Point-Counterpoint: Is Non-Surgical Care The Best Course For Plantar Warts?

Yes.

This author notes she frequently treats patients with verrucae who have failed surgical treatment and notes that a topical retinoid and non-ablative lasers provide successful alternatives.   

By Tracey C. Vlahovic, DPM

Anyone who has been my student knows I treat the majority of warts that walk in through my facility’s doors and that I can count on one hand how many times I have surgically removed a verruca.
There are currently no published randomized, controlled studies that utilize the surgical removal of verruca for the foot. Sure, I could state that a surgical procedure involves anesthesia, special care if one performs the procedure on the plantar foot and postoperative pain, but that is not my argument against performing surgery.

A vast majority of the verrucae that I have treated have come to me from other physicians who already have tried various other methods including excision. The worst warts I have treated over the years have been the ones someone tried to excise, scrape, burn or use a CO₂ laser to resolve. In these cases, there was warty recurrence, gross resurgence and hypertrophy within the surgical scar.

How The Koebner Phenomenon And HPV Complicate The Picture
Here is the issue behind the recurrence following excision: the Koebner phenomenon and subclinical/latent presentations of cells infected with human papillomavirus (HPV).  

The Koebner phenomenon or isomorphic response is the development of pathologic lesions in traumatized uninvolved skin (i.e. what can occur during excision of a verruca). Many associate this response with psoriatic lesions but it also occurs with Kaposi’s sarcoma, lichen planus and warts caused by HPV.¹ After trauma to the skin, new lesions arise that are histopathologically identical to the original lesion. Couple this with the disorganized collagen bundles consistent with scar tissue and you have a therapeutic headache.

Most of my patients reported having a small lesion at the first physician visit, consenting to the surgical procedure they thought would be curative and quick, and then had multiple and sometimes larger lesions return a few weeks to months after the procedure. They present to me angry, frustrated and confused as to why this occurred.

Now to be fair, I do not see the successful cases of wart excision. I only see failures. One could argue that any trauma to a wart could incite the Koebner phenomenon and that can certainly happen, but it seems to happen at a greater rate after scalpel or ablative laser procedures in my clinical experience.  

The second reason I prefer a non-surgical approach to warts is what you cannot see on the skin, namely the cells with latent virion particles that have not switched “on” yet.² If you look at the genital HPV data, half of the women who have HPV have no visible symptoms and some even estimate that 1 in 100 people infected with HPV have a visible, clinical lesion.² The HPV can be latent or in an unexpressed state in surrounding cells for up to 20 years.² Obviously, during a surgical excision, one cannot detect the cells that are latent and doing a wide excision to encompass the surrounding tissue would be fruitless and anatomically impossible on the foot.  

A Closer Look At Effective Non-Surgical Treatments
According to Lipke, “surgical excision and cautery of warts is not recommended as a standard therapy because it can be painful and cause scars that are difficult to treat.”³ One should choose the plethora of available non-surgical approaches on the basis of the number of lesions, anatomic location, pain, concomitant medical conditions and, of course, patient input. Most patients want a pain-free regimen or something they perceive to be harmful to the wart while yielding little downtime for their lifestyle.  

So what treatments are available that have been published in the literature as non-surgical options?

One option is the topical retinoid adapalene. Topical retinoids are in common use for acne as they alter keratinization in the epidermis, act as an anti-inflammatory and inhibit cell proliferation. While clinicians use adapalene 0.1% gel (Differin, Galderma Laboratories) in the treatment of mild to moderate acne, a current article in the Indian Journal of Dermatology described the off-label use of this agent for plantar verrucae.⁴ In the randomized study involving 50 patients with 424 plantar warts, patients in group A applied adapalene 0.1% twice daily under occlusion and those in Group B received cryotherapy treatment once every two weeks. Patients had weekly follow-up until the warts cleared and then reported for monthly visits for six months post-clearance to determine if there was any recurrence.

Twenty-four out of 25 patients in Group A had complete clearance of 286 warts in about 36 days.⁴ In Group B, 24 out of 25 patients had complete clearance of 124 warts in 52 days. Group A patients experienced no adverse events while Group B had scarring, pain and redness (all the side effects that are expected with the use of cryotherapy). There was no recurrence in any patient. In this study, adapalene 0.1% gel seemed to clear warts faster and with fewer side effects than cryotherapy alone. This is an off-label indication and non-painful option for plantar warts.  

