1) The document discusses treatment options for common warts, which are caused by human papillomavirus. It provides an overview of different wart types and treatments.
2) Many common warts will resolve spontaneously, but recalcitrant warts often require ongoing treatment. The evidence and efficacy of different treatment options is considered important when choosing how to treat recalcitrant warts.
3) For fresh common warts, the best practice is to first use salicylic acid, and if no improvement after 6 weeks, proceed to liquid nitrogen cryotherapy. Recalcitrant warts that do not resolve after repeated treatments may require alternative options such as laser therapy or intralesional immunotherapy.
A member of the American College of Cardiology and the American Heart Association American College of Physicians, Dr. Rajan Bhatt is a skilled cardiologist double board-certified in internal medicine and cardiovascular disease and practices medicine in Scottsdale, Arizona. Additionally, Dr. Rajan Bhatt oversees a team of medical professionals at Spectrum Dermatology, which provides preventative treatments for various skin disorders, including warts.
Warts are abnormal skin growths that most commonly develop on the fingers and toes but can occur elsewhere in the body. The human papillomavirus, or HPV, causes warts. Children are more likely to get warts because their immune systems are not as robust as adults'.
People usually get warts by contracting them from another person. Some people are more susceptible to warts by nature than others. Direct contact with the virus may transmit it, and shaking many people's hands is a typical occurrence. Warts are transmitted by cuts that come into touch with the virus. The infection can be started by any tiny wound, such as a hangnail or shaving nick.
Although warts are harmless, many individuals want them removed. They're also very infectious, so getting these pimples properly removed as soon as possible is a good idea.
Depending on the location and kind of skin, dermatologists have a few choices for treating warts. One of the most common options is to use liquid nitrogen to freeze the wart. It is sometimes preferable to burn the wart off. For particularly persistent warts, a dermatologist may use a laser. In some cases, cantharidin, a specific chemical, is used to cause the skin to blister and fall off.
Warts are growths on the skin caused by an infection with the human papilloma virus, or HPV. Types of warts include:
-- Common warts (often appear on the fingers)
-- Plantar warts (often appear on the soles of the feet)
-- Genital warts (sexually transmitted diseases)
-- Flat warts (usually appear in places where one shaves frequently)
In children, warts often go away on their own. In adults, however, they tend to stay. Warts are often removed for cosmetic reasons or to eliminate discomfort.
http://www.nlm.nih.gov/medlineplus/ency/article/000885.htm
Find the most vital information on daily health news,alternative medicine,complementary health & allergy therephy to make yourself stay fit and healthy.
A member of the American College of Cardiology and the American Heart Association American College of Physicians, Dr. Rajan Bhatt is a skilled cardiologist double board-certified in internal medicine and cardiovascular disease and practices medicine in Scottsdale, Arizona. Additionally, Dr. Rajan Bhatt oversees a team of medical professionals at Spectrum Dermatology, which provides preventative treatments for various skin disorders, including warts.
Warts are abnormal skin growths that most commonly develop on the fingers and toes but can occur elsewhere in the body. The human papillomavirus, or HPV, causes warts. Children are more likely to get warts because their immune systems are not as robust as adults'.
People usually get warts by contracting them from another person. Some people are more susceptible to warts by nature than others. Direct contact with the virus may transmit it, and shaking many people's hands is a typical occurrence. Warts are transmitted by cuts that come into touch with the virus. The infection can be started by any tiny wound, such as a hangnail or shaving nick.
Although warts are harmless, many individuals want them removed. They're also very infectious, so getting these pimples properly removed as soon as possible is a good idea.
Depending on the location and kind of skin, dermatologists have a few choices for treating warts. One of the most common options is to use liquid nitrogen to freeze the wart. It is sometimes preferable to burn the wart off. For particularly persistent warts, a dermatologist may use a laser. In some cases, cantharidin, a specific chemical, is used to cause the skin to blister and fall off.
