1. Warts are of course ubiquitous. They do involute — resolution rates are high in the placebo arms of even quite short controlled trials — but they also often recur. In kids with warts in less bothersome places, consider watching and waiting if the child and parents are willing. Warts don’t leave scars, but treatment can.
2. Kids are often treatment-averse. Agree beforehand that you’ll cancel the treatment if a child pulls away during cryotherapy or curettage. If they want, let patients try over-the-counter cryotherapy or salicylic acid kits first (silver nitrate pens are best avoided). They’re weaker than office-based equivalents, but will often do the trick. Home treatment failures can then be addressed in the office.
3. And while self-treating, why not begin with the old standby duct tape? Apply a small patch over the wart and leave it for a week. Then remove it, soak the wart in warm water, scrub with pumice or emery board and leave open overnight. Then repeat, each week for 2 months. Duct tape has better clinical evidence than many futuristic and potent drugs being used for warts today. In fact, simple daily immersion in hot (45-48°C) water has been shown to resolve many hand and plantar warts.
4. The quadrivalent HPV vaccine protects against 2 types (6 and 11) that cause 90% of genital warts. Give it to those affected and to family members. It has no therapeutic effect, but can prevent contagion and — maybe — wart recurrence.
5. Office cryotherapy has risks. Spills can be dangerous. Avoid it in small children. Get solid informed consent in older ones, mentioning that it hurts and may not work. Expect multiple treatments. Guns are easier than swabs. 10 seconds for a small wart, 30 for a large one. Freeze for 1 mm around the edge. Pinch up the skin around warts on the back of the hands.
6. Photodynamic therapy, lasers and curettage are useful for facial warts where salicylic acid isn’t an option. Recurrence generally comes from untreated margins. More thorough treatment reduces recurrence but increases scarring risk.
7. Salicylic acid is popular, especially in kids. But it’s slow and compliance is demanding. Patches can be had OTC at 40% strength. Changed every 48 hours, they’re simpler than 17% OTC topical salicylic acid, which is daily-use. Pare down warts with emory board before treatment.
8. Bleomycin is strictly for recalcitrant warts. Price is steep, side effects are large (especially in finger warts) and it’s contraindicated in many. Retinoids, both systemic and topical, appear effective, though teratogenic. Imiquimod is slow and expensive but works. Squaric acid esters and DPC are best left to expert hands. These immune modulating drugs may hold the promise of lower recurrence rates. Podophyllin suppresses warts temporarily but won’t resolve them. Cimetidine is ineffective, cantharidin unproven, 5-fluorouracil still rather experimental.
9. Dermatologists often rely not on one treatment, but on combinations such as salicylic acid + imiquimod or laser + bleomycin. One combo to consider at home would be duct tape + OTC salicylic acid with abrasive paring and zinc supplements.
10. Why oral zinc? Because zinc is a potent immune modulator and has been shown in placebo-controlled trials to have high success rates on recalcitrant warts within 2 months. Dose is 10 mg/kg up to 600 mg max daily. Response depends on serum zinc levels achieved, with 200 μg/100 mL — about 3 or 4 times normal — generally bringing wart resolution. It’s very safe and tolerable, and since this is another immune-stimulating approach, recurrence rates may be lower.