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#173 Acid, freeze, or duct tape: What works best for common warts?


CLINICAL QUESTION
What is the efficacy of commonly used treatments for non-genital warts?


BOTTOM LINE
Highest quality primary care evidence finds warts resolve with cryotherapy (39%) and salicylic acid (24%) more than no treatment (16%) at 13 weeksCryotherapy has more pain and blistering (up to ~80%)but greater patient satisfaction (~70%). Evidence for duct tape is limited and inconsistent.  



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EVIDENCE
  • Highest-quality primary care Randomized Controlled Trial (RCT):1 240 children and adults, new warts, cryotherapy (2-10 seconds via cotton applicator three times every two weeks), daily 40% salicylic acid (SA), or no treatment. Cure a13 weeks: 
    • All warts: Cryotherapy 39%, SA 24%, no treatment 16%. 
      • Versus no treatment: SA Number Needed to Treat (NNT)=13, cryotherapy NNT=5. 
    • Plantar warts: Cryotherapy 30%, SA 33%, no treatment 23% (none statistically significant): 
      • No patient >12 years old had spontaneous resolution of plantar warts. 
    • Other outcomes cryotherapy versus SA: 
      • Patient satisfaction: 69% versus 24%, NNT=3. 
      • Adverse effects:  
        • Pain: 81% versus 12%, Number Needed to Harm (NNH)=2. 
        • Blistering: 51% versus 9%, NNH=3. 
  • High quality primary/secondary care RCT:2 229 patients >12 years oldmostly recalcitrant plantar warts (median duration >1 year), randomized to cryotherapy (~10 seconds via spray or probe, every 2-3 weeks) or daily 50% SA. At 12 weeks, cryotherapy versus SA: 
    • Cure: No difference (both 14%). 
    • Patient satisfaction62% versus 41% SA, NNT=5. 
      • Blistering: 2% versus 0. 
  • Systematic review of RCTs.3 
    • Limitations: Small heterogeneous studies, incomplete reporting, high risk of bias 
    • Cryotherapy not significantly better than placebo (three RCTs, 227 patients) but equivalent to SA (four RCTs, 707 patients) which is superior to placebo with NNT=6, (six RCTs, 486 patients) 
  • Duct tape: Inconsistent RCT findings.4-6  
    • Cure: 17versus 12% placebo (not statistically significant). 
    • Limitations: Short follow-up (six weeks),4 added clear duct tape to moleskin5 and no evidence of blinding or intention-to-treat.6   
Context:   
  • Warts affect up to 1/3 of school-aged children7 
    • Transmission appears increased: 
      • When family member or classmates have warts.8 
      • With communal shower use (plantar warts).9 
  • Spontaneous resolution occurs in ~50% at ~1 year10 and appears greater in: 
    • Younger children.1,10  
    • Non-plantar warts.1 


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Author(s):

  • Caitlin Finley BHSc
  • Christina Korownyk MD CCFP
  • Michael R Kolber BSc MD CCFP MSc

1. Bruggink SC, Gussekloo J, Berger MY, et al. CMAJ. 2010; 182:1624-30.

2. Cockayne S, Hewitt C, Hicks K, et al. BMJ. 2011; 342:d3271.

3. Kwok CS, Gibbs S, Bennett C, et al. Cochrane Database Syst Rev. 2012; (9):CD001781.

4. de Haen M, Spigt MG, van Uden CJT, et al. Arch Pediatr Adolesc Med. 2006; 160:1121-5.

5. Wenner R, Askari SK, Cham PMH, et al. Arch Dermatol. 2007; 143:309-13.

6. Focht III DR, Spicer C, Fairchok MP. Arch Pediatr Adolesc Med. 2002; 156:971-74.

7. van Haalen FM, Bruggink SC, Gussekloo J, et al. Br J Dermatol. 2009; 161:148-52.

8. Bruggink SC, Eekhof JAH, Egberts PF, et al. Pediatrics. 2013; 131:928-34.

9. Johnson LW. J Fam Pract. 1995; 40:136-8.

10. Bruggink SC, Eekhof JAH, Egberts PF, et al. Ann Fam Med. 2013; 11:437-41.

Authors do not have any conflicts to disclose.