43

Verrucas

Causes 285 Product recommendations 289

Treatment 285 References 289

Product selection points 288

Verrucas (plantar warts) are benign viral infections of the epidermis on the
sole of the foot.

Causes
Verrucas are caused by the human papillomavirus and result in hyperkeratin-
isation. A verruca is simply a wart that has been compressed by the weight put
upon it; it is painful because of pressure exerted on the nerve endings.
Verrucas are most common in children and, although they resolve spontane-
ously, they are usually treated actively as resolution can take months or even
years.

Treatment
Treatment is by gradual removal of the hyperkeratotic skin layers and the
viral core by keratolytic agents.
Several products are marketed for the removal of corns and calluses and
also for warts and verrucas. Compounds used include:
* salicylic acid
* lactic acid
* podophyllum resin
* formaldehyde
* glutaraldehyde
* silver nitrate.
286 | Non-prescription Medicines

Salicylic acid
Mode of action
When used in the treatment of warts and verrucas, salicylic acid reduces
viral numbers by mechanical removal of infected tissue. It also stimulates
production of protective antibodies in response to the mildly irritant effect
of the acid. Salicylic acid is a constituent of many wart and verruca treat-
ments, alone and in combination with other ingredients. Some products are
the same as those marketed for corns and calluses. A Cochrane Review
concluded that simple topical treatments containing salicylic acid have a
therapeutic effect in the treatment of warts, increasing complete wart clear-
ance, successful treatment or loss of one or more warts after 6–12 weeks
compared with placebo.1 In a comparative trial, salicylic acid was found to
have a high cure rate (84%) for simple plantar warts and to be as effective as
cryotherapy for hand warts; a podophyllum treatment also had a high cure
rate of 81%.2

Product examples
* Salicylic Acid Collodion BP (12%: see Chapter 9 Corns and calluses)
* Bazuka Extra Strength (26% in a film-forming gel)
Dendron
* Occlusal (26% in a polyacrylic vehicle)
Alliance
* Scholl Verruca Removal System (medicated discs containing 40%)
* Scholl Seal and Heal Verruca Removal Gel (12.5% in a film-forming gel)
both SSL International
* Verrugon (ointment containing 50%)
Ransom

Lactic acid
Mode of action
Lactic acid has corrosive properties and is included with salicylic acid in
several verruca products. It is claimed to enhance the effects of salicylic acid.
Care must be taken that preparations do not spread on to unaffected skin.

Product examples
* Containing 16.7% lactic acid, with 16.7% salicylic acid in a collodion
base
– Duofilm
Stiefel
– Salactol Wart Paint
Dermal
 Verrucas | 287

* Containing 4% lactic acid, with 11–12% salicylic acid in a film-forming

gel
– Bazuka
Dendron
– Cuplex gel
Crawford
– Salatac gel
Dermal

Podophyllum resin
Mode of action and adverse effects
Podophyllum resin (podophyllin) is obtained from the dried rhizome of the
May-apple (Podophyllum peltatum). Podophyllum resin has a potent corro-
sive action, and for non-prescription use it is indicated solely for plantar
warts. It is cytotoxic and a caustic and powerful skin irritant; care must be
taken to confine its application to the verruca only. There have also been
reports of teratogenicity; it is contraindicated in pregnancy.

Product
* Posalfilin ointment (20% podophyllum resin, plus 25% salicylic acid)
Norgine

Formaldehyde
Mode of action
Formaldehyde has antiviral activity; it also has a direct anhidrotic action,
drying the verruca and surrounding skin.

Products
* Veracur gel (0.75% formaldehyde in an aqueous gel base – a disadvantage
is that it must be used twice daily)
Typharm
* Solution of formaldehyde (3% – can be used for daily foot soaks if there
are a large number of verrucas, although care must be taken to protect
unaffected skin)

Glutaraldehyde
Mode of action
Glutaraldehyde has similar properties to formaldehyde. However, glutaral-
dehyde appears to have no advantage over formaldehyde and may be a more
potent skin sensitiser. It stains skin brown, but this fades once treatment is
discontinued.
288 | Non-prescription Medicines

Product
* Glutarol Wart Paint (10%)
Dermal
Silver nitrate
Mode of action
Silver nitrate is a caustic agent. It is used in the form of a stick or pencil (95%
toughened with 5% potassium nitrate) to destroy warts, verrucas and other
skin growths. Unlike other treatments for verrucas, silver nitrate pencil is used
for only a short period; the manufacturer of the only commercially available
product claims that three daily applications are sufficient, but that a maxi-
mum of six daily applications may be made. In a clinical trial, silver nitrate
stick completely or partially cured common warts in 69% of subjects, com-
pared with 25% with placebo.3

Product
There is only one product:
* Avoca Wart and Verruca Set
Bray
Application and use
Removal of verrucas is achieved by a process of gradual abrading of the
infected tissue, and the same basic method is used for all preparations. The
following points of advice should be given to patients:
* Before application, gently rub away the top layer of skin with a file, emery
board or pumice stone.
* Apply the preparation directly to the top of the verruca, taking precautions
to confine the preparation to that area.
* Cover the verruca with a plaster to encourage maceration and improve
penetration of the medicament.
* Remove the plaster after 24 hours and file away the dead tissue on top of
the verruca.
* Repeat the process daily until all traces of the verruca have been removed;
this may take up to 3 months (except for treatment with silver nitrate – see
above), but the verruca may regrow if all infected tissue has not been
removed.

Product selection points

* Salicylic acid has been shown to be an effective treatment for plantar and
hand warts, and collodion-based products provide a convenient and
efficient method of application.
 Verrucas | 289

* There is little published evidence of effectiveness for other agents used in

the treatment of verrucas and warts.

Product recommendations
* Salicylic Acid Collodion BP or similar preparation.

References
1. Gibbs S, Harvey I. Topical treatments for cutaneous warts. Cochrane Database Syst Rev
2006; issue 2.
2. Bunney MH, Nolan MW, Williams DA. An assessment of methods of treating viral warts by
comparative treatment trials based on a standard design. Br J Dermatol 1976; 94: 667–679.
3. Yazar S, Basaran E. Efficacy of silver nitrate pencils in the treatment of common warts.
J Dermatol 1994; 21: 329–333.
44
Warts

Cause 291 Reference 292

Treatment 291

Warts are benign growths caused by viral infection. They occur most fre-
quently on the hands and fingers, and less commonly on the elbows and knees.
Cutaneous warts, or common warts as they are more usually known, can
occur at any age, but incidence peaks at 12–16 years and declines after
20 years of age. They occur mostly in children and young adults, with
an overall incidence of 10%. A study of schoolchildren found that 4% of
11-year-old children had warts, but 93% of these no longer had warts by the
age of 16 years.1

Cause
Like verrucas, warts are caused by the human papilloma virus. Apart from
their location and the fact that they are usually painless because they are not
compressed, warts are identical to verrucas (see Chapter 43 Verrucas).

Treatment
Treatment is essentially the same as for verrucas (see Chapter 43 Verrucas),
and nearly all the products available are licensed for both warts and verrucas.
Of the products listed under verrucas, most are licensed for treatment of
both common and plantar warts. Some are licensed exclusively for the latter
because they are presented as kits containing plasters or pads to relieve pain
resulting from pressure exerted by body weight on plantar warts. Only
Posalfilin (Norgine) is restricted to treatment of plantar warts by virtue of
one of its constituents – podophyllum resin.