Viral Warts

Presentation

Warts are caused by a common viral infection, the human papillomavirus (HPV). Most resolve spontaneously within a year or two. They may vary in appearance depending on the types of HPV, the anatomical site involved and the host immune response. They often have small black dots, representing coagulated capillaries, particularly evident on paring.

Common hand warts

Deep plantar wart (verruca)

  • May be tender on pressure

Mosaic plantar wart

  • May be slow to resolve in comparison to other warts

Plane wart

  • Flat topped pink or pale brown. Often on face or other sun exposed sites

Filiform facial wart

Management

Most patients with viral warts can be managed in primary care.

Consider no  treatment as warts usually resolve spontaneously

Common hand warts

  • Self treatment daily with salicylic acid (up to 26%) or glutaraldehyde paints or gels after paring the warts
  • Continue treatment for at least three months then review
  • Consider 3-weekly cryotherapy in non-responders, occlusion under waterproof plaster, and use in combination with topical therapy
  • Cryotherapy may be distressing and therefore inappropriate for young children

Deep plantar wart / mosaic plantar warts

  • Self treatment with daily salicylic acid paint (up to 50%)
  • Paring of plantar warts with single-use file enhances treatment response
  • Consideration of cryotherapy three weekly for up to 10 treatments: single or double freeze thaw cycle(s)
  • Patients with painful plantar warts can be treated with corn plasters

Plane warts

  • Plane warts often resolve spontaneously
  • Avoid cryotherapy
  • Apply topical retinoic acid if persistent

Filiform facial warts

  • Do not apply wart paints
  • Treat filiform facial warts with careful cryotherapy for 5-10 seconds to the wart but avoid surrounding skin
  • Repeat every 2 or 3 weeks
Referral
  • Symptomatic warts persistent for at least two years and unresponsive to topical agents and cryotherapy
  • Diagnostic uncertainty especially in the elderly
  • Multiple recalcitrant warts in the immunosuppressed
  • If you need support for a patient with anogenital warts, seek advice from your local genito-urinary medicine team
Therapeutic Tips
  • Do not use salicylic acid on the face
  • Cryotherapy should be administrated by appropriately trained staff
  • Diagnostic doubt over solitary wart: remove by curettage for histopathology
  • Children with verrucae should not be banned from swimming pool but can wear verruca socks
Patient Information