Warts are growths on the skin caused by an infection with the human papilloma virus, or HPV. Types of warts include:
-- Common warts (often appear on the fingers)
-- Plantar warts (often appear on the soles of the feet)
-- Genital warts (sexually transmitted diseases)
-- Flat warts (usually appear in places where one shaves frequently)
In children, warts often go away on their own. In adults, however, they tend to stay. Warts are often removed for cosmetic reasons or to eliminate discomfort.
http://www.nlm.nih.gov/medlineplus/ency/article/000885.htm
Find the most vital information on daily health news,alternative medicine,complementary health & allergy therephy to make yourself stay fit and healthy.
www.mimsindia.com/
This article discusses about the different types of skin disorders and their treatments available in best treatment centres in India
Superficial Mycoses Mycology - Tinea Versicolor / Tinea Nigra/Piedra
For Downloading PDF note
As the channel name suggests, our channel will be a perfect lounge for the malayali medicos..we wil be covering videos which will be like lecture classes related to the subjects biochemistry and microbiology in which we are specialised.. It will be a better learning experience for the students especially for those who are not able to understand and follow the normal classes in college..we assure the students that you will get a basic idea regarding the topic and extra reading can be done from the reference textbooks..
Qualification
AHLAD T O
Maneesha M Joseph
MSc MLT (Microbiology)
Assistant Professor
Baby memorial college of allied Health science
Kozhikode
Our Partner Channel
Health & Voyage channel link - https://youtu.be/nzKqRVjlwc0
#Superficial Mycoses Mycology microbiology
#Medical
#Microbiology
#Superficial Mycoses Mycology malayalam lecturer
#Mallu Medicos Lounge
##MalluMedicosLounge
#MLT
#Tinea Versicolor
#Tinea Nigra
#Piedra
www.mimsindia.com/
This article discusses about the different types of skin disorders and their treatments available in best treatment centres in India
Superficial Mycoses Mycology - Tinea Versicolor / Tinea Nigra/Piedra
For Downloading PDF note
As the channel name suggests, our channel will be a perfect lounge for the malayali medicos..we wil be covering videos which will be like lecture classes related to the subjects biochemistry and microbiology in which we are specialised.. It will be a better learning experience for the students especially for those who are not able to understand and follow the normal classes in college..we assure the students that you will get a basic idea regarding the topic and extra reading can be done from the reference textbooks..
Qualification
AHLAD T O
Maneesha M Joseph
MSc MLT (Microbiology)
Assistant Professor
Baby memorial college of allied Health science
Kozhikode
Our Partner Channel
Health & Voyage channel link - https://youtu.be/nzKqRVjlwc0
#Superficial Mycoses Mycology microbiology
#Medical
#Microbiology
#Superficial Mycoses Mycology malayalam lecturer
#Mallu Medicos Lounge
##MalluMedicosLounge
#MLT
#Tinea Versicolor
#Tinea Nigra
#Piedra
Dr Patrick Treacy shares some of his most challenging cases. This month he talks about treating cutaneous warts. Warts appear in various forms on different sites of the body and include common warts (verruca vulgaris), plane or flat warts, myrmecia, plantar warts, coalesced mosaic warts, filiform warts, periungual warts, anogenital warts (venereal or condyloma acuminata), oral warts and respiratory papillomas.
Molluscum contagiosum is a viral disease with following characteristics:
Benign viral infection
Caused by a pox virus
Double stranded DNA virus
Spread by direct contact, bath towels, tattoo instruments, beauty parlour implements, swimming pools in children
In adults, most commonly an STD, males>females
Incubation period – 2-7 weeks but can be as long as 26 weeks
More common and severe in patients with A.D.
More common in certain geographic areas with warm climates (Fiji, Congo, Papua New Guinea)
Recurrent miscarriages need to be investigated actually. You had live births but now had four consecutive miscarriages. It is better to have a thrombophilia screen and products of conception needed to be send out for histopathology to check any chromosomal, congenital, structural anomaly.
Read More:https://www.icliniq.com/qa/miscarriage/why-am-i-having-frequent-miscarriages
The most common cause of bleeding from gums is inflammation of the gums, otherwise called as gingivitis which leads to periodontitis if left untreated.
Read More:https://www.icliniq.com/qa/bleeding-gums/what-is-the-cause-and-solution-for-bleeding-gums
It is difficult to come to terms with the loss of a loved one or to deal with a chronic or terminal illness. People often keep all their emotions bottled up, which starts affecting their physical and mental health. To know about ways to acknowledge and accept the loss and to cope with grief more healthily click the link below https://www.icliniq.com/articles/emotional-and-mental-health/grief
Vaccines are the way to boost immunity and thus prevent a lot of diseases. The preparations are available as dead or live attenuated form. This article helps to understand the composition, mechanism of action and other important and basic concepts about vaccination.
