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BMJ Clin Evid. 2009; 2009: 1710.
Published online 2009 September 24.
PMCID: PMC2907820

Warts (non-genital)

Steven King-fan Loo, Medical and Health Officer# and William Yuk-ming Tang, Consultant Dermatologist#

Abstract

Introduction

Warts are caused by the human papillomavirus (HPV), of which there are over 100 types, which probably infects the skin via areas of minimal trauma. Risk factors include use of communal showers, occupational handling of meat, and immunosuppression. In immunocompetent people, warts are harmless and resolve as a result of natural immunity within months or years.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for warts (non-genital)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2008 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found 12 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic, review we present information relating to the effectiveness and safety of the following interventions: intralesional bleomycin; cimetidine; contact immunotherapy; cryotherapy; duct tape occlusion; formaldehyde, glutaraldehyde; homeopathy; photodynamic treatment; pulsed dye laser; surgical procedures; topical salicylic acid; and zinc sulphate.

Key Points

Warts are caused by the human papillomavirus (HPV), of which there are over 100 types, which probably infects the skin via areas of minimal trauma.

  • Risk factors include use of communal showers, occupational handling of meat, and immunosuppression.
  • In immunocompetent people, warts are harmless and resolve as a result of natural immunity within months or years.
  • For what is such a common condition, there are few large, high-quality RCTs available to inform clinical practice.

Topical salicylic acid increases complete wart clearance compared with placebo.

Cryotherapy may be as effective at increasing wart clearance as topical salicylic acid, but studies have been small and have given inconclusive results. We found insufficient evidence on the effects of cryotherapy versus placebo.

Photodynamic treatment may increase the proportion of warts cured compared with placebo, although RCTs were small. It may increase pain or discomfort compared with placebo.

Contact immunotherapy with dinitrochlorobenzene may increase wart clearance compared with placebo, but it can cause inflammation.

We don't know whether intralesional bleomycin speeds up clearance of warts compared with placebo, as studies have given conflicting results.

We don't know whether cimetidine, formaldehyde, glutaraldehyde, homeopathy, duct tape occlusion, pulsed dye laser, surgery, or oral zinc sulphate increase cure rates compared with placebo, as few high-quality studies have been found.

About this condition

Definition

Non-genital warts (verrucas) are an extremely common, benign, and usually self-limited skin disease. Infection of epidermal cells with the human papillomavirus (HPV) results in cell proliferation and a thickened, warty papule on the skin. There are over 100 different types of HPV. The appearance of warts is determined by the type of virus and the location of the infection. Any area of skin can be infected, but the most common sites are the hands and feet. Genital warts are not covered in this review (see review on genital warts). Common warts are most often seen on the hands and present as skin-coloured papules with a rough "verrucous" surface. Flat warts are most often seen on the backs of the hands and on the legs. They appear as slightly elevated, small plaques that are skin-coloured or light brown. Plantar warts occur on the soles of the feet and look like very thick callouses.

Incidence/ Prevalence

There are few reliable, population-based data on the incidence and prevalence of non-genital warts. Prevalence probably varies widely between different age groups, populations, and periods of time. Two large population-based studies found prevalence rates of 0.84% in the US and 12.9% in Russia. Prevalence is highest in children and young adults, and two studies in school populations have shown prevalence rates of 12% in 4 to 6 year olds in the UK and 24% in 16 to 18 year olds in Australia.

Aetiology/ Risk factors

Warts are caused by HPV, of which there are over 100 different types. They are most common at sites of trauma, such as the hands and feet, and probably result from inoculation of virus into minimally damaged areas of epithelium. Warts on the feet can be acquired from walking barefoot in areas where other people walk barefoot. One observational study (146 adolescents) found that the prevalence of warts on the feet was 27% in those that used a communal shower room and 1.3% in those that used the locker (changing) room. Warts on the hand are also an occupational risk for butchers and meat handlers. One cross-sectional survey (1086 people) found that the prevalence of warts on the hand was 33% in abattoir workers, 34% in retail butchers, 20% in engineering fitters, and 15% in office workers. Immunosuppression is another important risk factor. One observational study in immunosuppressed renal transplant recipients found that, at 5 years or longer after transplantation, 90% had warts.

Prognosis

Non-genital warts in immunocompetent people are harmless and usually resolve spontaneously as a result of natural immunity within months or years. The rate of resolution is highly variable and probably depends on several factors, including host immunity, age, HPV type, and site of infection. One cohort study (1000 children in long-stay accommodation) found that two-thirds of warts resolved without treatment within a 2-year period. One systematic review (search date 2005; 60 RCTs) comparing local treatments with placebo found that 48% of people using placebo (range 10%–54%) had no warts at between 6 weeks and 18 months after initiation of therapy.

