Treatment of warts are very cumbersome both for the doctors and patient. Not all warts require treatment as few of many will have pain while few of many will have self-resolution. However, self-resolution may take variable form 1-5 years.
Simple advices to the patient help to prevent the spread of the infection. Subungual and periungual wart are more come in nail bitter, such practice should be strictly discouraged in patient with common warts on the hands. Used of application adhesive strapping after the application ‘wart paint’ help to prevent nail bitting habits. Planter warts should be covered with adequate plaster strapping. Use of sandals at swimming pools, shower and communal baths, and use of close fitting rubber ‘verrucous socks’ should be encouraged.
No single treatment will help in all type of warts. Different types of wart will require different site dependent treatment and combination of treatment. (20A) In 1995, American academy of dermatology proposed the guidelines for indication of treatment of viral warts which includes 1)symptoms of bleeding, pain, burning or itching 2) disabling or disfiguring lesion 3) large size and numerous lesion 4)immunocompromised patient 5)patient’s desire for the therapy 6) patient’s desire to prevent the spread of lesion to self or others. (56A)
Aims of treatment of warts should be: 1) to remove wart with no recurrence 2) to produce lifelong immunity 3) to produce no scars. (20A)
Treatment of wart is divided into:
1) First line therapy: treatment can be used by patient at home
2) Second line therapy: they are administered by the treating physician, more time consuming and mostly destructive type.
3) Third line therapy: they are considered only for the recalcitrant or severe infection.
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FIRST LINE THERAPY:
1) Folk and alternative remedies
Historic folkfore remedies were the reminder that warts resolve spontaneously. Famous folkfore is “Rub a dusty, dry toad on warts, and they will disappear”.
There are many case report and studies of complete resolution of wart with hypnosis or autosuggestive therapy.(63,64A). hypnosis could stimulate the immune system which leads to resolution of lesion. However this treatment is not time tested.
Allium sativum (component of garlic) have antiviral activity and it prevent the proliferation of virus infected cells. (70A). One place bo controlled study shows the complete clearance of the wart after application of chloroform extract of garlic, with no recurrence after 3-4 months.(72A)
In 1978, Dr. Jerome Litt showed for the first time the complete clearance of the wart by using duct tape.(73A) This treatment again come to light in 2002 when Dr.Foch compare duct tape therapy with cryotherapy. (74A). Duct tape is applied over the wart and remove it after the 6 days Pumice stone or emery board is used to scrub the wart after soaking in water and then left open overnight. The next 6-day cycle is repeated following morning. The mechanism is still speculative. Distant warts also respond well which raise the possibility of immune stimulation by local irritation. It is ideal treatment for the children as this completely painless therapy.
2) Salicylic Acid
Salicylic acid is the first line of treatment for most of the patient, as it over the counter available drug. It is keratolytic agent which reduce the virus affected epidermal thickness and also stimulate the immune system through local irritant action. It is available in market in concentration ranging from10 to 60%.(93A) Over the counter available preparation is 17 % salicylic acid with 17% lactic acid in flexible collodion or acrylate base. Compliance is very important in this therapy. Warts should be soaked in warm water for 5 minutes and then debride with pumice stone, emery board or foot file which lead to removal of dead hyperkeratotic debris and increase the penetration of the drug. It is to be applied with fine applicator like match sticks or a cocktail sticks which prevent surrounding tissue damage. After drying, whitish deposits form. Response can be enhanced using occlusive adhesive tape which promotes the maceration of hyperkeratotic lesions and reduce the barrier function. (74 rooks). The advantages includes minimal cost, convenience of application, painless and reasonably effective. Disadvantages are occasional chance of irritant contact dermatitis, results require weeks to months and potential risk of systemic toxicity in children if higher concentration and higher amount is applied.plantar warts responds well to salicylic acids with occlusion as compare to hand warts.(97A). Wart paint should not be used over the facial wart, it can cause severe irritation and scarring. (20A repeat)
It is virucidal and available as 10% concentration in aqueous ethanol base preparation. It is typically applied twice a day and, can harden the skin and stain the skin brown which limit its use (1A Repeat). It can also cause contact sensitization. 20% glutaraldehyde produced a cure rate of 72%. No randomized control trial of glutaraldehyde in warts treatment have been published. (19A)
It is also virucidal agent which disrupt the upper epidermis and destroy the virons.2-3% formalin in water soaks or compresses may be effective for the plantar wart with cure rate of 80% in children in reported study. Disadvantages are chance of irritant contact dermatitis in surrounding normal skin and its harden the lesional skin. Formalin is preservative in many cosmetic products like shampoos and lotions, can cause contact sensitization , so should be avoided in patient with eczema and allergies. (1A)
Monochloroacetic acid, tichloroacetic acid, silver nitrate, phenol and formic acid have caustic irritant effect, so use in warts therapy but it may cause painful reaction. The peeling agent, glycolic acid and pyruvic acid can be useful for plane warts treatment. (97 rooks)
It is derived from cantharis vesicatoria, blister beetle. It is applied over the pared wart with occlusive tap for 24hours, blister will form and resolved within next 1-2 weeks (83A). Such cycle should be repeated very 1-3 weeks. (93A repeat).