Dr. Dockery: Do you have a single favorite topical or chemical treatment that you use for a patient who presents to your office for the first time with warts?
Dr. Salk: I typically will use 5-fluorouracil (5-FU). It’s a treatment course that I’ve had great success with over the last two years. Generally, my patients want to get rid of this virus as quickly as possible. I’ve had patients who told me they don’t want to try salicylic acid therapy over again. They’ve tried this with other doctors or they’ve done home therapy with OTC products.
My first line of treatment is 5-fluorouracil. The drug has FDA approval for actinic keratoses and basal cell carcinomas. The interesting aspect of 5-fluorouracil is that it inhibits DNA synthesis and also has an affinity toward the virus or abnormal tissue. Therefore, the drug isolates itself directly to the human papilloma virus without affecting the surrounding tissues unlike salicylic acid or cantharidin or other types of treatments that are destructive in nature. We have found 5-fluorouracil to be a very innovative treatment approach and we have had great success.
We are currently conducting a controlled clinical trial on 5-fluorouracil. One part of the treatment arm is using 5-FU with tape occlusion versus tape occlusion alone. The reason why we have tape occlusion alone is because of Dr. Focht’s article on duct tape in October 2002 in the Archives of Pediatrics and Adolescent Medicine that showed 85 percent efficacy for duct tape.2
In our controlled trial of 40 adult patients, we have already seen that 10 out of 10 patients with 5-FU have had clearance of their warts, and only one out of nine without 5-FU have had clearance with an occlusive tape similar to duct tape. The preliminary results of this study have already shown for me that 5-FU is an excellent conservative treatment modality.
Dr. Chang: I actually agree a fair amount with Dr. Salk and 5-FU has really become a standard now in our practice. It is nice to see our own anecdotal results over the years confirmed with the early findings in our study. However, I feel combination therapy is an extremely important concept that makes a difference. Yes, we have the ability to apply something topically but we also have the ability to actively and aggressively debride the lesion. That is a true benefit of going to a podiatrist because podiatrists debride lesions well and that’s something that patients cannot do as well at home.
Then we always couple debridement and the topical with occlusion therapy. Each of these three treatment options has been shown to work by itself, but I think it’s pretty powerful when you combine all three. I know mono- and trichloroacetic acid have been helpful but I think, whatever topical you choose, when you combine it with debridement and occlusion, it will probably exponentially increase your chances of success, especially in the frustrating resistant ones.
Dr. Dockery: Dr. Lemont, do you want to comment on that?
Dr. Lemont: My experience with 5-FU has not been as glowing. This may be due to the fact that we have a separate dermatology clinic here and most of the patients who see us at the foot and ankle institute have more advanced warts. They tend to be more numerous in presentation and are more difficult to treat.
In terms of topical treatments, for the last 35 years, I have basically stuck with one thing that works. From time to time, I try various other topicals because they were touted. I tried 5-FU, which works very well for Bowen’s disease. My mainstay treatment is monochloroacetic acid and I like it because it destroys the wart. Monochloroacetic acid works directly as a chemo-surgical agent to destroy tissue. Even though it is destroying tissue, the amount of scarring is minimal compared to other forms of therapy in terms of surgery. Scarring isn’t an issue when you’re using monochloroacetic acid. I make up my own solution and I actually make up 100 percent solution. I weigh 100 grams of crystals and add (qs) back to 100 cc of water.
I like topical monochloroacetic acid but I don’t think that’s where the story ends. Too often, a lot of podiatrists allow the patients to get the bandage wet. I don’t. I’ll apply monochloroacetic acid, I’ll apply moleskin and Elastoplast. I will tell them they’re going to have redness and they may have swelling, aseptic lymphangitis and/or some pain, but they should leave it on. Usually within one or two visits, there’s enough tissue that’s destroyed to full-thickness skin. In a sense, topical monochloroacetic acid works as a surgical procedure (chemosurgery) and I can count on it. There are a lot of things to try, but this is what I count on and I know it works.
Dr. Dockery: I have used monochloroacetic acid with pretty good results. My other problem with this acid, as well as with canthardin and other blistering compounds, is that it is inconsistent from patient to patient. My experience with topically applied 5-fluorouracil 1% has been fair with about a 60 percent resolution rate. Now, I’m talking about using this on small single warts only with daily application for one or two weeks. I still recommend its use but I think there are other topicals that work just as well, if not better. I actually like to use imiquimod 5% cream on warts. I have the patient apply a small amount on the warts daily. For larger warts or the mosaic type of warts, I debride the wart tissue to pinpoint bleeding and then apply the imiquimod, and cover it with moleskin dressing. This is then repeated weekly.3
Exploring Different Approaches
To Combination Therapy
Dr. Dockery: I do want to get back to Dr. Chang’s comments about combination therapy. Now for patients who have not had previous therapy, I would start with monotherapy. If we start off with monotherapy and it doesn’t respond quickly and in the style we would appreciate, then we can become more aggressive and start using combination therapy.