Aims of intervention

To eliminate warts, with minimal adverse effects.

Outcomes

Wart clearance (generally accepted as complete eradication of warts from the treated area); reduction in number of warts (if wart clearance not reported); wart recurrence; and adverse effects of treatment.

Methods

Clinical Evidence search and appraisal June 2008. We have reported complete wart clearance where possible; however, some RCTs reported outcomes such as number of warts cured or loss of single warts. The following databases were used to identify studies for this systematic review: Medline 1966 to June 2008, Embase 1980 to June 2008, and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials, 2008, Issue 2 (1966 to date of issue). An additional search was carried out of the NHS Centre for Reviews and Dissemination (CRD) — for Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA). We also searched for retractions of studies included in the review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the contributor for additional assessment, using pre-determined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews of RCTs and RCTs in any language and with more than 80% of patients followed up. We included trials of any size. A minimum length of follow-up for inclusion was 4 weeks. We included studies described as "open", "open label", or not blinded. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the reviews as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).

Table
GRADE Evaluation of interventions for Warts (non-genital).

Glossary

Contact immunotherapy
Contact sensitisers such as dinitrochlorobenzene, diphencyprone, and squaric acid dibutyl ester result in allergic dermatitis, which stimulates an immune reaction in close proximity to the wart.
Cryotherapy
A destructive treatment based on the targeted freezing of tissue using liquid nitrogen, dimethyl ether propane, or carbon dioxide snow. Liquid nitrogen achieves the lowest temperatures and is now the most commonly used agent.
Low-quality evidence
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Moderate-quality evidence
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Photodynamic treatment
Combines the application of a photosensitising substance (usually aminolaevulinic acid) to the wart and subsequent irradiation with wavelengths of light that are absorbed by the photosensitising substance and lead to destruction of the target tissue.
Very low-quality evidence
Any estimate of effect is very uncertain.

Notes

Disclaimer

The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients. To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.

Notes

Genital warts

Contributor Information

Steven King-fan Loo, Social Hygiene Service, Centre for Health Protection, Department of Health, , Hong Kong SAR.

William Yuk-ming Tang, Shatin International Medical Centre, Union Hospital, , Hong Kong SAR.