Read More :Patient's Guide to Vaccines
https://www.icliniq.com/articles/healthy-living-wellness-and-prevention/a-patients-guide-to-vaccines
Emotions can be both boon or bane. One of the psychotherapies that uses emotions as the basis to manage patients having difficulty in controlling or adapting emotions is EFT (emotion-focused therapy). It is beneficial in improving one's own self and interpersonal relationships by following and guiding their emotional experiences and thus, bringing positive emotional changes and ultimately, a better change in life. The two major conditions where it is employed more commonly are depression and emotional trauma and have been clinically proven to be successful
Read More information about Emotion Focused Therapy: https://www.icliniq.com/articles/emotional-and-mental-health/emotion-focused-therapy
Bell’s palsy, also known as facial palsy, is a condition that causes sudden and temporary weakness or paralysis of the facial muscles, which results in an inability to control the muscles on the affected side of the face.
H1N1 is an influenza A virus which is the causative pathogen for swine flu. There have been seasonal outbreaks every year. The reason being, it is contagious, and mutations in the virus strain put everyone at risk every season. Awareness about this disease and its transmission, prevention, and management is critical to control the spread of the disease. We also need to clarify few myths associated with this disease
https://www.icliniq.com/articles/infectious-diseases/swine-flu-everything-you-need-to-know
Injury to the skin caused by exposure to extreme cold is called frostbite. This happens when you are exposed to temperatures below the freezing point of your skin.
https://www.icliniq.com/articles/diseases-and-disorders-common-medical-conditions/frostbite
Panic disorder is a condition characterized by extreme anxiety attacks which mimic heart attack symptoms such as rapid heartbeat, palpitation, heavy breathing, sweating, choking, etc. But, this is not due to any medical problem. It is completely a psychological issue and can be treated through psychological treatment.
https://www.icliniq.com/articles/emotional-and-mental-health/best-treatment-for-panic-disorder
Fordyce spots are clusters of enlarged oil glands known as sebaceous glands that appear as raised bumps. They are harmless and appear over the borders of the lip, insides of the cheek, shaft of the penis, scrotum or labia in females.
https://www.icliniq.com/qa/medical-conditions/fordyce-spots
Jock itch, also called tinea cruris, more commonly known as ringworm, is a kind of fungal infection which frequently affects the groin area although it can affect any part of the skin.
Pain in the anus is one of the most common complaints encountered in the outpatient clinics. The pain is sometimes described by the patient as 'my worst pain ever. This article provides some suggestions on how to avoid facing this annoying issue by making few dietary and lifestyle changes.
Source : https://www.icliniq.com/articles/gastro-health/anal-fissure-causes-prevention-and-cure
Dolo 650mg is a Paracetamol tablet which is commonly prescribed to reduce fever and for pain killer.
Source : https://www.icliniq.com/qa/fever/what-could-a-fever-of-two-days-duration-and-rigors-be-due-to
Many people are tired of sacrificing their favorite food and unable to find extra time for a workout. We all know how difficult it is to reduce weight by controlling food habits and exercises.
There are many such ways to involve yourself in different everyday activities, eat anything you want and still lose weight.
Visit the article given below to know about some smart ways to lose weight without sacrificing your lifestyle.
https://www.icliniq.com/articles/fitness/smart-ways-to-lose-weight
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
Remove Warts
1. clinical
Reprinted from Australian Family Physician Vol. 39, No. 12, december 2010 933
Lawrence Leung
Treating common warts
Options and evidence
Background
Nongenital warts are a common condition seen in general practice, affecting patients
of all ages. There are many treatment options and patients often self medicate with
remedies from folklore or tradition before presenting to their doctor.
Objective
This article attempts to summarise the quality of different treatments and to provide
recommendations and a quick reference for treating common warts.
Discussion
Many common warts will resolve spontaneously but others are recalcitrant and often
require ongoing treatment beyond first line measures. Without definite guidelines for
treating recalcitrant warts, it is important for the general practitioner to consider the
available evidence for efficacy and contraindication of the various treatment options.
