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Dr Friedman on Treating Warts 

At the 2019 Fall Clinical Dermatology Conference in Las Vegas, NV, Adam Friedman, MD, professor of dermatology at George Washington School of Medicine, presented on treating warts. According to Dr Friedman, there is not a lot of evidence for the current therapies used for warts; however, new studies are starting to give some credibility to a few options.

He suggested asking patients:

  • How long have you had the wart?
  • Is it symptomatic?
  • What have you tried?
  • Is it painful?
  • What has been done before by another provider?

Set realistic expectations during the visit, he suggested. “A one and done approach does not work for treating warts and patients will have to come back frequently until it is resolved,” he said. He also suggested using a dermoscopy to help identify warts and determine clearance.

While most warts are pretty simple, there are several types that can be difficult. For example, epidermodysplasia verruciformis, periungual warts, plantar warts, perianal warts, and skin tags. 

According to Dr Friedman, there are 3 different methods for treating warts: destructive, immunologic, and cytotocix. He recommended a combination of these therapies for the best results.

Liquid nitrogen is commonly used for warts but is painful and can cause dyspigmentation. Dr Friedman stressed the importance of hitting warts hard with this therapy, saying over the counter cold sprays do not really work. According to Dr Friedman, providers need to create an ice ball to effectively remove a wart. Ten seconds has been found to effectively treat warts but is associated with more pain and morbidity, he added. He suggested providers discuss adverse effects, such as blistering following treatment, with patients, as well as talk them through what to expect.

Another option is cantharidin, which uses a similar approach and is done it until clearance, he added. While the procedure is painless, he told attendees not to oversell this because the blister can be painful and pop. At the moment, cantharidin is not approved for treating warts, but that may change, he stated.

In addition, he said paring the wart is associated with better outcomes. Salicylic acid can be used and helps break down thick skin, which prevents therapies from getting through, said Dr Friedman. In addition, imiquimod 5% cream works for perianal and genital warts, and can be used in combination with acitretin.

Ingenol mebutate gel can be used for patients who prefer natural remedies, but this can be difficult to get covered, said Dr Friedman. Other therapies he reviewed included sinecatechin, IL-Candida, cimetidine, zinc sulphate, and bleomycin. He also discussed the latest research on the use of HPV vaccine for treating warts, along with a case report on it effectively treating basal cell carcinoma. Microwave therapy may be a new device that could treat warts, he added.

“Combo kills it, don’t hit and quit, and don’t give up,” he concluded, adding that patients are very frustrated when they come into the office and dermatologists have a real opportunity to help them.


Friedman A. What’s new in the treatment of warts. Presented at: 2019 Fall Clinical Dermatology Conference; Oct 18, 2019; Las Vegas.

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