Dr. Chang: Dr. Dockery, I’ve always been intrigued listening to you lecture on supplements that you have found useful in treating warts, whether it’s zinc, vitamin A, combinations of that, and maybe an oral cimetidine. We will also implement this as part of the combination approach. I’m just wondering if you still use supplements as part of your initial treatment. How do you use them in your practice?
Dr. Lemont: I have used that when a patient came in with multiple mosaic warts. If the patient has multiple warts, hasn’t had prior treatment and doesn’t have that much pain, I’ll put him or her on cimetidine and vitamin A and maybe give the patient some salicylic acid preparations to apply on his or her own. I’ll also explain that in some patients, this therapy may be curative. That’s how I handle extensive warts on the first visit. I don’t rush into treatment. I introduce adjunctive type things that sometimes do work very well.
Dr. Dockery: First of all, I am not a big fan of the use of cimetidine or other H2-receptor antagonists for the treatment of warts. Several open-label, uncontrolled studies have documented successful treatment of warts with cimetidine, whereas other placebo-controlled, double-blind studies and open-label comparisons have failed to demonstrate efficacy. In most cases, efficacy was not statistically superior to that of placebo alone. There does, however, appear to be a greater efficacy in younger patients under the age of 15.4-5
I have on the other hand used a lot of vitamin A and zinc combinations in my patients with warts. The combination that I use and recommend is 10,000 IU of vitamin A with 15 mg of zinc in a single tablet (which is available as A+Zinc) I recommend one tablet twice a day for 30 days. In very young patients I recommend giving one-half of the tablet twice daily. It is absolutely amazing how many patients have had complete resolution of their warts with this therapy. I have used this vitamin and mineral treatment alone but often will combine it with other methods.
Dr. Lemont: If the patient has multiple mosaic warts, hasn’t had prior treatment, doesn’t have that much pain and just wants to get rid of them, I’ll put him or her on cimetidine and vitamin A, and maybe give the patient some topical salicylic acid preparations to apply on his or her own. I’ll also give patients a lot of reinforcement, saying this could really do a great job, etc. I would say this works a certain percentage of the time. Now I don’t know whether this is due to the placebo effect. That’s how I handle extensive warts on the first visit. I start with adjunctive type things that sometimes do work.
Dr. Dockery: I would agree. I’m much more likely to use that approach on a patient who has multiple lesions, bilateral lesions or has been through a series of treatments at some other clinic. I don’t want to repeat a lot of the same things. I might go to the oral forms with the vitamin A and zinc tablets as well. Also, I always add a huge amount of placebo effect to my discussion about the treatment of warts.
I tell the patients this is going to work. I put the onus on them to make themselves better by doing what I say. I’m very firm in my approach to the patients. I’ll tell them that if this doesn’t work, it’s because they are not following the directions properly. Once in awhile, I have to bite my tongue when they really are doing everything and there’s some recurrence or resistance. They may feel I’m mad at them and they’re very apologetic so I have to be more careful in my next set of statements to these them.
However, I agree with what you said earlier, Dr. Lemont. If you seem very confident in your approach and you explain to the patient you will work with him or her to get rid of this problem, you’re telling the patient that he or she has to be compliant as well. I think that combination therapy and autosuggestion is beneficial. This is perhaps a little more effective in the younger patients than in the older patients, who don’t always believe anything you say.
Dr. Salk: I wholeheartedly agree. The absolute key to treatment is combination therapy. You can look at combination therapy in two ways. One can be home therapy, whether it’s 5-FU, imiquimod or salicylic acid. You want the patients to be involved with the treatment modality. Then there are the in-office treatments, which include monochloroacetic acid, cantharidin, podophyllin, cryotherapy, etc.
I agree with Dr. Chang about emphasizing aggressive debridement. I will take a patient almost to pinpoint bleeding and do so many times because no matter what you put on this wart, if there’s a hyperkeratotic tissue layer, that’s a protective barrier of the virus. You also should educate the patient on the use of a pumice stone or emery board in order to be able to take off that layer of skin if they’re using salicylic acid, 5-FU or imiquimod. Otherwise, the topical is not going to be effective.