Keywords: warts; skin diseases; treatment; salicylic acid; cryosurgery
Nongenital cutaneous warts are commonly
seen in general practice with an overall
prevalence of 7–10%1 and a peak age of
presentation of 12–16 years.1–2 They are
most commonly found on the hands and
feet but can also be found on the face,
eyelids and torso. The causative agent is
human papilloma virus (HPV). Without
treatment, one-third of cutaneous warts
will resolve spontaneously within 3 months
and two-thirds within 2 years.3 Myrmecia
warts often persist despite repeated
treatments and become recalcitrant warts.
There is no consensus on the prevalence
of, and most effective treatment for,
recalcitrant warts.
Classification of nongenital
cutaneous warts
There are over 100 identified types of HPV;4
the most common types of cutaneous warts are
type 1, 2, 3, 4, 7, 10, 27 and 57.2,4 Cutaneous
warts can present in various forms and sizes. An
excellent review has been written by Jablonska
et al;5 and a brief summary of the various types of
common warts is given in Table 1 (Figure 1–4).
Pathogenesis
With a minor breach in the epithelial surface,
HPV enters the epithelial cells via putative
surface receptors and proliferates. This results
in persistent viral infection with metaplasia
of keratinocytes, which gradually accumulate
keratohyalin granules6 and are sloughed off.4
As these virally infected keratinocytes are not
destroyed, the HPV virions are rarely exposed to
the Langerhans cells of the skin, and therefore
evade being cleared by systemic immunity. This
facilitates the viral persistence and continual
growth of the wart.
Diagnostic features and
differential diagnoses
Cutaneous warts often present as localised flat
or dome shaped papules with well demarcated
edges. Histological findings include epidermal
acanthosis, papillomatosis, hyperkeratosis
and parakeratosis with elongated rete ridges
often curving toward the centre of the wart.
Figure 1. Myrmecia warts on the ball of
calcaneum. These are painful. Notice the
typical round appearance with pitting when
keratinised plates were removed
2. Treating common warts – options and evidenceclinical
934 Reprinted from Australian Family Physician Vol. 39, No. 12, december 2010
Capillary vessels are often prominent and may
be thrombosed, giving the pathognomonic brown
dots at the centre of the lesion when the warts are
pared down. Due to the continuous viral induced
hyperkeratotic changes, the surface papillary
lines of the skin are disrupted resulting in a rough
surface. Most lesions are of skin colour but can
appear black due to thrombosed capillaries which
are used to feed the wart. While most cutaneous
warts tend to be exophytic and painless (ie.
grow out of and above the skin), those affecting
the palm and soles are often endophytic (ie.
grow inwards into the skin) and lead to pain and
discomfort. When several warts with different
morphologies cluster together, a mosaic wart is
formed.4 Due to the myriad of morphologies and
wide area of possible distribution, cutaneous
warts have to be differentiated from other skin
conditions such as seborrhoeic keratosis, callous,
lichen planus, molluscum contagiosum, mole,
melanoma, keratoacanthoma and cutaneous horn.7
Treatment options
Most cutaneous warts are self limiting and
resolve within 2 years. When they pose
discomfort or aesthetic problems, patients often
seek treatment. With a record of existence going
back to the ancient Greeks and Romans, the
common wart in no way lacks curative options,
including hypnotherapy;8 garlic;9 duct tape;7 fig
tree latex;10 oral zinc sulphate;11 oral histamine
2 receptor antagonist;11 cautery;7 hyfrecation;7
surgical removal;12 salicylic acid;2,7 liquid
nitrogen cryotherapy;7 local hyperthermia;13 CO2
laser;3 YAG laser;12 pulsed dye laser;14 intense
pulsed light (IPL);15 topical imiquimod;16 topical
5-fluorouracil;17 squaric acid;18 intralesional
injection of bleomycin;19 interferon;2 candida
antigen 1;20 measles, mumps and rubella
(MMR) vaccine;21 and autoimplantation of wart
materials.22 Detail of each treatment modality
is beyond the scope of this article and readers
are referred to Lipke’s excellent reviews.7
Classification of quality of evidence (Table 2)
Table 1. Categories of common warts with their HPV subtypes
Type HPV
type
Morphology Mode of regression
Myrmecia
warts
(Figure 1)
1 Round keratinised lesions found
commonly on pressure point of
foot, often painful endophytic
growth with central pit when
central hyperkeratotic plate
removed
Vascular extravasation
and haemorrhage
with minimal
inflammatory infiltrate
Common
warts
(Figure 2)
2, 4, 57 Flat or raised papules or nodules
with irregular hyperkeratotic
surfaces commonly found on
dorsum of hand and periungually,
and can involve the sole of the
foot or face – often painless.
