When the patient returned another 6 days later (day 18 of treatment), he complained of minor tenderness and stinging when he applied WP (Figure 5). This is usually a sign that the wart has been destroyed and the treatment is contacting normal skin. Light curettage was performed, and normal pink dermis was visualized. The patient was advised to discontinue all treatment and return in 4 weeks.
At follow-up 4 weeks posttreatment, the wart was found to be fully resolved. It required an active treatment time of only 11 days. The other warts, which were less severe, were also treated with the WP treatment and had fully resolved. The patient was very pleased with the results (Figure 6) and relieved that his 2-year battle with warts was over.
This case study illustrates how even the most severe warts can be treated quickly and with little discomfort or disruption to patients’ lives with WP.
The two ingredients, 5-FU and SA, are commonly used as separate treatments in dermatology practices, so their side effects are well documented. With WP, there is no specific safety data for the product despite what we know about 5-FU and SA individually from the literature. For patients, proper education on treatment use and appropriate follow up is critical to the success of their case and safety of the treatment.
In my practice, a few patients have experienced early discontinuation due to pain, burning, and/or erythema. The patients that did discontinue treatment early were patients who did not let WP fully dry, especially on application to flat warts in sensitive, thin-skinned areas, or who were aged 6 years or younger. For similar patient groups, I recommend treating only one small area initially so the patient can gain experience before expanding the treatment.
It is difficult for patients to scar with WP. It is strong and fast acting, but it is not so powerful that it can easily damage the dermis. When WP irritates the dermis, burning, stinging, and pain occur at the application site, and the vast majority of patients discontinue use because of the discomfort. In my experience, one case of scarring did occur. This patient had a high pain tolerance and was applying WP on the distal second toe. He did not let the treatment dry or apply the tape following application. It routinely transferred to his great toe and caused scarring, which he hardly noticed due to his high pain tolerance. Hyperpigmentation does routinely occur but is less than with cantharidin, cryotherapy, and hyfrecation.
Discussing WP With Your Patient
Because patients most often have to pay cash for this medication, every provider will have to decide how to introduce this product to their patients. I have worked in a predominantly Medicaid population, and unless desperate, most patients want to try covered procedures (eg, cryotherapy) first, even after I explained their poor efficacy. If the wart has not improved by the next appointment, many patients will then begin to consider WP as a therapeutic option. I have also worked in middle-class areas where 75% of patients will want WP at the first visit when informed about its contrasts with existing nonsurgical treatments. Additionally, patients are used to going to their own pharmacy, so the prescribing health care professional will have to explain that this is a patented medicine that only comes through the mail from one specific pharmacy.
As with any therapy, there were few treatment failures among the patients who received WP in my practice. Some patients were immunosuppressed patients; some had severe and widespread palmoplantar warts; and a few patients, several of whom were children younger than 6 years, had excessive irritation or complained of burning or pain.
I always present WP as an option for wart removal, even if patients must pay out of pocket to receive the treatment. Its effectiveness, as demonstrated in the mentioned case report, is invaluable in eliminating warts that can cause pain, embarrassment, and social stigma. Many patients with warts present on their first visit having already had multiple treatments and are looking for new, more effective options. Due to its speed, effectiveness, and tolerability, WP has become a vital first-line treatment for cutaneous warts.