Tape occlusion is also key in combination with many of these creams and ointments that we have for treating warts. It has been shown that tape occlusion works by macerating the tissue and also potentially increasing the local temperature of the virus.2
Dr. Dockery has published many articles on the use of vitamin A and zinc.6,7 In one of my algorithms, I will prescribe 5-FU and educate the patient on tape occlusion and debridement. I’ll also write some cimetidine 400 mg tib and tell the patients they are going to take cimetidine for three months. I will also tell them to take a multiple vitamin.
Surgical Intervention For Warts:
Is It Necessary Anymore?
Dr. Dockery: What types of surgical treatments — such as excision or blunt dissection and curettage — are you doing for warts now?
Dr. Salk: In the last three years, I have performed only one case of surgical intervention for warts, whether it’s surgical excision, curettage or laser treatments. I’ve had very few patients that have had failures. So the absolute key is combination therapy.
Dr. Chang: When I was at the school, I remember performing curettage and surgical excisions of warts on a weekly basis with the students and residents. However, we rarely do this now in clinical practice. I think probably the last time I excised a wart was several months ago. It just shows you there’s a lot more knowledge and a lot more excitement about what we’re doing with 5-FU, imiquimod, bleomycin and combination therapy.
Dr. Lemont: We talked about topical treatment but the other mode of therapy I use is surgical, using blunt dissection without using sharp instrumentation. I use a Kleiner-Kutz, which is a little sharper than a Freer, to remove the lesions to that white membrane, which is the superficial fascia.
I think this is indicated for warts that orthologically have a sharp outline. If they have a sharp outline, they don’t seem to recur. I use the outline of the wart to help define the predictability of recurrence. The less sharply circumscribed the wart, the more chance of recurrence. Of course, the mosaic wart is the hardest to treat because of the lack of circumscription. I believe you can use conservative removal with blunt dissection in certain circumstances in which you’re not really cutting in to viable tissue but almost separating out the wart.
Dr. Chang: I agree. As a podiatrist, I am very comfortable injecting patients for anesthesia. I think the dermatologists and internists may be more concerned with foot injections and especially PT nerve injections as well as sharp dissection and post-excision scarring. While we as podiatrists have grown up with techniques that minimize scarring, we have found that the need to do that in our practice is almost minimal.
Can Autosuggestive Techniques Be Useful For Warts?
Dr. Dockery: Moving on to a little different approach, I have a real interest in old wives’ tales, home remedies and autosuggestive techniques.8,9 Do you think there is a place in today’s medical practice to use autosuggestive techniques for warts?
Dr. Chang: I would say there is and I reserve autosuggestive techniques as a discussion with parents when they bring their kids in with warts. This may just be the natural course of a wart resolving by itself. There are studies that show there is a natural resolution to warts and this may occur over the course of a two-year period.10 Obviously, we know it is a self-limiting virus.
However, I have two children of my own who recently benefited from discussing their wart with us and kind of being angry at their wart, and talking to the warts at night. They were resolved in two to three weeks. That was an option that I felt was appropriate to try although I still kept an eye on the wart to make sure it wasn’t getting worse.
With some of these non-FDA approved oral options for pediatric patients, there may be some concerns with blood levels and other things. I feel autosuggestive therapy is worth trying for kids. I think parents also understand that it may be something worth trying for kids to get them a little more involved.
Dr. Salk: We obviously know that these lesions are self-limiting and they may regress spontaneously. Dr. Chang alluded to a study done by Massing and Epstein who showed that 66 percent of warts resolve on their own within a two-year period of time.10 I personally have great difficulty telling my patients to utilize any sort of autosuggestive techniques. There is a lot of literature out there and there are a lot of things that we do in practice. If autosuggestive therapy works and you feel comfortable with that as a clinician, there is no reason you shouldn’t try it. I personally don’t use that in my office setting.
Dr. Lemont: I think the biggest type of suggestive therapy is having a doctor who feels confident about his treatment. There’s no question that when the doctor comes across as confident, and rightly so because he believes in his therapy, the patient ends up buying into that. In my opinion, when that happens, there is an enhancement of therapy, a resolution, and that autosuggestion plays a powerful role in resolution of warts.
Dr. Dockery: As I stated earlier, I always add a strong component of suggestion to all treatments I perform. When treating young children, say under the age of 8, I have been extremely successful in treating their warts by simply painting them with genetian violet and covering them with tape. I tell the child not to look at it for two weeks. On the next visit, most warts are gone.