.5-2.0 mg/kg/d PO divided bid with food
Toxicity may occur with vitamin A or acitretin coadministration; pseudotumor cerebri or papilledema may occur when coadministered with tetracyclines; reduced plasma levels of carbamazepine
Documented hypersensitivity, pregnancy, breastfeeding, paraben sensitivity, history of psychiatric disturbance
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Common reactions include dry skin, cheilitis, photosensitivity, hypertriglyceridemia, hair loss, and decreased night vision; inflammatory bowel disease may occur; may be associated with development of hepatitis; diabetes patients may experience problems in controlling blood glucose while on therapy; discontinue treatment if rectal bleeding, abdominal pain, or severe diarrhea occurs; caution if history of depression or other psychiatric disorders; associated with severe birth defects; females must use 2 forms of birth control throughout therapy and pregnancy tests must be checked qmo
Antiviral agents
Cidofovir (Vistide)
Nucleotide analog that inhibits viral DNA polymerase and induces apoptosis. Currently, only available for IV administration to HIV patients for treatment of cytomegalovirus infection. A topical gel has been evaluated in clinical trials for use in treatment of HPV infection.
Adult
Not established
Pediatric
Not established
Coadministration of aminoglycosides, amphotericin B, IV pentamidine, and foscarnet may increase nephrotoxicity
Documented hypersensitivity; coadministration with other nephrotoxic agents; serum creatinine >1.5 mg/dL; CrCl <55 mL/min; urine protein >100 mg/dL
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor neutrophil counts; IV prehydration with NS and coadministration of probenecid can minimize nephrotoxicity; monitor serum creatinine and urine protein 48 h prior to treatment (adjust dose accordingly); topical cidofovir may cause erythema and irritation
More on Warts, Nongenital |
| Overview: Warts, Nongenital |
| Differential Diagnoses & Workup: Warts, Nongenital |
 Treatment & Medication: Warts, Nongenital |
| Follow-up: Warts, Nongenital |
| Multimedia: Warts, Nongenital |
| References |
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Further Reading
Keywords
nongenital warts, human papilloma viruses, HPV, common warts, verruca vulgaris, flat warts, palmoplantar warts, myrmecia, focal epithelial hyperplasia, Heck disease, plantar cysts, epidermodysplasia verruciformis, verrucous carcinoma, filiform warts, Koebner phenomenon, butcher's warts, hyperproliferative cauliflowerlike lesions, mosaic wart, cystic warts, plantar epidermoid cysts, epidermal inclusion cyst