References

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2. Beliaeva TL. The population incidence of warts. Vestn Dermatol Venerol 1990;2:55–58. [PubMed]
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9. Gibbs S, Harvey I. Topical treatments for cutaneous warts. In: The Cochrane Library, Issue 2, 2008. Chichester, UK: John Wiley & Sons, Ltd. Search date 2005.
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11. Rosado-Cancino MA, Ruiz-Maldonado R, Tamayo L, et al. Treatment of multiple and stubborn warts in children with 1-chloro-2,4-dinitrobenzene (DNCB) and placebo. Dermatol Rev Mex 1989;33:245–252.
12. Stender IM, Lock-Anderson J, Wulf HC. Recalcitrant hand and foot warts successfully treated with photodynamic therapy with topical 5-aminolaevulinic acid: a pilot study. Clin Exp Dermatol 1999;24:154–159. [PubMed]
13. Connolly M, Basmi K, O'Connell M, et al. Cryotherapy of viral warts: a sustained 10-s freeze is more effective than the traditional method. Br J Dermatol 2001;145:554–557. [PubMed]
14. Bourke JF, Berth-Jones J, Hutchinson PE. Cryotherapy of common viral warts at intervals of 1, 2 and 3 weeks. Br J Dermatol 1995;132:433–436. [PubMed]
15. Stender IM, Na R, Fogh H, et al. Photodynamic therapy with 5-aminolaevulinic acid or placebo for recalcitrant foot and hand warts: randomised double-blind trial. Lancet 2000;355:963–966. [PubMed]
16. Fabbrocini G, Di Constanzo MP, Riccardo AM, et al. Photodynamic therapy with topical delta-aminolaevulinic acid for the treatment of plantar warts. J Photochem Photobiol 2001;61:30–34. [PubMed]
17. Veien NK, Genner J, Brodthagen H, et al. Photodynamic inactivation of Verrucae vulgares II. Acta Derm Venereol 1977;57:445–447. [PubMed]
18. Bunney MH, Nolan MW, Buxton PK, et al. The treatment of resistant warts with intralesional bleomycin: a controlled clinical trial. Br J Dermatol 1984;111:197–207. [PubMed]
19. Rossi E, Soto JH, Battan J, et al. Intralesional bleomycin in Verruca vulgaris Double-blind study. Dermatol Rev Mex 1981;25:158–165.
20. Munkvad M, Genner J, Staberg B, et al. Locally injected bleomycin in the treatment of warts. Dermatologica 1983;167:86–89. [PubMed]
21. Perez Alfonzo R, Weiss E, Piquero Martin J. Hypertonic saline solution vs intralesional bleomycin in the treatment of common warts. Dermatol Venez 1992;30:176–178.
22. Hayes ME, O'Keefe EJ. Reduced dose of bleomycin in the treatment of recalcitrant warts. J Am Acad Dermatol 1986;15:1002–1006. [PubMed]
23. Adalatkhah H, Khalilollahi H, Amini N, et al. Compared therapeutic efficacy between intralesional bleomycin and cryotherapy for common warts: a randomized clinical trial. Dermatol Online J 2007;13:4. [PubMed]
24. Rogers CJ, Gibney MD, Siegfried EC, et al. Cimetidine therapy for recalcitrant warts in adults: is it any better than placebo? J Am Acad Dermatol 1999;41:123–127. [PubMed]
25. Karabulut AA, Sahin S, Eksioglu M. Is cimetidine effective for nongenital warts: a double-blind, placebo-controlled study. Arch Dermatol 1997;133:533–534. [PubMed]
26. Yilmaz E, Alpsoy E, Basaran E. Cimetidine therapy for warts: a placebo-controlled, double-blind study. J Am Acad Dermatol 1996;34:1005–1007. [PubMed]
27. de Haen M, Spigt MG, van Uden CJ, et al. Efficacy of duct tape vs placebo in the treatment of verruca vulgaris (warts) in primary school children. Arch Pediat Adol Med 2006;160:1121–1125. [PubMed]
28. de Haen M, Spigt MG, van Uden CJ, et al. Duct tape or placebo? Treatment of warts in primary school children. Huisarts en Wetenschap 2007;50:416–421. [PubMed]
29. Wenner R, Askari SK, Cham PM, et al. Duct tape for the treatment of common warts in adults: a double-blind randomized controlled trial. Arch Dermat 2007;143:309–313. [PubMed]
30. Focht DR, Spicer C, Fairchok MP. The efficacy of duct tape vs cryotherapy in the treatment of Verruca vulgaris (the common wart). Arch Pediatr Adolesc Med 2002;156:971–974. [PubMed]
31. Labrecque M, Audet D, Latulippe LG, et al. Homeopathic treatment of plantar warts.CMAJ 1992;146:1749–1753. [PMC free article] [PubMed]
32. Kainz JT, Kozel G, Haidvogl M, et al. Homoeopathic versus placebo therapy of children with warts on the hands: a randomized, double-blind clinical trial. Dermatology 1996;193:318–320. [PubMed]
33. Villeda LLD. Homeopathic Thuja occidentalis vs placebo in common warts. Dermatol Rev Mex 2001;45:14–18.
34. Passeron T, Sebban K, Mantoux F, et al. [595 nm pulse dye laser therapy for viral warts: a single-blind randomized comparative study versus placebo]. Ann Dermatol Vener 2007;134:135–139. [In French] [PubMed]
35. Al-Guraira FT, Al-Waiz M, Sharquie KE. Oral zinc sulphate in the treatment of recalcitrant warts: randomized placebo-controlled clinical trial. Br J Dermatol 2002;146:423–431. [PubMed]
2009; 2009: 1710.
Published online 2009 September 24.

Salicylic acid (topical)

Summary

Topical salicylic acid increases complete wart clearance compared with placebo.

Benefits and harms

Topical salicylic acid versus placebo or no treatment:

We found one systematic review (search date 2005) of topical salicylic acid.

Wart clearance

Topical salicylic acid compared with placebo or no treatment Topical salicylic acid may be more effective at increasing the proportion of people with wart clearance after 6 to 12 weeks (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

Systematic review
322 people with warts
5 RCTs in this analysis
Proportion of people with complete wart clearance 6 to 12 weeks
117/160 (73%) with topical salicylic acid
78/162 (48%) with placebo or no treatment

RR 1.6
95% CI 1.16 to 2.23
NNT 4
95% CI 3 to 7
Results should be interpreted with caution; see further information on studies
Small effect sizetopical salicylic acid

Wart recurrence

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

Systematic review
People with warts (number not clear) Adverse effects
with topical salicylic acid
with placebo or no treatment

Topical salicylic acid versus cryotherapy:

See option on cryotherapy.

