How To Treat Recalcitrant Plantar Warts

Christina A. Weber, DPM, FACFAS, and Kristine M. Hoffman, DPM

Current Insights On Surgical Excision Of Recalcitrant Warts

Pringle and Helms showed that blunt surgical dissection can have a 90 percent cure rate for warts.29 This surgical technique involves administering a local anesthetic block with subsequent, standard surgical skin preparation of the skin. Then one would circumscribe the margins of the lesion with a curette or scalpel to create a plane of dissection from the surrounding normal skin. Blunt dissection then continues along the cleavage plane, eventually removing the wart in a single piece.

   Physicians should take care not to enter the dermis on dissection due to the potential to create painful scar tissue with healing. One can then apply electrocautery to the wound bed following excision.

What The Authors Have Found To Be Successful

We have found that evaluating the wart size, number, depth and response to prior treatment modalities are key factors in the treatment of recalcitrant warts. In our practice, we have found that solitary, recalcitrant lesions respond well to a single injection of 0.1-2.0 IU of bleomycin. We have found that painful myrmecia lesions respond well to surgical excision. Diindolylmethane supplementation is a well-tolerated, successful adjunctive treatment when multiple wart lesions are present.

   Clinicians should obtain a punch biopsy for histopathological diagnosis if there is a suspicion for underlying malignancy or if any lesion shows resistance for several months to multiple treatment modalities.

Case Study One: When A Patient Presents With Multiple, Painful Plantar Warts

A 51-year-old female presented to our clinic with a complaint of multiple painful plantar warts of three years in duration. Past treatment included seven cryotherapy treatments and topical 40% salicylic acid for 15 weeks. The physical exam showed a cluster of plantar verrucae measuring 2.0 cm x 1.5 cm to the plantar midfoot with numerous immediate satellite lesions, two solitary verrucae to the distal forefoot near the third and fourth metatarsal heads, and two lesions to the plantar hallux, all on the right foot. Additionally, there was a single plantar verruca to the left forefoot.

   Our treatment consisted of debridement, cantharidin (Cantharone, Dormer Laboratories) treatment under occlusive dressing and diindolylmethane supplementation of six 150 mg capsules per day in divided dosage. At four weeks, there was a decrease in the size and number of verrucae. We increased the diindolylmethane dosage to eight 150 mg capsules per day to enhance the response to diindolylmethane and repeated debridement and the use of cantharidin. Five weeks later at her third office visit, there was complete resolution of all verrucae.

Case Study Two: Addressing Recurrent Plantar Warts In A 17-Year-Old Swimmer And Wrestler

A 17-year-old male swimmer and wrestler presented to our clinic with recurrent verrucae to his heel of several months duration. Past treatment included multiple cryotherapy treatments. The physical exam revealed a large plantar verruca on the left heel measuring 10 mm x 19 mm with multiple smaller satellite lesions. His initial two office visits to our clinic one month apart consisted of debridement of the skin lesion and application of cantharidin under occlusion followed by daily home applications of 60% salicylic acid.

   The lesions persisted so we recommended diindolylmethane supplementation of six 150 mg capsules per day in divided dosage, which the patient started one month after his second office treatment. At his third office visit two months later, there was complete resolution of the verrucae lesions.

In Summary

When it comes to the treatment of recalcitrant warts, there are numerous modalities including topical treatment, intralesional injections, oral medication/supplementation, laser treatment and surgical excision. We recommend a punch biopsy for confirmed histopathological diagnosis for all suspicious lesions and lesions that fail to respond to conventional treatment modalities.

   Dr. Weber is a Fellow of the American College of Foot and Ankle Surgeons. She is in private practice in Boulder, Colo.

   Dr. Hoffman is in private practice in Boulder, Colo.

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