British Association of Dermatologists' Guidelines for the Management of Cutaneous Warts 2014

J.C. Sterling; S. Gibbs; S.S. Haque Hussain; M.F. Mohd Mustapa; S.E. Handfield-Jones

The British Journal of Dermatology. 2014;171(4):696-712.

Purpose and Scope

The overall objective of the guideline is to provide up-to-date, evidence-based recommendations for the management of infectious cutaneous warts caused by papillomavirus infection. The document aims to (i) offer an appraisal of all relevant literature since January 1999, focusing on any key developments; (ii) address important practical clinical questions relating to the primary guideline objective, i.e. accurate diagnosis and identification of cases and suitable treatment; (iii) provide guideline recommendations, where appropriate with some health economic implications; and (iv) discuss potential developments and future directions.

The guideline is presented as a detailed review with highlighted recommendations for practical use in the clinic, in addition to an updated patient information leaflet [available on the British Association of Dermatologists' (BAD) website, www.bad.org.uk].

Exclusions

This guideline does not cover anogenital warts, bowenoid papulosis, focal epithelial hyperplasia or seborrhoeic keratoses (sometimes called seborrhoeic warts).

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Table 1. Summary of recommended treatments for hand warts
Strength of recommendation	Treatment	Suggested method of use for hand warts
A	Salicylic acid (SA)	Topical preparations of 15–26% SA, applied daily after removing thick keratin layer, with occlusion if possible. Continue for 3–4 months^11,35
B	Cryotherapy	Keep wart frozen for 15–30 s, repeating every 2–4 weeks for at least 3 months or six treatments^11,35
C	Bleomycin	A 0·1–1 U mL⁻¹ (0·1–1 mg mL⁻¹) solution injected or pricked into wart after local anaesthesia – one to three treatments. Painful during and after treatment^101,102
	Contact immunotherapy	After initial sensitization, DPC or SADBE at strength appropriate for patient, applied from twice weekly to every 3 weeks for 3–6 months^133,134
	5-Fluorouracil	A 5% cream applied daily + occlusion for 4–12 weeks^92,93
	Laser	Pulsed-dye laser after paring and/or SA pretreatment. Two to four treatments at 7–10 J cm⁻² are usually needed^59–61
D	Acupuncture	Auricular acupuncture weekly for 10 weeks¹⁷¹
	Cantharidin	A 0·7% solution applied every 3 weeks up to four times⁴¹
	Cidofovir	A 1% cream daily for 5 days each week under occlusion for 8 weeks^121,122
	Formaldehyde	A 3–4% solution as a daily 15–20-min soak for plantar warts, with emollient protection of unaffected skin for up to 8 weeks⁷⁸
	Glutaraldehyde	A 10% solution applied daily after paring or rubbing down for 3 months⁷⁹
	Hyperthermia	Heat wart(s) to 40–44 °C for 30 min on three to five consecutive days^55,56
	Imiquimod	A 5% cream twice daily for up to 6 months¹²⁸
	Phenol	An 80% solution applied weekly for up to 6 weeks⁴⁰
	Photodynamic therapy	ALA-PDT after paring and/or SA pretreatment, up to three treatments⁷¹
	Podophyllin	Podophyllin but not podophyllotoxin tested. After paring or rubbing down. 25% in liquid paraffin applied under occlusion.¹¹ Authors advise weaker strength (10–15%) and cautious use⁹⁰
	Pyruvic acid	A 70% solution applied daily for up to 2 months⁴⁴
	Retinoids, systemic	Acitretin 0·5–1 mg kg⁻¹ per day for up to 3 months¹¹³
	Surgery	Curettage, cautery, or hyfrecation for filiform warts
	Trichloroacetic acid	Trichloroacetic acid 50–80% solution applied weekly for up to 8 weeks
	Vitamin D analogues	Maxacalcitol three times a day for 2–6 months, with or without SA plaster^82,83 Calcipotriol once daily for 2–3 months⁸⁴
Insufficient evidence	Citric acid	Although they may be used in practice, further study is needed before these can be recommended
	Dithranol
	Formic acid
	H2 receptor antagonists
	Herbal treatment
	Homeopathy
	Hypnotherapy
	Intralesional immunotherapy
	Occlusotherapy (e.g. duct tape)
	Retinoids, topical
	Silver nitrate
	Zinc oxide
	Zinc sulfate

DPC, diphencyprone; SADBE, squaric acid dibutyl ester; ALA-PDT, aminolaevulinic acid photodynamic therapy.