Further information on studies

One of the five RCTs included in the meta-analysis compared topical salicylic acid plus lactic acid versus placebo, and one compared topical salicylic acid plus monochloroacetic acid crystals versus placebo. The RCTs varied in their study design and methodology, and only one RCT was classified as having a high methodological quality. Trial heterogeneity and poor quality of the RCTs included in the review mean that the pooled results should be treated with caution.

Comment

None.

Substantive changes

Topical salicylic acid Data from one systematic review updated. Categorisation unchanged (Beneficial).

2009; 2009: 1710.
Published online 2009 September 24.

Contact immunotherapy

Summary

Contact immunotherapy with dinitrochlorobenzene may increase wart clearance compared with placebo, but it can cause inflammation.

Benefits and harms

Contact immunotherapy (dinitrochlorobenzene) versus placebo or no treatment:

We found one systematic review (search date 2005; 2 RCTs; 80 people).

Wart clearance

Contact immunotherapy compared with placebo or no treatment Contact immunotherapy using dinitrochlorobenzene may be more effective at increasing the proportion of people with wart clearance (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

Systematic review
80 people
2 RCTs in this analysis
Proportion of people with wart clearance end of trial
32/40 (80%) with contact immunotherapy (dinitrochlorobenzene 2% solution followed by 1% solution)
15/50 (38%) with placebo or no treatment

RR 2.12
95% CI 1.38 to 3.26
NNT 2
95% CI 2 to 4
One RCT included in the meta-analysis was published in only abstract form.
Moderate effect sizecontact immunotherapy

Wart recurrence

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
People with warts
In review
Adverse effects
with contact immunotherapy (dinitrochlorobenzene)
with placebo or no treatment

Comment

We found one systematic review that identified one RCT comparing dinitrochlorobenzene with cryotherapy; however, the data were published in only abstract form, which does not meet our reporting criteria and so is not discussed further.

Substantive changes

Contact immunotherapy Data from one systematic review updated. Categorisation unchanged (Likely to be beneficial).

2009; 2009: 1710.
Published online 2009 September 24.

Cryotherapy

Summary

Cryotherapy may be as effective at increasing wart clearance as topical salicylic acid, but studies have been small and have given inconclusive results. We found insufficient evidence on the effects of cryotherapy versus placebo.

Benefits and harms

Cryotherapy versus placebo or no treatment:

We found one systematic review (search date 2005) of cryotherapy, which identified two RCTs (69 people) comparing cryotherapy versus topical placebo cream or no treatment.

Wart clearance

Cryotherapy compared with placebo or no treatment We don't know whether cryotherapy is more effective at increasing the proportion of people with wart clearance after 2 to 4 months (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

Systematic review
69 people
2 RCTs in this analysis
Proportion of people with wart clearance 2 to 4 months
11/31 (35%) with cryotherapy
13/38 (34%) with topical placebo cream or no treatment

RR 0.88
95% CI 0.26 to 2.95
The RCTs may have been too small to detect a clinically important difference, and the review authors categorised both RCTs as low quality
Not significant

Wart recurrence

No data from the following reference on this outcome.

Adverse effects

No data from the following reference on this outcome.

Cryotherapy versus photodynamic treatment:

We found one systematic review (search date 2005) of cryotherapy, which identified one RCT comparing cryotherapy versus photodynamic treatment.

Wart clearance

Cryotherapy compared with photodynamic treatment Cryotherapy may be less effective at reducing the number of warts after 4 to 6 weeks in people who also used topical salicylic acid plus lactic acid; however, evidence was weak. We don't know about wart clearance (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

RCT
5-armed trial
30 adults with recalcitrant hand and foot warts of different sizes and categories
In review
% reduction in number of warts 4 to 6 weeks
20% with cryotherapy
73% with three episodes of white light photodynamic treatment
Absolute numbers not reported

P <0.01
Effect size not calculatedwhite light photodynamic treatment

RCT
5-armed trial
30 adults with recalcitrant hand and foot warts of different sizes and categories
In review
% reduction in number of warts 4 to 6 weeks
20% with cryotherapy
71% with one episode of white light photodynamic treatment
Absolute numbers not reported

Reported as significant; P value not reported
Effect size not calculatedwhite light photodynamic treatment

RCT
5-armed trial
30 adults with recalcitrant hand and foot warts of different sizes and categories
In review
% reduction in number of warts 4 to 6 weeks
20% with cryotherapy
42% with three episodes of red light photodynamic treatment
Absolute numbers not reported

P = 0.03
Effect size not calculatedred light photodynamic treatment

RCT
5-armed trial
30 adults with recalcitrant hand and foot warts of different sizes and categories
In review
% reduction in number of warts 4 to 6 weeks
20% with cryotherapy
28% with three episodes of blue light photodynamic treatment
Absolute numbers not reported

P = 0.03
Effect size not calculatedblue light photodynamic treatment

Wart recurrence

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
5-armed trial
30 adults with recalcitrant hand and foot warts of different sizes and categories
In review
Adverse effects
with cryotherapy
with three episodes of white light photodynamic treatment
with one episode of white light photodynamic treatment
with three episodes of red light photodynamic treatment
with three episodes of blue light photodynamic treatment

Cryotherapy versus intralesional bleomycin:

See option on intralesional bleomycin.

