How To Treat Recalcitrant Plantar Warts

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Author(s): 
Christina A. Weber, DPM, FACFAS, and Kristine M. Hoffman, DPM

   In addition to the use of oral retinoids, there is fair evidence to support the use of topical retinoids for the treatment of recalcitrant warts.15,16 Gupta showed that weekly debridement and application of adapalene 0.1% gel (Differin, Galderma Laboratories), a topical retinoid, under occlusion resulted in complete resolution of plantar verrucae in an average of 39 days.17 Ilaria and coworkers and Rami and coworkers showed successful use of acitretin for the treatment of resistant viral warts.18,19

   Cimetidine. Cimetidine is a histamine H2-receptor antagonist that inhibits stomach acid production. Clinicians most commonly use cimetidine for the treatment of gastroesophageal reflux disease and peptic ulcers. Research has demonstrated that cimetidine exhibits immunomodulatory activity through increased mitogen-induced lymphocyte proliferation and inhibition of T-cell function at histamine receptor sites.20 Orlow and Paller first showed the successful use of cimetidine to eliminate multiple warts in a study population of 36 children.21 In 2005, Mullen and colleagues showed an 84.3 percent success rate with the use of oral cimetidine (25-40 mg/kg per day) for the treatment of pedal verrucae.22

   Diindolylmethane. Diindolylmethane is a natural phytochemical found in cruciferous vegetables. Diindolylmethane is a natural indole and research has shown it to have in vitro as well as in vivo efficacy in the treatment of HPV-related conditions.23,24 The hypothesis is that diindolylmethane prevents or reduces the growth of warts by promoting apoptosis activity in HPV-transformed keratinocytes.23 An orally active, absorbable formulation of pure diindolylmethane (BioResponse DIM, BioResponse) is commercially available as a dietary supplement. Useful clinical responses to formulated diindolylmethane have occurred in individuals with recurrent respiratory papillomatosis and HPV-related conditions of the airway epithelium.25

   The recommended dosage of Bioresponse DIM is 6 mg/kg twice per day. Side effects include gastrointestinal upset and discoloration of urine. A study conducted in our clinic showed diindolylmethane to be a well-tolerated treatment modality for recalcitrant plantar verrucae with a 94 percent cure rate.26 The mean time first response to diindolylmethane was 2.3 months and the mean time to resolution was 4.1 months.26

What You Should Know About The Efficacy Of Pulsed Dye Laser

The pulsed dye laser selectively targets hemoglobin and dermal blood vessels within the wart tissue. The laser heats the hemoglobin and dissipates thermal energy to surrounding tissues, causing cauterization and leading to a necrotic wart that eventually sloughs off. The pulsed dye laser causes significantly less tissue damage than a standard CO2 laser.

   Patients generally tolerate the treatment well and local anesthesia is not required. Typically, one to three treatments are required for clinical resolution. Researchers have reported success rates of 76 to 89 percent with the use of the pulsed dye laser for treatment of recalcitrant warts.27,28

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