Lesions can converge to form
mosaic warts and can be
endophytic
Cellular inflammatory
infiltrate involving
the lymphocytes,
natural killer cells and
macrophages
Butcher’s
warts
(Figure 3)
7 Found exclusively in butchers
and meat handlers, cauliflower-
like exophytic lesions found on
both sides of the hand but rarely
periungually
Vascular extravasation
and minimal
inflammation
Plane warts
(Figure 4)
3, 10 Multiple flat papules with
relatively smooth but
hyperkeratotic surfaces found on
the hand and face, often painless
and brought on by Koebner
phenomenon
Simultaneous
inflammatory
infiltration of
mononuclear cells
Intermediate
warts
10, 27 Intermediate morphology
between common and plane
warts found mostly on dorsum of
hands in the immunosuppressed
Simultaneous
inflammatory reaction
Figure 3. Butcher’s wart from a food handler
with the exophytic cauliflower morphology
on the lateral aspect of the digit. Notice the
coexistence of plane warts on the dorsum
and base of the finger
Figure 4. Multiple plane warts on dorsum of
hand. Notice the papular appearance which
can be smooth or hyperkeratotic
Figure 2. Common warts on the sole of the
foot with irregular hyperkeratosis. These are
relatively painless
3. clinicalTreating common warts – options and evidence
Reprinted from Australian Family Physician Vol. 39, No. 12, december 2010 935
plantar warts and should be used with caution
for lesions around the eye. When patients
present with common warts it is likely they
have already tried salicylic acid or even liquid
nitrogen at home with no result. In such cases,
the GP can pursue more aggressive liquid nitrogen
cryotherapy, which has longer contact time with
paring down to the base and increased risks of
pain and blistering. Intralesional immunotherapy
or chemotherapy, laser and electrosurgery are
better reserved as second line treatments and
are not recommended for common warts at initial
presentation.
Best practice for treating fresh
common warts
Nonfacial lesions are best treated with a salicylic
acid gel, cream or instant dry film preparation.
Commercial brands come in various strengths
from 15–40%. Apply on alternate days with
contact time of 8 hours, adding occlusive dressing
(adhesive bandage or plastic wrap) if necessary
to enhance effects. If no improvement is observed
after 6 weeks, proceed to liquid nitrogen
application with four sets of five freeze-thaw
cycles per treatment, to be repeated fortnightly.
Lesions with hyperkeratinisation should either
be pared down with a scalpel or rubbed with a
pumice stone in warm water before treatment.
For facial lesions, salicylic acid application
is not recommended because of the possibility
of scarring. They are best treated in the practice
with liquid nitrogen. Apply the liquid nitrogen
with a fine nozzle spray or cottonwool tip with
two sets of five freeze-thaw cycles to be repeated
fortnightly. If lesions do not resolve within 3
months, or after five rounds of liquid nitrogen
treatment, the warts are considered refractory or
recalcitrant.
Lesions that are resolved with initial
treatments can recur and they are treated as fresh
lesions, albeit with a lower chance of success.
Lesions with unusual morphology, bleeding
or pigmentation should be biopsied to exclude
possible malignancy.
Recalcitrant warts
When warts fail to resolve after repeated
treatments, they are considered recalcitrant. There
is no consensus for the definition of recalcitrant
warts but as a general rule, they can be described
3 months and two-thirds disappear in 2 years’
rule. Should the wart persist, the best initial
treatment is salicylic acid (evidence I-A), which
has clear evidence of advantage over placebo.
Next in line would be cryotherapy with liquid
nitrogen (evidence I-B), which has not been
shown to be superior over other treatments
such as salicylic acid or placebo. Liquid nitrogen
may have better efficacy than salicylic acid for
and recommendations (Table 3) according to the
United States Preventive Services Task Force are
applied to a summary of treatment options and
evidence in Table 4.