Cryotherapy versus topical salicylic acid:

We found one systematic review (search date 2005) of cryotherapy, which identified two RCTs (320 people) comparing cryotherapy versus topical salicylic acid.

Wart clearance

Cryotherapy compared with topical salicylic acid We don't know how cryotherapy and topical salicylic acid compare at improving wart clearance after 3 to 6 months (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

Systematic review
320 people
2 RCTs in this analysis
Proportion of people with wart clearance 3 to 6 months
107/165 (65%) with cryotherapy (weekly or 3 weekly)
96/155 (62%) with topical salicylic acid

RR 1.04
95% CI 0.88 to 1.22
Not significant

Wart recurrence

No data from the following reference on this outcome.

Adverse effects

No data from the following reference on this outcome.

Cryotherapy versus duct tape occlusion:

See option on duct tape occlusion.

Aggressive versus gentle cryotherapy:

We found one systematic review (search date 2005) of cryotherapy, which identified four RCTs (592 people) comparing aggressive cryotherapy versus gentle cryotherapy.

Wart clearance

Aggressive cryotherapy compared with gentle cryotherapy Aggressive cryotherapy (not further defined) may be more effective than gentle cryotherapy (not further defined) at increasing the proportion of people with wart clearance after 1 to 3 months (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

Systematic review
592 adults
4 RCTs in this analysis
Proportion of people with wart clearance 1 to 3 months
159/304 (52%) with aggressive cryotherapy
89/288 (31%) with gentle cryotherapy

RR 1.90
95% CI 1.15 to 3.15
NNT 5
95% CI 3 to 7
For details of methodological limitations, see further information on studies
Small effect sizeaggressive cryotherapy

Wart recurrence

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
200 people with warts
In review
Pain or blistering
64/100 (64%) with aggressive cryotherapy
44/100 (44%) with gentle cryotherapy

RR 1.45
95% CI 1.12 to 2.31
NNH 5
95% CI 3 to 15
Small effect sizegentle cryotherapy

Interval between freezes:

We found one systematic review (search date 2005, 7 RCTs, 641 people) of cryotherapy.

Wart clearance

More frequent cryotherapy compared with less frequent cryotherapy We don't know how cryotherapy given more frequently compares with cryotherapy given less frequently (2 weeks apart v 3 or 4 weeks apart; 3 weeks apart v 4 weeks apart) at improving wart clearance after 3 to 6 months (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

Systematic review
313 people
3 RCTs in this analysis
Proportion of people with wart clearance 3 to 8 months
77/158 (49%) with 2-week interval between cryotherapy treatments
70/155 (45%) with 3-week interval between cryotherapy treatments

RR 1.03
95% CI 0.77 to 1.37
Not significant

Systematic review
161 people
2 RCTs in this analysis
Proportion of people with wart clearance 3 to 6 months
50/77 (65%) with 3-week interval between cryotherapy treatments
41/84 (49%) with 4-week interval between cryotherapy treatments

RR 1.42
95% CI 0.76 to 2.63
Not significant

Systematic review
167 people
2 RCTs in this analysis
Proportion of people with wart clearance 3 to 6 months
49/83 (59%) with 2-week interval between cryotherapy treatments
41/84 (49%) with 4-week interval between cryotherapy treatments

RR 1.29
95% CI 0.70 to 2.38
Not significant

Wart recurrence

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
People with warts
In review
Proportion of people with pain, blistering, or both
29% with cryotherapy at 1-weekly intervals
7% with cryotherapy at 2-weekly intervals
0% with at 3-weekly intervals

Significance not assessed

Further information on studies

Aggressive versus gentle cryotherapy: Definitions of aggressive and gentle differed between RCTs in the systematic review, and some RCTs included warts that were resistant to treatment and others did not. In one RCT all people received topical salicylic acid plus lactic acid, and in another, people in the aggressive treatment group received lactic acid whereas people in the gentle treatment group did not. The review reported that "although these trials were in different populations, on different types of warts and used different definitions of aggressive and gentle, it was felt that the results could be usefully combined for analysis."

