Letters to the Editor

Physicians Need More Evidence on Treatments of Warts



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Am Fam Physician. 2003 Nov 1;68(9):1714-1717.

to the editor: The recent article, “Molluscum Contagiosum and Warts,”1 is a praiseworthy attempt to update family physicians on the current treatment options for this commonly encountered problem. However, this paper does not guide physicians on which treatment to choose based on good evidence.

It should be made clear that the methodologic quality of research on various local treatments is mediocre at best. According to the updated systematic review2,3 on local treatments for cutaneous warts in healthy people, there is only good evidence for the therapeutic efficacy and safety of simple topical salicylic acid. Little evidence exists for the efficacy of the other choices of treatment that were mentioned in the article.1 We, as physicians, have no convincing evidence that cryotherapy is any more effective than simple topical treatments.

REFERENCES

1. Stulberg DL, Hutchinson AG. Molluscum contagiosum and warts. Am Fam Physician. 2003;67:1233–40.

2. Gibbs S, Harvey I, Sterling J, Stark R. Local treatments for cutaneous warts: systematic review. BMJ. 2002;325:461.

3. Gibbs S, Harvey I, Sterling JC, Stark R. Local treatments for cutaneous warts. Cochrane Database Syst Rev. 2001;2:CD001781.

in reply: Dr. Chow's comments astutely refer physicians to availing themselves to the best possible evidence in the care of our patients. First, Dr. Chow requests guidance as to which treatments to choose based on good evidence. Dr. Chow has referred to the same Cochrane Review1 that Dr. Hutchinson and I refer to in our article,2 which reviews the most appropriate studies to offer assistance in the treatment approach to warts. In addition to referencing that work, our article presents several small studies that explore other treatment options that are prevalent in clinical practice, with reference to the nature of the study, its size, and its outcome. The accompanying table summarizes the estimated treatment success rates based on the information presented in the Cochrane review,1 in our article,2 and in a recent article about using duct tape to treat warts.3

Efficacy Rates of Various Treatments for Warts

Treatment Efficacy (%)

None/placebo

30 (range: 0 to 70)

Topical salicylic acid

75

Cryotherapy

30 to 75*

Dinitrochlorobenzene

80

Cimetidine (in children)

46 to 75 †

Cimetidine with levamisole

86

Candida or mumps injection

74

Imiquimod

56

Duct tape

853


*—Extrapolated from Cochrane review1 noting two randomized controlled trials showing equivalence to placebo and two randomized trials showing equivalence to topical salicylic acid. The larger trials of cryotherapy were excluded because of lack of a placebo arm.

†—Control arm of cimetidine alone from one trial4 was as effective as topical salicylates or cryotherapy.5

Efficacy Rates of Various Treatments for Warts

View Table

Efficacy Rates of Various Treatments for Warts

Treatment Efficacy (%)

None/placebo

30 (range: 0 to 70)

Topical salicylic acid

75

Cryotherapy

30 to 75*

Dinitrochlorobenzene

80

Cimetidine (in children)

46 to 75 †

Cimetidine with levamisole

86

Candida or mumps injection

74

Imiquimod

56

Duct tape

853


*—Extrapolated from Cochrane review1 noting two randomized controlled trials showing equivalence to placebo and two randomized trials showing equivalence to topical salicylic acid. The larger trials of cryotherapy were excluded because of lack of a placebo arm.

†—Control arm of cimetidine alone from one trial4 was as effective as topical salicylates or cryotherapy.5

Two of Dr. Chow's statements, nearly verbatim from the Cochrane review,1 are best interpreted together. (1) “There is only good evidence for the therapeutic efficacy and safety of simple topical salicylic acid,” and (2) “no convincing evidence that cryotherapy is any more effective than simple topical treatments.” Cryotherapy is not more effective, but, if it is equally effective as two of the allowed studies in the Cochrane review1 indicate, then it should be an acceptable treatment, because many patients prefer a one-time treatment to weeks or months of daily applications.

The Cochrane review1 included only randomized controlled trials and did not include data from most of the large trials involving cryotherapy, because those trials primarily compared various methods of cryotherapy. It is my understanding that many trials are appropriate studies comparing variations of treatments without imposing a placebo arm, just as we would hope in chemotherapy trials testing new versus established therapies or in trials comparing aspirin and coumadin (Warfarin) for clotting disorders. An analysis of the large trials that compare various forms of cryotherapy with the estimated spontaneous resolution rate of 30 percent from the Cochrane analysis1 might yield useful information.

Perfect data are not available but based on the best available evidence, cryotherapy appears to be approximately 60 percent effective in the treatment of warts and topical salicylates are approximately 75 percent effective. Data from population studies and control arms of studies show spontaneous resolution to be approximately 30 percent. Physicians will make the decision with their patients as to which treatment or nontreatment will best suit the individual, based on tolerance of the time and work involved in the treatment, and the side effects and efficacy of the treatment.

REFERENCES

1. Gibbs S, Harvey I, Sterling JC, Stark R. Local treatments for cutaneous warts. Cochrane Database Syst Rev. 2001;2:CD001781.

2. Stulberg DL, Hutchinson AG. Molluscum contagiosum and warts. Am Fam Physician. 2003;67:1233–40.

3. Focht DR III. The efficacy of duct tape vs cryotherapy in the treatment of verruca vulgaris (the common wart). Arch Pediatr Adolesc Med. 2002;156:971–4.

4. Bauman C, Francis JS, Vanderhooft S, Sybert VP. Cimetidine therapy for multiple viral warts in children. J Am Acad Dermatol. 1996;35:271–2.

5. Rogers CJ, Gibney MD, Siegfried EC, Harrison BR, Glaser DA. Cimetidine therapy for recalcitrant warts in adults: is it any better than placebo?. J Am Acad Dermatol. 1999;41:123–7.

Send letters to Kenneth W. Lin, MD, MPH, Associate Deputy Editor for AFP Online, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.

Please include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

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