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Wart Treatments: What Works?

Salicylic acid is the only treatment for uncomplicated warts shown to be effective in this systematic review of randomized, controlled trials.

Wart treatments are numerous and varied. Which if any of these treatments actually cure warts? These investigators performed a systematic review of all published controlled, randomized trials of uncomplicated wart treatments. The main outcome measure was complete clearance of warts.

Fifty randomized, controlled trials were identified. The authors classified 41 trials (82%) as low quality, 7 (14%) as intermediate quality, and only 2 (4%) as high quality; different methods limited the pooling of data. In the 17 placebo-controlled trials that were analyzed together, placebo achieved an average cure rate of 30%. In the 6 trials that examined salicylic acid versus placebo, active treatment had an average cure rate of 75%, compared with a 48% rate for placebo. Cryotherapy was no more effective than placebo in 2 trials and was as effective as salicylic acid in another 2 trials. "Aggressive" cryotherapy was more effective than "gentle" cryotherapy (cure rates, 52% vs. 31%, respectively). Neither frequency of treatment nor number of treatments had any effect on cryotherapy cure rates. Dinitrochlorobenzene (DNCB) immunotherapy had a cure rate of 80% vs. 38% for placebo in 2 small trials. Cure rates for intralesional bleomycin ranged from 16% to 94%. Aminolevulinic acid photodynamic therapy had a cure rate of 56% vs. 42% for placebo. Pulsed-dye laser treatment was no more effective than cryotherapy or cantharidin therapy. There were no controlled studies of other therapeutic interventions.

Comment: In this rigorous analysis, salicylic acid was the only treatment that proved to be effective for the treatment of uncomplicated warts, with DNCB immunotherapy coming in a distant second. Cryotherapy, if chosen, should be aggressive, with the aim of producing blistering of the wart. Laser treatments were notable by their absence among controlled trials. Given a substantial placebo effect and a high rate of spontaneous resolution, placebo-controlled trials are necessary to establish treatment efficacy, but these have been few and far between. It would be unfortunate if reviews such as this were used by managed care companies to limit wart treatment; it is to be hoped that such reviews will prompt future controlled studies of the treatments that most dermatologists find effective in daily practice.

— George J. Hruza, MD

Published in Journal Watch Dermatology October 29, 2002

Citation(s):

Gibbs S et al. Local treatments for cutaneous warts: Systematic review. BMJ 2002 Aug 31; 325:461-9.

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