Exploring Current Approaches To Plantar Warts

By Harvey Lemont, DPM

      In general, plantar warts are very difficult to treat and pose a certain challenge to physicians and their patients. Both physicians and patients should not be discouraged by an initial poor result. With proper communication between the doctor and patient, one can achieve realistic outcomes.       Too often, doctors downplay treatment, only to be reproached by a frustrated and angry patient who received unrealistic expectations. For example, the treatment of chemosurgery using acids may take as long as six weeks. If the warts resolve in three weeks, the patient is delighted and may consider the doctor a hero. Podiatric physicians should tell patients what to expect in terms of treatment regimens and outcome before initiating any treatment.       Before starting treatment, one should also inform patients that there may be recurrence of some of the warts either during or after treatment. Inform the patient this is common and those warts will need to be retreated. Patients should also get realistic estimates of the doctor’s success rate for treating certain kinds of warts. For example, I tell patients that there is an initial 75 percent chance of total cure rate with simple plantar warts but perhaps only 50 percent when dealing with mosaic warts. Other DPMs’ figures may be higher or lower. What matters is that the doctor and the patient are on the same page.       One should also inform patients of the risk, albeit small, of painful scarring or painful callus formation at the wart site. The use of electrocoagulation or inappropriate use of cutting lasers are more common culprits in this regard. Patients also should be aware there is no panacea for all warts. The modality one selects should be based on the individual patient’s presentation. For example, is the patient a child, a very nervous adult or does he or she have a low pain threshold? Try prescribing over-the-counter acid preparations such as salicylic acid under occlusion. These medications are safe and effective in uncomplicated cases.       The duration of the warts is also a factor in determining treatment. How long have the warts been present? Has the patient had the warts for two months or two years? Patients who just developed a batch of warts may not be psychologically prepared to undergo certain treatment regimens if they perceive an aggressive or prolonged course of treatment.       Other factors include the type of warts. Are you looking at mosaic warts or simple plantar warts? Extensive mosaic warts are a challenge quite distinct from other plantar warts. Initial surgical removal of mosaic warts as a rule is not indicated because of the high rate of recurrence within scar tissue. One should first try a more conservative initial approach using oral medications like high dose oral vitamin A and cimetidine, or even placebo therapy. It has been estimated that anywhere from 30 to 70 percent of patients with warts may respond to a placebo.       Is the patient immunocompromised? Immunocompromised patients with extensive warts are not only particularly predisposed to developing warts but eradicating these warts is also much more difficult. Before initiating treatment, one should tell patients who are on steroids (even those on low dosages), patients with diabetes and patients with hepatitis or AIDS that their treatment may be prolonged, recurrences are common, and the treatment in some cases may not work at all. These patients may do well with contact immunotherapy using squaric acid, dinitrochlorbenzene (DNCB) or Candida albicans antigen injections.       The doctor should evaluate all prior treatments and ask how they were applied. One might opt, for example, to select a previously “failed” treatment plan used by another doctor but modify its protocol. A common example is a failed chemosurgical approach that allowed the patient to bathe after treatment. Allowing the patient to bathe after the application of an acid dilutes the acid concentration in the tissue and prevents the acid from working. For isolated, sharply demarcated warts, blunt removal of a wart is a safe and effective option.

Add new comment