Are We Compelled To Treat Warts?

Bryan Markinson DPM FASPD

Every practicing DPM understands the enigmatic and unpredictable nature of warts and wart treatment. Frustration is not uncommon on the part of patients and clinicians.

As time goes on, we try more and more treatments, and those treatments join the ever-growing pile of “mediocre” treatments. It can be puzzling when one treatment we use clears one patient in a few weeks yet has no effect on another patient. In discussions with colleagues, it is also not uncommon to hear claims of favorite treatments that work “most of the time.”

In this blog, I would like to change course and ask you the following question: Does the presence of warts compel us to treat them? If yes, why? What factors into the decision to treat?

For myself, I believe the majority of warts resolve spontaneously on their own when they are ready. I have yet to witness the scenario I learned in podiatry school that leaving warts alone will result in them overtaking the entire skin envelope. Yes, there is certainly local spread and I have seen some impressive cases in the immunosuppressed but these are not the rule.

Therefore, unless warts are painful and affecting one’s activities of daily life, I increasingly recommend no treatment at all. What say you, colleagues?

Comments

I believe warts and sweaty feet are related especially during puberty or pregnancy. Control the excess perspiration, and the warts will resolve in time. If the wart is not getting worse during the watchful waiting, you are winning.

The last one I excised (I rarely do this) came back squamous cell carcinoma. It appeared as any other wart. Skin color, perfectly round, border regular, cauliflower texture. I am trying not to let that influence my decisions from here out! But its pretty hard. It's all about education, if they are not bothersome, educate them as to the usual benign course and life cycle. Unfortunately, most of the time patients come to me because it is a concern due to pain or cosmesis. So, they are looking for treatemnt. I once read that if you wait as long as 2 years, all warts die off by that time. Not true, from what I can tell. On a personal note, as I go into my 10th year of practice, I am finding that, strangely, I dont like to even see warts anymore! I feel that no matter how much I educate, and how hard I try to tell patients about the multiple treatments for warts and there variable efficacy, I think patients tend to "give you" 2 cracks at it then they go shop it around. Indeed, half of my new wart patients seem to have had it treated by someone else already. They usaully say, dismissively, that this other doc "just put some stuff on it", or "tried to freeze it". Then I try to explain to them that I'm going to do the same thing...with different stuff! I think thats why docs like lasers, its no more efficacious, but sure as heck looks like something "more advanced" to the patient. Michael Munson, DPM Columbia, SC

Great topic, Dr. M. Should inconsistent outcomes determine podiatric treatment choices? If DPMs don't treat these, even with a similar explanation, patients are likely to go elsewhere -- another podiatrist or dermatologist. Quick story -- my 10 year old daughter had issues with a finger wart that wouldn't resolve, and a plantar heel wart that was causing discomfort. I took her to a dermatologist, largely for an education in their treatment approach. He burned off the finger wart, then explained that plantar warts reappear more than half the time, and that he didn't want to subject her to the painful treatment, given the likely outcome. Instead he recommended 4 weeks of 'home treatment' (nightly application of WartStick, pumice debridement, 'wait and see'). I was suprised at the strategy. Even moreso when it worked and the wart dissapeared. I recommend DPMs do what they know works, even if only a percentage of the time, with the vital sharing of realistic expectations a comparably important part of treatment.

I had a patient about 15 yrs ago with one foot solid wart & other foot about 2/3 wart & was spreading to his children as well. He had gone 6 year before without any care. If wart is growing, spreading or painful it is certainly our obligation to treat. A Landis DPM

Yes we should treat them. I personally have great success and satisfaction in treatment of this condition. If it is not painful, there is a psychosocial aspect of this that the patient has come in for. After explaining what a wart is, and my recommended treatment, the patient always has the option not to treat. I wouldn't hesitate to say that our treatment regimen, usually two to three weeks in length, is 95% successful. It may be more. We do topical treatments progressing from cantharidin through efudex and aldara, to cimetidine. I can only remember a hand full of failures in the past seven years. Of course we often fail to register those patients that just don't return when we talk about our successes. Although, I always know because it is part of our protocol to see every chart of every patient that cancels or no-shows. Jon Purdy, DPM

No pain, no spreading, no local growth ( increase in diameter) and no psycho-social concerns = no treatment.

David Gurvis, DPM

Warts can be left alone. If some treatment is chosen, I start with simple sal acid plaster.
If the warts are large or multiple, I sometimes try Aldara or Carac. Laserformalyde may work and is cheaper.

So far, I have not seen a big need to start cutting them out.

If a patient has a problem with my regimen, they are free to find a laser, a scalpel, or some crazy apparatus in some other medical building. Picking up a blade and being a big surgeon is an urge that many of us podiatrists can not resist.

Dr.Markinson is correct as usual.

Vladimir Gertsik, DPM
New York

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