Guidelines for the Management of Cutaneous Warts

November 6, 2014

Guidelines for the Management of Cutaneous Warts

  1. Craig A. Elmets, MD

Guidelines point to the need for new, reliable wart treatments and help to provide an evidence-based rationale for currently available treatments.

  1. Craig A. Elmets, MD

Sponsoring Organization: British Association of Dermatologists

Target Population: Primary care providers, dermatologists, pediatricians

Background and Objective

Warts, or verrucae, are a common skin condition caused by human papilloma virus (HPV) infection. More than 150 genotypes have been identified. HPV types 1, 2, 4, 27, and 57 are the most frequent strains in common warts, and HPV 3 and 10 cause plane warts (verruca plana). Compilers of these guidelines reviewed research on the management of warts published between January 1999 and March 2014 in the English-language literature.

Key Points

  • Meta-analysis shows preparations containing salicylic acid as the active ingredient — the most common destructive wart therapy — to be more effective than placebo but less effective than cryotherapy for warts of the hands.

  • Liquid nitrogen cryotherapy is the most common treatment used by physicians. Results for plantar warts, but not hand warts, can be improved by paring the wart prior to treatment. The median cure rate with cryotherapy is 49%. It is more effective on the hands than on the feet. After 6 weeks, cryotherapy every 4 weeks produced cure rates equal to treatment every 2 to 3 weeks.

  • No high-quality studies have evaluated curettage, cautery, or CO2 laser treatment.

  • A few studies show that photodynamic therapy with topical aminolevulinic acid and pulsed dye laser are more effective than placebo. These methods may be combined with other therapies.

  • Topical 5% 5-fluorouracil applied with occlusion for up to 4 weeks has been shown to cure up to 95% of warts. In addition, 0.5% 5-FU in combination with salicylic acid was significantly better than salicylic acid alone. Several open-label studies show response rates of 65% to 85% with intralesional bleomycin, albeit with possible pain at the injection site.

  • Topical retinoids are effective primarily for flat warts.

  • Diphencyprone and squaric acid dibutylester are immunomodulatory agents seen in retrospective studies to regress warts in >85% of patients. Similar results were noted with intralesional candida, mumps, and tuberculin antigens. H2-receptor antagonists are thought to augment cell-mediated immunity. Cimetidine, however, was ineffective in randomized, controlled trials. Ranitidine was found to cause complete wart regression in 49% of patients in an open-label study. Imiquimod, used primarily for condyloma acuminata, was reported in open-label trials to regress 50% to 76% of cutaneous warts.

  • Little evidence supports alternative therapies — acupuncture, homeopathy, hypnosis — as effective wart treatments.


Despite frequent use, few wart treatments have received large randomized clinical efficacy trials. Based on the published literature, estimated cure rates of placebo administered for 3 to 4 months are 20% to 30%, which complicates interpretation of nonrandomized studies. These guidelines highlight the need for new, reliable wart treatments and help provide an evidence-based rationale for currently available treatments.

Editor Disclosures at Time of Publication

  • Disclosures for Craig A. Elmets, MD at time of publication Consultant / Advisory board Astellas Pharmaceuticals Grant / Research support NIH; NIH/NCI; Veteran’s Administration; Ferndale Laboratories; Abbvie Editorial boards Cancer Prevention Research; Photodermatology, Photoimmunology, & Photomedicine; UpToDate; eMedicine; Journal of Dermatological Sciences Leadership positions in professional societies American Academy of Dermatology (Chair, Clinical Guidelines and Research Committee); Photomedicine Society (Board of Directors)


Reader Comments (2)

marthaapodaca83 Resident, Other

Very useful article for me and other people who are facing this problem. I was also suffering from Plantar warts . It is a very embarrassing problem since it leaves marks on our parts of our body . Thanks alot

Jules LEROY Physician, Pediatric Subspecialty, Retired from clinical in hospital work

Useful summary of treatment of a very common problem.

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