Warts and all
New approaches, existing therapies tackle those stubborn skin disorders.
Every dermatologist at some point in their career will run into that most pernicious of protrusions — the stubborn wart that just won’t go away.
Peter Friedman, MD, PhD, FAAD, a dermatologist at the Skin Center Dermatology Group in New City, New York, and instructor in clinical dermatology at Columbia University – New York Presbyterian Hospital, said hard-to-manage warts are a daily occurrence in his practice, in part because he sees many children. Dr. Friedman said there are several possible explanations for poor outcomes in managing warts.
Where did that wart come from?
“Sometimes there is an explanation, like the lesions are very big or they are in areas where traditional treatments can’t be used to the fullest extent,” he said. “The side effects or the logistics associated with traditional treatments can also reduce [patient] compliance, and occasionally underlying medical issues, such as immunosuppression, reduce the efficacy of treatments. However, sometimes there is no obvious reason — the wart just doesn’t get better.”
Dr. Friedman takes a twofold approach when it comes to tackling the toughest warts.
“First, I do not do the ‘first-line treatment, second-line treatment after failure’ approach,” he said. “I try to look at every wart patient with all the treatment options in mind and recommend a plan that uniquely suits their individual scenario.”
The second prong of his attack involves a combination of treatments.
“I use the traditional methods — I do freeze many warts and I do recommend using over-the-counter salicylic acid products, but almost never as monotherapy and only when that seems more appropriate for the given patient than anything else I can offer,” he said. “It has been my experience, which is also supported by a number of studies, that certain combination treatments can work better than monotherapies.”
New treatments now and on the horizon
Dr. Friedman discussed several evolving methods that are showing promising results for wart treatment, along with one new one that he said is matching some traditional treatments in terms of efficacy.
“One of the truly novel methods is cold atmospheric plasma, which was developed by a research team I am part of,” he said. “This is a very well-tolerated treatment with efficacy on par with the more traditional treatments. The limitation is that it does require a device to administer the treatment, and it is not yet on the market.”
Ultimately, Dr. Friedman said there are multiple factors to consider when treating stubborn warts, not the least of which is the cost to the patient.
“Cost is a very important question and can be a significant barrier,” he said. “If we prescribe a medication, the patient may or may not have a co-pay. If they come to the office for treatment, they may or may not have a co-pay or deductible. One part of their benefit package may be more favorable than the other, depending on their insurance. They may live far from the office or work multiple jobs, so it is a big issue to come to see me every three or four weeks for a treatment.”
Aside from the cost of the office visit, Dr. Friedman said the cost of just getting to the office and the monetary value of the time patients have to spend on office visits can add up quickly.
“These variables, and not just the purely medical considerations, all factor into the decision process when choosing the best treatment for a patient,” he said. “So there really is no one treatment I would recommend above all for all patients.
“We must constantly remind ourselves that our most commonly used first-line wart treatments are far from perfect, as large reviews and analyses have shown time and time again,” Dr. Friedman said.
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