Best Wart Treatments

Treating warts may not be on par with the professional challenges we face everyday – from generating differential diagnoses to judiciously applying modern diagnostic modalities, and relaying complex medical information in a patient-centered fashion. But what the cutaneous wart lacks in ability to elicit a sense of medical wonder at initial presentation, it makes up for in the ability to generate awe with its recalcitrance.

Recall that spontaneous remission of warts occurs in up to two-thirds of patients within two years. But our impatience with our own immune system has spawned an arms race against the human papillomavirus that calls on us to use everything from duct tape to immunotherapy.

We all occasionally need to be reminded of what the most effective, simple, and readily accessible approaches are for our patients presenting with a new common or plantar wart. Last week, Dr. Justin Ko at Harvard and colleagues commented on the a previously published randomized clinical trial evaluating the comparative effectiveness of cryotherapy, topical salicylic acid, and a wait-and-see approach for leading to clearance of lesions at 13 weeks (CMAJ. 2010;182: 1,624–30).

In this study, 250 patients received treatment. Observed cure rates for the common warts were 39% (30/76) for cryotherapy, 24% (20/82) for the salicylic acid arm, and 16% (13/82) for wait-and-see (P =.001). No significant differences were noted between treatments for plantar warts with cure rates of 30% (11/37) for cryotherapy, 33% (14/43) for salicylic acid, and 23% (10/44) for wait-and-see. Notably, patients with common warts were more satisfied after treatment with cryotherapy (69%) compared with salicylic acid (24%), and wait-and-see (22%; P < .001). No differences in satisfaction were observed with the treatments among patients with plantar warts.

Dr. Ko and colleagues commented that the study “calls into question the current practice of office treatment of plantar warts for curative intent with recurrent sessions.”

Indeed, but the study does not address the most common scenario in our practice, which is a patient reporting that they have exhausted all of the over-the-counter remedies and are asking us to “step up the game.”

For common warts, we will use the cryo-gun; for plantar warts we will perform curettage followed by the cryo-gun. But these studies are hard to do.
What we need is more information on the effectiveness of combination therapy for particularly recalcitrant plantar warts such as curettage and cryotherapy followed by salicylic acid treatment. The arms race continues.

Jon O. Ebbert, M.D., is a professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He declares having no conflicts of interest. The opinions expressed are solely those of the author. Contact him at ebbert.jon@mayo.edu.

Treating warts may not be on par with the professional challenges we face everyday – from generating differential diagnoses to judiciously applying modern diagnostic modalities, and relaying complex medical information in a patient-centered fashion. But what the cutaneous wart lacks in ability to elicit a sense of medical wonder at initial presentation, it makes up for in the ability to generate awe with its recalcitrance.

Recall that spontaneous remission of warts occurs in up to two-thirds of patients within two years. But our impatience with our own immune system has spawned an arms race against the human papillomavirus that calls on us to use everything from duct tape to immunotherapy.

We all occasionally need to be reminded of what the most effective, simple, and readily accessible approaches are for our patients presenting with a new common or plantar wart. Last week, Dr. Justin Ko at Harvard and colleagues commented on the a previously published randomized clinical trial evaluating the comparative effectiveness of cryotherapy, topical salicylic acid, and a wait-and-see approach for leading to clearance of lesions at 13 weeks (CMAJ. 2010;182: 1,624–30).

In this study, 250 patients received treatment. Observed cure rates for the common warts were 39% (30/76) for cryotherapy, 24% (20/82) for the salicylic acid arm, and 16% (13/82) for wait-and-see (P =.001). No significant differences were noted between treatments for plantar warts with cure rates of 30% (11/37) for cryotherapy, 33% (14/43) for salicylic acid, and 23% (10/44) for wait-and-see. Notably, patients with common warts were more satisfied after treatment with cryotherapy (69%) compared with salicylic acid (24%), and wait-and-see (22%; P < .001). No differences in satisfaction were observed with the treatments among patients with plantar warts.

Dr. Ko and colleagues commented that the study “calls into question the current practice of office treatment of plantar warts for curative intent with recurrent sessions.”

Indeed, but the study does not address the most common scenario in our practice, which is a patient reporting that they have exhausted all of the over-the-counter remedies and are asking us to “step up the game.”

For common warts, we will use the cryo-gun; for plantar warts we will perform curettage followed by the cryo-gun. But these studies are hard to do.
What we need is more information on the effectiveness of combination therapy for particularly recalcitrant plantar warts such as curettage and cryotherapy followed by salicylic acid treatment. The arms race continues.

Jon O. Ebbert, M.D., is a professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He declares having no conflicts of interest. The opinions expressed are solely those of the author. Contact him at ebbert.jon@mayo.edu.

Treating warts may not be on par with the professional challenges we face everyday – from generating differential diagnoses to judiciously applying modern diagnostic modalities, and relaying complex medical information in a patient-centered fashion. But what the cutaneous wart lacks in ability to elicit a sense of medical wonder at initial presentation, it makes up for in the ability to generate awe with its recalcitrance.

Recall that spontaneous remission of warts occurs in up to two-thirds of patients within two years. But our impatience with our own immune system has spawned an arms race against the human papillomavirus that calls on us to use everything from duct tape to immunotherapy.

We all occasionally need to be reminded of what the most effective, simple, and readily accessible approaches are for our patients presenting with a new common or plantar wart. Last week, Dr. Justin Ko at Harvard and colleagues commented on the a previously published randomized clinical trial evaluating the comparative effectiveness of cryotherapy, topical salicylic acid, and a wait-and-see approach for leading to clearance of lesions at 13 weeks (CMAJ. 2010;182: 1,624–30).

In this study, 250 patients received treatment. Observed cure rates for the common warts were 39% (30/76) for cryotherapy, 24% (20/82) for the salicylic acid arm, and 16% (13/82) for wait-and-see (P =.001). No significant differences were noted between treatments for plantar warts with cure rates of 30% (11/37) for cryotherapy, 33% (14/43) for salicylic acid, and 23% (10/44) for wait-and-see. Notably, patients with common warts were more satisfied after treatment with cryotherapy (69%) compared with salicylic acid (24%), and wait-and-see (22%; P < .001). No differences in satisfaction were observed with the treatments among patients with plantar warts.

Dr. Ko and colleagues commented that the study “calls into question the current practice of office treatment of plantar warts for curative intent with recurrent sessions.”

Indeed, but the study does not address the most common scenario in our practice, which is a patient reporting that they have exhausted all of the over-the-counter remedies and are asking us to “step up the game.”

For common warts, we will use the cryo-gun; for plantar warts we will perform curettage followed by the cryo-gun. But these studies are hard to do.
What we need is more information on the effectiveness of combination therapy for particularly recalcitrant plantar warts such as curettage and cryotherapy followed by salicylic acid treatment. The arms race continues.

Jon O. Ebbert, M.D., is a professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He declares having no conflicts of interest. The opinions expressed are solely those of the author. Contact him at ebbert.jon@mayo.edu.