Cryotherapy and Treatment of Plantar Warts

Pre-Treatment Procedures

• Gently debride the overlying hyperkeratotic skin with a surgical blade prior to treatment, as recommended by the British Journal of Dermatology guidelines 1
• Inform patients that the procedure will be painful and blistering may occur, according to the British Journal of Dermatology guidelines 1

Treatment Techniques

• For plantar warts, a double freeze-thaw cycle is more effective than a single cycle, with a 65% vs 41% cure rate, as reported by the British Journal of Dermatology 1
• Maintain freeze for approximately 10 seconds for improved efficacy, as suggested by the British Journal of Dermatology guidelines 1
• Use more gentle freezing techniques for patients with diabetes, peripheral vascular disease, or areas near tendons or nerves, as recommended by the British Journal of Dermatology guidelines 1

Treatment Outcomes

• Plantar warts may be more resistant to cryotherapy than warts at other sites, with recent evidence suggesting cryotherapy alone may have limited efficacy (14-30% cure rate), according to the British Journal of Dermatology 1
• Wart treatment options include high-concentration salicylic acid, cryotherapy with liquid nitrogen, Imiquimod 5% cream, and other modalities, as recommended by the American Academy of Dermatology and the Centers for Disease Control and Prevention (CDC) 2, 3

Treatment Modalities

• High-concentration salicylic acid (60%) can cause local side effects, including erythema, scaling, burning/stinging, skin irritation, and potential salicylate toxicity, especially with prolonged use over large areas, according to the American Academy of Dermatology 3
• The CDC recommends various treatment options for facial flat warts, including:
• A combination of provider-administered cryotherapy with liquid nitrogen and patient-applied salicylic acid (15-40%) is recommended as the first-line treatment approach, with clearance rates of up to 86%, as recommended by the CDC and the British Journal of Dermatology 1, 2
• The following treatment efficacy rates have been reported:

1

Special Considerations

• Patients with diabetes or peripheral vascular disease should use high-concentration salicylic acid with caution, and interactions with anticoagulants, antidiabetic agents, aspirin, corticosteroids, diuretics, methotrexate, and uricosuric agents should be considered, as reported by the American Academy of Dermatology 3
• Podophyllin is contraindicated during pregnancy due to safety concerns, as advised by the CDC 2
• Immunotherapy-based treatments, such as contact immunotherapy with diphenylcyclopropenone (DPC) or squaric acid dibutyl ester (SADBE), are recommended as first-line treatments for skin warts in SLE patients due to their high efficacy and acceptable safety profile, with an 88% complete clearance rate and a median treatment time of 5 months, as recommended by the British Journal of Dermatology 1
• HPV vaccines are safe and immunogenic in SLE patients, and live-attenuated vaccines are contraindicated in immunocompromised SLE patients, as recommended by the Autoimmunity Reviews and the ACIP 4

Treatment Response and Follow-up

• The recurrence rate for facial flat warts is approximately 30% with all treatment modalities, and spontaneous resolution occurs in 20-30% of cases, as reported by the CDC 2
• Most warts respond within 3 months of therapy, with a high recurrence rate of approximately 30% with all treatment modalities, according to the CDC 5
• Persistent hypopigmentation or hyperpigmentation occurs commonly with ablative treatments, according to the CDC 5
• Scarring is uncommon but possible, especially with insufficient healing time between treatments, as reported by the British Journal of Dermatology 1
• Response to treatment and side effects should be evaluated throughout therapy, as recommended by the CDC 5
• Treatment modality should be changed if no substantial improvement is seen after a complete course or if side effects are severe, as recommended by the British Journal of Dermatology 1

Patient Education and Compliance

• Treatment duration should continue for up to 6 months if needed, as persistence is key, and pre-treatment preparation should include debridement of warts wherever possible, as recommended by the British Journal of Dermatology 1
• Clear instructions for home treatments, regular follow-up, and persistence are essential for patient compliance, as most treatments require multiple applications, and the application area should be limited to less than 20% of body surface area to prevent systemic absorption, as recommended by the British Journal of Dermatology and the American Academy of Dermatology 1, 6
• Sun protection is essential for SLE patients with skin manifestations, as recommended by the Annals of the Rheumatic Diseases and the Autoimmunity Reviews 4, 7