Laser therapy that is non-ablative, unlike the CO₂ laser, is another option for plantar warts. The neodymium-doped yttrium aluminum garnet (Nd:YAG) laser has a wavelength of 1064 nm, which is in the infrared range. This is a non-ablative laser with a target chromophore (the entity in the body that absorbs the laser wavelength) of oxyhemoglobin and allows for selective heating of the capillary rich active verrucae.⁵ The non-ablative pulsed dye laser also targets oxyhemoglobin around the 585-595 nm wavelength.⁵ Neither of these lasers “cut” the skin like the CO₂ device does.

In a study following 46 patients with warts, patients received treatment with either the Nd:YAG or the pulsed dye laser.⁶ Due to the oxyhemoglobin absorbing the Nd:YAG wavelength less well than the pulsed dye wavelength, a higher fluence (energy per surface area) is necessary for the application of the Nd:YAG laser versus the pulsed dye laser. In this study, the authors used the Nd:YAG laser at a fluence of 100 J/cm² in comparison to the pulsed dye laser fluence of 8 J/cm². There was no significant difference in the use of the two lasers (clearance rates of 73.9 percent for the pulsed dye laser versus 78.3 percent for the Nd:YAG laser) except the Nd:YAG laser was more painful and the pulsed dye laser required more treatments. This observation is consistent with what I have seen in patients as I use both lasers. These lasers facilitate less downtime than the CO₂ device, which is truly an ablative (i.e. cutting like a scalpel) device.  

In Conclusion
There are many treatment options available for plantar warts but only a few have been utilized in proper research protocols. I choose to use the above two options in my facility not only because of the published data but also for the effective non-ablative and non-surgical approach.  

Dr. Vlahovic is an Associate Professor and J. Stanley and Pearl Landau Fellow at the Temple University School of Podiatric Medicine. She writes a monthly blog for Podiatry Today. Readers can access Dr. Vlahovic’s blog at https://tinyurl.com/qbe6s4w .

References  

1. Thappa DM. The isomorphic phenomenon of Koebner. Indian J Dermatol Venereol Leprol [serial online] 2004 [cited 2015 Nov 30];70:187-9. Available from: https://www.ijdvl.com/text.asp?2004/70/3/187/11105 .
2. Watson RA. Human papillomavirus: confronting the epidemic—a urologist’s perspective. Reviews Urology. 2005; 7(3):135–44.
3. Lipke MM. An armamentarium of wart treatments. Clin Med Res. 2006; 4(4):273-293.  
4. Gupta R, Gupta S. Topical adapalene in the treatment of plantar warts; randomized comparative open trial in comparison with cryo-therapy. Indian J Dermatol. 2015; 60(1):102.
5. Patil UA, Dhami LD. Overview of lasers. Indian J Plast Surg. 2008;41(Suppl):S101-S113.
6. El-Mohamady Ael-S, Mearag I, and El-Khalawany M, et al. Pulsed dye laser versus Nd:YAG laser in the treatment of plantar warts: a comparative study. Lasers Med Sci. 2014;29(3):1111-6.

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No.

Pointing to ineffective results, the long duration of conservative modalities and high recurrence rates, this author maintains that surgical management is the most effective option for plantar warts.  
 

By Ryan Fitzgerald, DPM, FACFAS

Painful plantar warts, or verrucae plantaris lesions, are a common presenting complaint among patients, particularly children and young adults.^1,2 These lesions are the result of an infection with the human papillomavirus (HPV). While there are over 100 serotypes of HPV, knowing the serotype does not influence the treatment of benign warts nor does it suggest an increase in the efficacy rates of treatment.^3,4

A review of the literature demonstrates many available treatment modalities for the management of this challenging condition but the efficacy of these treatments varies greatly.^5,6 The continuum of the treatments available in the management of verrucae lesions includes the application of topical medications, cryotherapy, intralesional injection therapy, oral medications, laser therapy, sharp debridement and surgical excision.^1,7,8