Comment

The evidence from available RCTs about cryotherapy is both limited and contradictory. Heterogeneity of study design, methodology, and the populations included make it extremely difficult to draw firm conclusions. For example, some RCTs identified by the review included all types of wart on the hands and feet in all age groups, whereas others were more selective and simply looked at hand warts, or excluded certain groups such as mosaic plantar warts or warts that were resistant to treatment. Of particular note is the likelihood that wart-clinic populations used for these RCTs might have had different characteristics in different periods of time. For instance, hospital-based studies carried out in the 1970s in the UK would have included a higher proportion of people with warts that had never been treated before — which have a greater chance of cure, spontaneous resolution, or both. In the 1980s and 1990s more people with warts were being treated in primary care; consequently, the people included in hospital-based RCTs were more likely to have warts resistant to treatment, with correspondingly lower cure rates. Hence strong evidence for the beneficial effect of cryotherapy is difficult to establish. However, the review identified evidence that aggressive cryotherapy is beneficial. We found one RCT identified by the systematic review that assessed the effect of duration of cryotherapy; however, it did not meet our reporting criteria and is not discussed further here. See comment from contact immunotherapy (dinitrochlorobenzene).

Clinical guide:

Taking these factors into account, cryotherapy is likely to be beneficial for people with non-genital warts where first-line treatment with topical salicylic acid has failed. Depending on the site, size, and status of the person, cryotherapy of different degrees of aggressiveness can be delivered at different time intervals.

Substantive changes

Cryotherapy Data from one systematic review updated. Categorisation unchanged (Likely to be beneficial).

2009; 2009: 1710.
Published online 2009 September 24.

Photodynamic treatment

Summary

Photodynamic treatment may increase the proportion of warts cured compared with placebo, although RCTs were small.

Photodynamic treatment may increase pain or discomfort compared with placebo.

Benefits and harms

Photodynamic treatment versus placebo photodynamic treatment:

We found one systematic review (search date 2005) of photodynamic treatment, which identified two RCTs (112 people) comparing photodynamic treatment versus placebo photodynamic treatment. The systematic review did not perform a meta-analysis because of heterogeneity between the RCTs.

Wart clearance

Aminolaevulinic acid photodynamic treatment plus topical salicylic compared with placebo photodynamic treatment Aminolaevulinic acid photodynamic treatment plus topical salicylic acid may be more effective than placebo photodynamic treatment plus topical salicylic acid at increasing the proportion of people with wart clearance after 18 weeks in people with warts unsuccessfully treated for over 3 months. Aminolaevulinic acid photodynamic treatment may be more effective than placebo photodynamic treatment at increasing the proportion of people with wart clearance after 4 months in people with warts unsuccessfully treated for 12 months (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

RCT
45 adults with warts unsuccessfully treated for >3 months
In review
Proportion of warts cured 18 weeks
64/114 (56%) with aminolaevulinic acid photodynamic treatment plus topical salicylic acid
47/113 (42%) with placebo photodynamic treatment plus topical salicylic acid

P <0.05
Effect size not calculatedaminolaevulinic acid photodynamic treatment plus topical salicylic acid

RCT
67 people with warts unsuccessfully treated for >12 months who had received keratolytic ointment under an occlusive dressing for 7 days
In review
Proportion of warts cured 4 months
48/64 (75%) with aminolaevulinic acid photodynamic treatment three times
13/57 (23%) with placebo photodynamic treatment

P <0.01
Effect size not calculatedaminolaevulinic acid photodynamic treatment

Wart recurrence

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
45 adults with warts unsuccessfully treated for >3 months
In review
Painful warts (pain ranging from light to unbearable) immediately after treatment
17% with aminolaevulinic acid photodynamic treatment plus topical salicylic acid
4% with placebo photodynamic treatment plus topical salicylic acid
Absolute numbers not reported

Significance not assessed

RCT
67 people with warts unsuccessfully treated for >12 months who had received keratolytic ointment under an occlusive dressing for 7 days
In review
Adverse effects
with aminolaevulinic acid photodynamic treatment three times
with placebo photodynamic treatment

Different types of photodynamic treatment versus each other:

We found one systematic review (search date 2005), which identified one RCT.

Wart clearance

Proflavine photodynamic treatment compared with neutral red photodynamic treatment We don't know how proflavine photodynamic treatment and neutral red photodynamic treatment compare at improving wart clearance after 8 weeks (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

RCT
3-armed trial
56 people
In review
Proportion of people with wart clearance 8 weeks
10/27 (37%) with proflavine photodynamic treatment
10/23 (43%) with neutral red photodynamic treatment

Significance not assessed

Wart recurrence

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
3-armed trial
56 people
In review
Adverse effects
with proflavine photodynamic treatment
with neutral red photodynamic treatment

Photodynamic treatment versus cryotherapy:

See option on cryotherapy.

