Treatment of Verruca Vulgaris

Abstract

A 14-year-old boy presented with a 5-mm wart on his ankle (Figure). His mother was given the option of various destructive measures. She chose cryosurgery. Liquid nitrogen was applied to the area with a Brymill Mini-Cryogun (Brymill Cryogenic Systems, Ellington, CT) in three 10-second bursts, with intervals of total tissue thawing. One month later, there was only residual mild macular erythema, but no wart was present in the area where the wart had been.No treatment eradicates all warts in all cases, and 20%-40% of verruca vulgaris (VV) will disappear over 1-2 years without treatment. Since VV causes morbidity and can spread, treatment is medically necessary. Treatment does not prevent wart dissemination, because the papilloma virus remains in the skin. 1 As straightforward as the use of liquid nitrogen could be, controversy exists surrounding its optimal use. For example, a 10-second cryogun application of liquid nitrogen to VV is more effective than shorter applications. 2 According to one study, cryogen gun and cotton tip with liquid nitrogen are equally effective. 3 The use of a double freeze-thaw cycle confers little or no advantage over a single freeze in hand VV treatment, but may be useful in plantar VV treatment. 4 Two freeze-thaw cycles and paring before freezing in one study improved the cure rate for plantar warts but not hand VV. 5,6 The optimal therapeutic interval between VV treatments is unclear, although one study noted that cure relates to the number of treatments rather than the frequency of treatments.Salicylic acid is an initial therapy for flat warts on the face, plantar warts, and flat and common warts on the hands. An evidencebased study 7 identified topical therapy with salicylic acid as safe and effective and reports that no clear evidence exists to prove that other therapies have an advantage in regard to higher cure rates or fewer adverse effects. Also noted was that six randomized clinical trials demonstrated a cure rate of 75% in those treated with salicylic acid compared with 48% in the control group. Salicylic acid-podophyllin-cantharidin combinations can be helpful for treating warts in children (81% effectiveness in one study). 8 Duct tape may have a role in treating VV. A study noted that of 51 patients, 26 (51%) were treated with duct tape and 25 (49%) were treated with cryotherapy; 22 patients (85%) in the duct tape arm vs. 15 (60%) in the cryotherapy arm had complete resolution of their VV; however, this has not been the case for me. 9 Electrodesiccation, pulse dye laser, and photodynamic therapy can treat VV, but they have not been shown to be more effective than cryotherapy.Several studies using imiquimod, which is only indicated for the condyloma, note high cure rates when applied twice daily for 2-12 months or once a day and occluded for 4 weeks. I have never found imiquimod useful in treating VV. Using a bifurcated needle, bleomycin sulfate (1 mg/mL sterile saline solution) can be introduced into warts with excellent effectiveness, but with many possible side effects. Or...

Treatment of cutaneous viral warts in children: A review

“…Due to warts being thicker on the soles, as well as the persistent friction from footwear, the rates for clearance of plantar warts is generally lower and slower than warts at other sites 9,27 . Paring hyperkeratotic warts, especially palmar or plantar warts, using a surgical blade is recommended before application of cryotherapy, to increase the efficacy of treatment 28 . Interestingly, a study using an N 2 O gas operated machine for 1 to 2 minutes, applied once every fortnight reported a clearance rate of 100.0% over 75 days for eight patients 26 …”

“…9,27 Paring hyperkeratotic warts, especially palmar or plantar warts, using a surgical blade is recommended before application of cryotherapy, to increase the efficacy of treatment. 28 Interestingly, a study using an N 2 O gas operated machine for 1 to 2 minutes, applied once every fortnight reported a clearance rate of 100.0% over 75 days for eight patients. 26 The most common side effects of cryotherapy are pain and blistering.…”

“…19,20 • Paring before cryotherapy is recommended for hyperkeratotic plantar or palmar warts. 28 Salicylic acid (SA) monotherapy and combination therapies…”