Further complicating the management of these lesions are the widely available over-the-counter products that patients frequently utilize as these products are commonly ineffective.^3,9 In addition, there is a high recurrence rate noted in the literature following the use of these conservative modalities.^3,9

While there are many clinicians who advocate one therapy over another, there is little objective evidence in the literature to support many of the medical treatments for the management of this condition.¹ Indeed, it seems at times that the reason there are so many available conservative treatments to manage plantar warts is simply a function of the fact that none of these modalities are particularly efficacious. While the duration of therapy varies with the use of medical modalities, it is not uncommon for patients who are using medical therapies to require months upon months of treatment.^10,11

Even with the use of these time-consuming conservative modalities, the success rates can be underwhelming. This prolonged duration of treatment, in the face of modest success, is often frustrating to both patients and clinicians. One can opine that the prolonged duration of treatment increases the generalized risk for further skin contamination and the development of satellite lesions.^4,12

Why Surgical Management Can Be Effective For Warts
It is my recommendation, considering the paucity of evidence supporting the efficacy of medical modalities for the management of verrucae plantaris lesions, that one utilize surgical management to provide the most effective treatment for complete resolution of symptoms in patients suffering from plantar warts.^13,14

One must remember that these lesions represent a skin infection with cutaneous manifestations and is accordingly a communicable condition. Perhaps this is why patients using medical therapy have a tendency for the development of satellite lesions as well as a high recurrence rate.¹⁵ However, when you consider the pathophysiology of plantar warts, it becomes evident that one can address these lesions surgically with relatively little risk or potential for comorbidity.¹⁶

There are a variety of techniques that one can utilize to address verrucae lesions surgically, ranging from basic curettage with healing occurring via secondary intention to sharp excision with primary closure. Often one can manage smaller lesions effectively with simple 3:1 skin ellipses oriented along the relaxed skin tension lines.

In those instances when large or mosaic lesions are present, local tissue rotation or transposition flaps can provide soft tissue coverage over the primary defect created upon excision of the lesion. Depending on the size, location and orientation of the offending lesion, I commonly utilize unilobed, bilobed and modified rhomboid transposition flaps to provide soft tissue coverage over the soft tissue defect — which I create upon the excision of the verrucae lesion — to allow for primary closure with minimal skin tension.^17-19

In other instances, split-thickness skin grafting (STSG) can provide wound coverage following the resection of large mosaic lesions.²⁰ For larger defects following the resection of extensive mosaic warts that encompassed large portions of the foot, one can apply dermoconductive skin substitutes to the subsequent defect to promote the development of granulation tissue to progress the patient toward soft tissue reconstruction either through subsequent application of STSG for definitive closure.

The postoperative course depends on the location and size of the lesion as well as the method of closure. However, these surgical sites are commonly fully healed within two to three weeks after surgical removal of the lesion. In addition, surgical resection of the lesion allows the clinician to send the specimen for pathological evaluation to confirm the diagnosis and rule out other, potentially more harmful conditions.²¹ This is particularly valuable in those patients who present with recurrent verrucae-type lesions following previous medical therapy.  

In Conclusion
Verruca plantaris lesions continue to present a management challenge to clinicians and there is no one treatment that research has shown to be dramatically more effective from a conservative or surgical standpoint. However, when one compares medical therapy’s modest success rates in the face of the prolonged duration of care, clinicians can see that a surgical solution, which allows for complete resolution and healing within a month of care, is a much more successful option. After all, plantar wart lesions are a cutaneous manifestation of a viral infection. Lower extremity surgeons commonly treat skin and soft tissue infection with surgical debridement. Accordingly, the surgical management of plantar warts is simply a variation on that theme.

In addition to promoting faster resolution of symptoms, the surgical management of plantar warts allows the clinician to obtain objective pathology data to confirm the diagnosis. This is of particular concern in recurrent cases in which the lesions demonstrate an atypical presentation. While there is always a risk when considering surgical intervention, in the correct patient population, this risk is minimal.

While further research is certainly warranted, a review of the currently available literature demonstrates that no one medical or conservative modality available for the management of verrucae plantaris lesions demonstrates greater efficacy than another. Conversely, surgical management of these lesions gives the clinician the confidence that he or she has removed the offending pathologic tissue, thus leading to the complete and timely resolution of symptoms.