Further information on studies

Photodynamic treatment versus placebo photodynamic treatment: Unpublished data from the second RCT reported in the systematic review showed cure rates at 22 months of 45/64 (71%) with photodynamic treatment compared with 13/57 (23%) with placebo and, using people as the unit of analysis, 26/34 (76%) with photodynamic treatment compared with 13/33 (42%) with placebo.

Comment

None.

Substantive changes

Photodynamic treatment One systematic review added. It found that photodynamic treatment was more effective at wart clearance than placebo or cryotherapy, and that neutral red photodynamic treatment and proflavine photodynamic treatment have similar effects. Categorisation unchanged (Likely to be beneficial).

2009; 2009: 1710.
Published online 2009 September 24.

Bleomycin (intralesional)

Summary

We don't know whether intralesional bleomycin speeds up clearance of warts compared with placebo, as studies have given conflicting results.

Benefits and harms

Intralesional bleomycin versus placebo:

We found one systematic review (search date 2005, 4 RCTs, 133 people) comparing intralesional bleomycin versus placebo. The systematic review did not perform a meta-analysis because of heterogeneity among RCTs.

Wart clearance

Intralesional bleomycin compared with placebo We don't know whether intralesional bleomycin is more effective at increasing the proportion of people with wart clearance, or at increasing the number of warts cured, after 6 weeks to 3 months (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

RCT
24 adults with warts unsuccessfully treated for >3 months; matched pairs of warts on the left and right side of the body
In review
Proportion of people with a more favourable response (not defined) 6 weeks
21/24 (88%) with bleomycin 0.1%
3/24 (13%) with saline placebo

P <0.001
Effect size not calculatedbleomycin 0.1%

RCT
24 adults with warts unsuccessfully treated for >3 months; matched pairs of warts on the left and right side of the body
In review
Proportion of warts cured 6 weeks
34/59 (58%) with bleomycin 0.1%
6/59 (10%) with saline placebo

P <0.001
Effect size not calculatedbleomycin 0.1%

RCT
16 people
In review
Proportion of warts cured 6 weeks
31/38 (82%) with bleomycin 0.1%
16/46 (34%) with placebo

P <0.001
Results should be interpreted with caution; RCT randomised number of people but analysed number of warts
Effect size not calculatedbleomycin 0.1%

RCT
4-armed trial
62 adults
In review
Proportion of warts cured 3 months
4/22 (18%) with bleomycin 0.1% in saline
5/22 (23%) with bleomycin 0.1% in sesame oil
8/19 (42%) with saline placebo
5/11 (46%) with sesame-oil placebo

P = 0.018 for combined results for bleomycin v combined results for placebo
Results should be interpreted with caution; RCT randomised number of people but analysed number of warts
Effect size not calculatedplacebo

RCT
31 people
In review
Proportion of people with wart clearance 30 days
15/16 (94%) with bleomycin 0.1%
11/15 (73%) with placebo

RR 1.28
95% CI 0.92 to 1.78
Not significant

Wart recurrence

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
24 adults with warts unsuccessfully treated for >3 months; matched pairs of warts on the left and right side of the body
In review
Adverse effects
with bleomycin 0.1%
with saline placebo

RCT
16 people
In review
Adverse effects
with bleomycin 0.1%
with placebo

RCT
4-armed trial
62 adults
In review
Adverse effects
with bleomycin 0.1% in saline
with bleomycin 0.1% in sesame oil
with saline placebo
with sesame-oil placebo

No data from the following reference on this outcome.

Different concentrations of intralesional bleomycin:

We found one systematic review (search date 2005), which identified one RCT comparing different concentrations of intralesional bleomycin.