Fresh warts
For lesions that on initial presentation have mild
or no symptoms, the general practitioner can
choose to observe the ‘one-third disappear in
Table 2. Classification of quality of evidence
Level of
evidence
Quality of evidence
Level I Evidence obtained from at least one properly designed randomised
controlled trial (RCT)
Level II-1 Evidence obtained from well designed controlled trials without
randomisation
Level II-2 Evidence obtained from well designed cohort or case control analytic
studies, preferably from more than one centre or research group
Level II-3 Evidence obtained from multiple time series with or without the
intervention. Dramatic results in uncontrolled trials might also be
regarded as this type of evidence
Level III Opinions of respected authorities, based on clinical experience,
descriptive studies, or reports of expert committees
Adapted from United States Preventive Services Task Force. Available at www.ahrq.
gov/clinic/uspstfix.htm
Table 3. Recommendations: United States Preventive Services Task Force
Level Recommendations
Level A Good scientific evidence suggests that the benefits of the
clinical service substantially outweigh the potential risks.
Clinicians should discuss the service with eligible patients
Level B At least fair scientific evidence suggests that the benefits of
the clinical service outweigh the potential risks. Clinicians
should discuss the service with eligible patients
Level C At least fair scientific evidence suggests that there are
benefits provided by the clinical service, but the balance
between benefits and risks are too close for making general
recommendations. Clinicians need not offer it unless there are
individual considerations
Level D At least fair scientific evidence suggests that the risks of the
clinical service outweigh the potential benefits. Clinicians
should not routinely offer the service to asymptomatic patients
Level I Scientific evidence is lacking, of poor quality, or is conflicting,
such that the risk versus benefit balance cannot be assessed.
Clinicians should help patients understand the uncertainty
surrounding the clinical service
Adapted from United States Preventive Services Task Force. Available at www.ahrq.
gov/clinic/pocketgd09/gcp09app.htm#ApA
4. Treating common warts – options and evidenceclinical
936 Reprinted from Australian Family Physician Vol. 39, No. 12, december 2010
as warts that fail five rounds of first line
treatment (salicylic acid or liquid nitrogen). Plantar
warts are notorious for becoming recalcitrant.
Certain immunosuppressed conditions create a
higher risk of developing recalcitrant warts, these
include acute leukemia,25 organ transplant26,27 and
human immunodeficiency virus infections.28
There are no definite guidelines for treating
recalcitrant warts and available options
include destruction treatments (eg. laser and
electrosurgery), intralesional chemotherapy (eg.
bleomycin and 5-fluorouracil) and intralesional
immunotherapy (eg. interferon and MMR
vaccine). These are not first line treatments
for common warts and should be administered
only with prior training or in a specialist
centre so that possible side effects can be
monitored. A preferred option of the author is
Table 4. Summary of treatment and evidence for common warts
Method Level of evidence Comments
Salicylic acid2 I-A Benefits are established as compared to placebo but only modest. Most
trials look at use of salicylic acid in combination with other agents
Liquid nitrogen cryotherapy2,23 I-B Overall evidence is inconclusive to suggest a therapeutic advantage
of cryotherapy over other topical treatments or placebo. Aggressive
cryotherapy may be more effective but is offset by more pain and
blistering
Intralesional interferon2,23 I-C Trials use various forms of interferons (alfa, beta, gamma). Intralesional
injections are often painful and overall evidence of use is insufficient
Intralesional bleomycin I-C Cochrane review of trials used various dosages and concentrations
with different delivery systems, but none show sufficient evidence of
beneficial use2
I-B More recent studies showed significant benefits as compared to
cryotherapy19
Intralesional candida
antigen1,20
II-3B Data from case series and isolated reports. No RCT yet. Suggested use in
the more recalcitrant types of warts
Intralesional MMR vaccine21 I-B One RCT and one time series executed with recalcitrant plantar warts.