Dr. Fitzgerald is affiliated with the Greenville Health System (GHS) Center for Amputation Prevention in Greenville, SC. He is an Assistant Professor of Surgery at the University of South Carolina School of Medicine in Greenville, SC.

References

1. Bavinck JN, Eekhof JA, Bruggink SC. Treatments for common and plantar warts. Br Med J. 2011; 342:d3119.
2. Johnson LW. Communal showers and the risk of plantar warts. J Fam Pract. 1995; 40(2):136-8.
3. Aubin F, Gheit T, Pretet JL, et al. Presence and persistence of human papillomavirus types 1, 2, and 4 on emery boards after scraping off plantar warts. J Am Acad Dermatol. 2010; 62(1):151-3.
4. Bruggink SC, Gussekloo J, de Koning MN, et al. HPV type in plantar warts influences natural course and treatment response: secondary analysis of a randomised controlled trial. J Clin Virol. 2013; 57(3):227-32.
5. Khandelwal K, Bumb RA, Mehta RD, et al. Long-term efficacy of radiofrequency ablation in treatment of common and palmo-plantar warts. Australas J Dermatol. 2013; 54(4):307-9.
6. Soni P, Khandelwal K, Aara N, et al. Efficacy of intralesional bleomycin in palmo-plantar and periungual warts. J Cutan Aesthet Surg. 2011; 4(3):188-91
7. No authors listed. Medical practice question: laser therapy for plantar warts. West J Med. 1985; 143(3):332.
8. Salk RS, Grogan KA, Chang TJ. Topical 5% 5-fluorouracil cream in the treatment of plantar warts: a prospective, randomized, and controlled clinical study. J Drugs Dermatol. 2006; 5(5):418-24.
9. Pinto NM. Treating plantar warts: what to do when patients take matters into their own hands. Nurs Times. 2010; 106(48):15.
10. Stamuli E, Cockayne S, Hewitt C, et al., Cost-effectiveness of cryotherapy versus salicylic acid for the treatment of plantar warts: economic evaluation alongside a randomised controlled trial (EVerT trial). J Foot Ankle Res. 2012; 5:4.
11. Bruggink SC, Assendelft WJ. Cryotherapy for plantar warts more costly but no more effective than salicylic acid self-treatment. Evid Based Med. 2012; 17(5):156-7.
12. Carlson BA. Argon laser treatment tackles recurrent plantar verrucae. Clin Laser Mon. 1992; 10(4):61-2.
13. Pringle WM, Helms DC. Treatment of plantar warts by blunt dissection. Arch Dermatol. 1973; 108(1):79-82.
14. Leung L. Recalcitrant nongenital warts. Aust Fam Physician. 2011; 40(1-2):40-2.
15. Lichon V, Khachemoune A. Plantar warts: a focus on treatment modalities. Dermatol Nurs. 2007; 19(4):372-5.
16. Ecker HA. The use of salisacom treatment as preoperative preparation for excision and flap repair of plantar warts. Plast Reconstr Surg. 1966; 37(5):461-3.
17. Chasmar LR. The versatile rhomboid (Limberg) flap. Can J Plast Surg. 2007; 15(2):67-71.
18. Sahin C, Ergun O, Kulahci Y, et al. Bilobe flap for web reconstruction in adult syndactyly release: a new technique which can avoid the use of skin graft. Plast Reconstr Surg. 2015; 136(4 Suppl):28-9.
19. Boffeli TJ, Reinking R. Plantar rotational flap technique for panmetatarsal head resection and transmetatarsal amputation: a revision approach for second metatarsal head transfer ulcers in patients with previous partial first ray amputation. J Foot Ankle Surg. 2014; 53(1):96-100.
20. Belczyk R, Stapleton JJ, Blume PA, Zgonis T. Plantar foot donor site as a harvest of a split-thickness skin graft. Clin Podiatr Med Surg. 2009; 26(3):493-7.
21. Lee SY. A rapidly regressed giant plantar wart following biopsy. Ann Dermatol. 2013; 25(1):113-4.