**Any treatment options discussed below may be “off label” use and should only be attempted under the supervision of an appropriately trained physician.**
Warts, specifically Verruca Plantaris have been on my mind of late since 2 nasty little ones decided to “pop” up on the bottom of my right foot. They aren’t painful fortunately but have the potential to become so. Since I treat them on a daily basis I feel it is time to update the blog world on new treatments that I have recently implemented for my patients as well as myself and their success rates.
A plantar wart is a wart caused by the human papillomavirus (HPV) occurring on the sole (Latin planta) or toes of the foot. This infectious process is usually picked up by walking barefoot on a contaminated surface or by using shoes and socks contaminated by someone else who has the infection.
Plantar warts are almost unknown in habitually barefoot cultures and people. This is because walking barefoot for extended periods of time strengthens the skin and keeps it dry and uncompromised as well as wearing off the virus through friction on the soles of the feet, preventing infection. While infection occurs in an estimated 7–10% of the US population, plantar warts tend to affect only 0.29% of people who have never worn shoes. Though I am not recommending we all shuck our shoes for good (see post on barefoot running), it is interesting that a little barefoot time will get you the viral infection, and a lot of barefoot walking will actually help prevent it. I often go barefoot and it is for that reason that my little warts have stayed little and have allowed me to avoid treating them for quite some time. That being said there are about a thousand reasons to not go barefoot in the environment most of us find ourselves in today including, infection, laceration, warts, puncture wounds, painful callus, skin fissures etc.
Look closely at the picture above. You will notice black dots within the wart that are actually tiny capillary buds that have clotted off. You’ll also notice that the skin lines spread out and become wavy around the wart. If you could squeeze the wart from side to side it would be quite painful. These three classic signs in the diagnosis of plantar warts. A large number of patients come into my office convinced they have a wart that needs to be removed when in fact it is just a thick callus that has become painful (which is also treatable).
We recommend having warts treated as soon as they are found. The simple fact is that small warts are easy to treat and larger warts can be quite challenging and painful to treat.
Several studies have been published (J Cutan Aesthet Surg. 2011 Sep;4(3):188-91.) showing the effectiveness of Bleomycin injections into small warts. Most of these studies showed >90% cure rate.
Bleomycin has been demonstrated to be very effective for warts smaller than a dime. You do have to deal with a painful thick lesion after injection which needs to be removed within a week or two of the injection but it rarely results in scarring or recurrence.
Bleomycin has been and continues to be our primary treatment for small to moderate sized warts in our office. For over 2 years we have used a small device called a madajet which was developed for the purpose of numbing small, superficial areas of skin for dermatological procedures. It works better in our opinion at distributing bleomycin into a wart than does an injection.
The limitations of Bleomycin injections are two fold. It does leave a painful and sometimes deep wound, so if you inject a large area this becomes a big problem. Second, Bleomycin is a chemotherapy type drug and larger amounts can result in nausea and vomiting among other side effects.
Large warts or Mosaic Warts are another matter and can be uniquely challenging.
I like to approach larger warts from several angles at once. I have had great results in the toughest of situations (over 20 warts on a single foot) with the combination of using oral Zinc Sulfate, foot powder/drying agent and topical DNCB. All three of these have been demonstrated to cure warts on their own without painful scarring, however, their success rates are not as high as Bleomycin injections so they are combined for best results.
DNCB (dintrochlorobenzene) activates the immune system helping the body to fight the wart from within where ever applied. This can be a potent treatment option and needs to be monitored by your doctor. Zinc Sulfate enhances the immune system’s ability to fight warts and can be effective as the only treatment. Warts tend to prefer moist skin types and a good drying powder aids in changing the environment of the skin.
Even though DNCB has been an effective treatment option in my clinic I have certainly had patients who did not respond to it at all. For this reason I am always looking for other systemic treatment options.
A new treatment option which I have used very successfully with multiple patients when dealing with many warts of varying sizes is Tagamet. Yes that’s right I said Tagamet. For those of you out there who suffer from acid reflux or GERD you are likely familiar with this oral medication. What you may not know is that is has been studies for at least 10 years and used to treat plantar warts. The dose that you take is much higher than for treating stomach issues (30-40 mg/kg daily) and runs for 8-12 weeks. This is clearly an off label use of the drug but has been found to be safe. Recent studies show it is slightly more effective in pediatrics than adults but I have seen good results for both. Worse case scenario it has resolved enough warts that we were able to proceed with treatments like Bleomycin.
– Liquid Nitrogen: effective in other parts of the body where the skin is much thinner. I have found that the freezing agent just doesn’t work as well on the thick skin of the sole of the foot and require many treatments if it is effective at all.
– Laser Removal: can leave painful scarring and has a fairly high recurrence rate.
– “Bug Juice”: moderate results, often warts are resistant.
– Surgical Removal: carries with it a risk of scarring which can be as painful/annoying as was the wart but can be very effective if done right. I reserve this for a last resort treatment.
– Duct Tape: has actually be demonstrated to work for smaller warts, “occlusion” activates the body’s ability to fight the wart.
– Compounded Topical Creams: a combination of 5 Fluorouracil, salacylic acid, urea etc that has been shown to be effective killing the warts.
Please feel free to contact us at anytime for an appointment to be evaluated and treated or even just to ask us whatever questions you may have.
Darren Groberg, DPM
Dan Preece, DPM & Darren Groberg, DPM