Efficacy for other types of warts still unknown
Autoimplantation of wart
material22
II-3C Only one intention-to-treat series reported significant effects. No RCT
available
Topical 5-fluorouracil2 I-C Efficacy significant with one study using cream preparation in children,
but overall evidence becomes limited when pooled with other studies
Intralesional 5-fluorouracil24 I-B One double blind RCT using a 5-fluorouracil mixture of epinephrine and
lidocaine
Topical podophyllin7 II-2D Good efficacy from older case series in 1970s, not recommended now for
toxicities. No known RCT
Topical imiquimod16 II-2C Approved for use in genital warts, only two case studies of efficacy for
plantar warts. Evidence is still lacking
Topical squaric acid18 II-3C Intention to treat studies showed efficacy in children and cases of
recalcitrant wart, known risks of contact dermatitis
Duct tape2 I-I Perhaps the most controversial of all treatments, modest efficacy from
an RCT in school children is later refuted by another RCT in adults.
Evidence is too conflicting to suggest benefit
Laser (CO2 and YAG)14 I-C Good efficacy from intention to treat case series especially with
recalcitrant warts and in children. The only RCT does not show evidence
of benefit over conventional treatment
Intense pulsed light15,30 I-I One case study combines photosensitiser with IPL and shows efficacy,
another RCT using IPL alone shows no efficacy. Evidence is lacking
Electrosurgery
(electrodessication,
electrocoagulation and
cautery)7
II-1C Good efficacy from case reports with known risks of scarring and deep
tissue damage. One controlled trial compares electrocoagulation with
infrared coagulation with no difference, no known RCT. Often used for
recalcitrant warts
Surgical excision7 II-3D No RCTs so far, generally not recommended as first line treatment due to
scarring, pain and high rate of recurrence – up to 30%
5. clinicalTreating common warts – options and evidence
Reprinted from Australian Family Physician Vol. 39, No. 12, december 2010 937
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treatment of condylomata acuminata: a controlled
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mixture of 5-fluorouracil, lidocaine, and epinephrine:
a prospective placebo-controlled, double-blind rand-
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25. Tobin AM, Cotter M, Irvine AD, et al. Successful
treatment of a refractory verruca in a child with acute
lymphoblastic leukaemia with topical cidofovir. Br J
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festations in renal transplant recipients of Santiago,
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2009;31:561–73.
30. Kalil CL, Salenave PR, Cignachi S. Hand warts
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acid and intense pulsed light. Eur J Dermatol
2008;18:207–8.
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cryotherapy. Int J Dermatol 2007;46:524–6.
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22. Shivakumar V, Okade R, Rajkumar V.
electrodessication (hyfrecation) of the lesion
under local anaesthesia, which often results in
clearance after a single treatment. However,
this option is contraindicated in patients with
poor wound healing (eg. uncontrolled diabetes
or peripheral vascular diseases), keloid tendency
or patients with pace makers. It is also not
recommended for lesions on the face.
Best practice for treating recalcitrant
warts
Destructive options include aggressive
cryotherapy (maximum paring down with
scalpel and longer freezing time of 6 seconds
instead of the usual 3 seconds), hyfrecation
with local anaesthesia, laser treatment and
thermocoagulation.
Subject to availability 5-fluorouracil or
bleomycin can be administered either topically or
intralesionally, preferably in a specialist setting.
Lesions with unusual morphology, bleeding
or pigmentation should be biopsied to exclude
possible malignancy.
Summary
Common nongenital warts are common and may
persist despite active treatment. Salicylic acid is
the best evidence based treatment for warts on
initial presentation and can be complemented by
liquid nitrogen cryotherapy. For recalcitrant warts,
choices vary depending on availability and the
training of the GP. The expected efficacy must be
balanced against costs and possible side effects.
It is advisable to perform skin biopsy for suspicious
lesions where necessary in order to exclude
diagnoses such epidermodysplasia verruciformis
and verrucous carcinoma, which are HPV induced
squamous cell carcinomas of the skin.29
Author
Lawrence Leung MBBChir, BChinMed, MFM(Clin),
FRACGP, FRCGP(UK), is Assistant Professor,
Department of Family Medicine, Queen’s
University, Kingston, Ontario, Canada.
leungl@queensu.ca.
Conflict of interest: none declared.
References
1. Clifton MM, Johnson SM, Roberson PK, et al.
Immunotherapy for recalcitrant warts in children
using intralesional mumps or Candida antigens.
Pediatr Dermatol 2003;20:268–71.
2. Gibbs S, Harvey I. Topical treatments for cuta-
neous warts. Cochrane Database Syst Rev
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