Table 2. Recommendations in particular clinical situations
Plantar warts	Cure rates are lower at this site probably due to a thicker cornified layer and subsequent poorer penetration of treatments to the lower epidermis. Paring, if used to remove excess skin from warts before treatment, should avoid damaging surrounding skin because of the risk of spreading infection
	Salicylic acid (15–40%) topical paints or ointments¹²
	Cryotherapy, fortnightly for 3–4 months^12,32
	Salicylic acid and/or cryotherapy used with more aggressive regimens is probably more effective than standard regimens, but care is needed with worse side-effects. Combination treatments can be undertaken^10,17,20,21
	Other treatments: dithranol,⁸⁷ 5-FU,⁹³ formaldehyde,⁷⁸ glutaraldehyde,³⁵ hyperthermia,⁵⁵ laser,^58,65 PDT,^68,73 podophyllotoxin,⁹⁰ topical immunotherapy^133,136
Plane warts	On the backs of the hands or face, plane warts are mainly a cosmetic problem and spontaneous clearance can often be awaited. Destructive and caustic agents are more likely to produce scarring at these sites and should be used with care
	Salicylic acid cream/ointment 2–10% or cautious use of salicylic acid paint, 12–17%, used without occlusion
	Cryotherapy, milder freeze
	Topical retinoid^110,111
	Others treatments: acupuncture,¹⁷¹ cantharidin,⁴¹ 5-FU cream,⁹⁴ formaldehyde gel, glutaraldehyde solution 10%, glycolic acid 15%,^42,43 imiquimod,^131,132 PDT,^76,115 topical immunotherapy,¹³⁸ zinc oxide,¹⁵⁵ zinc sulfate 10% solution¹⁵⁴
Facial warts	Plane warts as above
	Treatment of filiform warts in the beard area should avoid damaging adjacent skin, which, like shaving, can spread the infection
	Cryotherapy, curettage or hyfrecation can be used
	Other treatments: glycolic acid 15%,^42,43 imiquimod,¹³¹ laser,¹⁷⁴ PDT,^175,176 topical immunotherapy^177,178
Warts in children (hand and foot warts)	Warts in children are often relatively short lived and are likely to clear within a year or two. Painful treatments are often not tolerated and should be avoided in young children if possible
	Salicylic acid (15–40%) topical paints or ointments¹²
	Cryotherapy, gentle, fortnightly for 3–4 months^12,32
	Other treatments: cidofovir,¹²¹ formaldehyde solution or gel,⁷⁸ glutaraldehyde 10% solution,⁷⁹ laser,^61,66 silver nitrate,³⁹ systemic retinoids,¹¹⁴ topical immunotherapy¹³⁶
Warts in the immunosuppressed	Treatment may not be likely to result in cure, but can help to reduce both size of warts and functional and cosmetic problems
	Standard treatments with paring, abrasive agents, salicylic acid and destructive methods (but avoiding damage to surrounding skin) can help to reduce wart bulk
	Other treatments: cidofovir systemic,^116–119 cidofovir topical,¹²² contact immunotherapy,¹³⁵ imiquimod,^129,179 laser (pulsed-dye laser),¹⁸⁰ laser + intralesional bleomycin,⁶³ surgery, topical retinoid,¹¹¹ systemic retinoid¹⁸¹

FU, fluorouracil; PDT, photodynamic therapy.

Appendix 1. Levels of evidence
Level of evidence^a	Type of evidence
1++	High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1+	Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1−	Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++	High-quality systematic reviews of case–control or cohort studies
2++	High-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
2+	Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
2−	Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal
3	Nonanalytical studies (for example case reports, case series)
4	Expert opinion, formal consensus

RCT, randomized controlled trial. ^aStudies with a level of evidence '−' should not be used as a basis for making a recommendation.

Appendix 2. Strength of recommendation
Class	Evidence
A	At least one meta-analysis, systematic review or RCT rated as 1++, and directly applicable to the target population, or
	A systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population and demonstrating overall consistency of results
	Evidence drawn from a NICE technology appraisal
B	A body of evidence including studies rated as 2++, directly applicable to the target population and demonstrating overall consistency of results, or
B	Extrapolated evidence from studies rated as 1++ or 1+
C	A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results, or
C	Extrapolated evidence from studies rated as 2++
D	Evidence level 3 or 4, or
	Extrapolated evidence from studies rated as 2+, or
	Formal consensus
D (GPP)	A good practice point (GPP) is a recommendation for best practice based on the experience of the guideline development