Wart clearance

Different concentrations of intralesional bleomycin versus each other We don't know how different concentrations of intralesional bleomycin compare at improving wart clearance at 3 months (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

RCT
3-armed trial
26 adults
In review
Proportion of warts cured (defined as disappearance of warts after 1 to 3 treatments and no recurrence within 3 months after treatment) 3 months
11/15 (73%) with bleomycin 0.25%
26/30 (86%) with bleomycin 0.5%

P >0.05 for bleomycin 0.25% v bleomycin 0.5%
Not significant

RCT
3-armed trial
26 adults
In review
Proportion of warts cured (defined as disappearance of warts after 1–3 treatments and no recurrence within 3 months after treatment) 3 months
11/15 (73%) with bleomycin 0.25%
25/34 (74%) with bleomycin 1.0%

P >0.05 for bleomycin 0.25% v bleomycin 1.0%
Not significant

RCT
3-armed trial
26 adults
In review
Proportion of warts cured (defined as disappearance of warts after 1–3 treatments and no recurrence within 3 months after treatment) 3 months
26/30 (86%) with bleomycin 0.5%
25/34 (74%) with bleomycin 1.0%

P >0.05 for bleomycin 0.5% v bleomycin 1.0%
Not significant

Wart recurrence

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
3-armed trial
26 adults
In review
Adverse effects
with bleomycin 0.25%
with bleomycin 0.5%
with bleomycin 1.0%

Intralesional bleomycin versus cryotherapy:

We found one RCT.

Wart clearance

Intralesional bleomycin compared with cryotherapy Intralesional bleomycin seems to be more effective at increasing the proportion of people with wart clearance after 6 weeks. However, evidence came from a small RCT (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

RCT
44 people above 12 years of age with warts on symmetric limbs Proportion of people with wart clearance 6 weeks
38/44 (87%) with bleomycin 0.5 mg/mL
30/44 (68%) with cryotherapy

RR 1.27
95% CI 1.0 to 1.6
P <0.05
Results should be interpreted with caution; see further information on studies for full details
Small effect sizebleomycin 0.5 mg/mL

Wart recurrence

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
44 people above 12 years of age with warts on symmetric limbs Adverse effects
with bleomycin 0.5 mg/mL
with cryotherapy

Further information on studies

The disparity in the number of warts assessed in each group could be explained by the exclusion of warts that spontaneously regressed from the analysis, and by a high withdrawal rate in people receiving intralesional bleomycin 0.25%.

The results should be interpreted with caution, as important parameters such as wart size and duration of disease were not mentioned. Furthermore, the clinical importance of the difference between treatments may not have been detected due to the small sample size.

Comment

None.

Substantive changes

Intralesional bleomycin Data from one systematic review updated, and one RCT added. The RCT found that intralesional bleomycin increased wart clearance compared with placebo. Categorisation unchanged (unknown effectiveness).

2009; 2009: 1710.
Published online 2009 September 24.

Cimetidine

Summary

We don't know whether cimetidine increases cure rates compared with placebo, as few high-quality studies have been found.

Benefits and harms

Cimetidine versus placebo:

We found no systematic review of cimetidine. We found three small RCTs.

Wart clearance

Cimetidine compared with placebo We don't know whether cimetidine is more effective at increasing the proportion of people with wart clearance after 12 weeks (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

RCT
39 people aged >15 years Proportion of people with wart clearance 12 weeks
5/19 (26%) with cimetidine 2400 mg daily
1/20 (5%) with placebo

RR 3.14
95% CI 0.75 to 5.66
RCT may have been underpowered to detect a clinically important difference
Not significant

RCT
54 people Proportion of people with wart clearance 12 weeks
10/36 (27%) with cimetidine 400 mg three times/day
4/18 (22%) with placebo

RR 1.3
95% CI 0.5 to 3.4
RCT may have been underpowered to detect a clinically important difference
Not significant

RCT
70 women and children Proportion of people with wart clearance 12 weeks
9/35 (26%) with cimetidine 25 to 40 mg/kg
8/35 (23%) with placebo

RR 1.1
95% CI 0.5 to 2.6
RCT may have been underpowered to detect a clinically important difference
Not significant

Wart recurrence

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
39 people aged >15 years Proportion of people with adverse effects
5/19 (26%) with cimetidine 2400 mg daily
5/21 (24%) with placebo

Reported as not significant
P value not reported
Not significant

RCT
54 people Adverse effects
with cimetidine 400 mg three times daily
with placebo

RCT
70 women and children Adverse effects
with cimetidine 25 to 40 mg/kg
with placebo

Comment

None.

Substantive changes

No new evidence

2009; 2009: 1710.
Published online 2009 September 24.

Duct tape occlusion

Summary

We don't know whether duct tape increases cure rates compared with placebo, as few high-quality studies have been found.

Benefits and harms

Duct tape occlusion versus placebo:

We found one systematic review (search date 2005) and two subsequent RCTs (3 publications) of duct tape occlusion. The systematic review found no RCTs comparing duct tape occlusion with placebo.

Wart clearance

Duct tape occlusion compared with placebo We don't know whether duct tape occlusion is more effective at increasing the proportion of people with wart clearance after 6 to 8 weeks (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

RCT
103 children aged 4 to 12 years Proportion of children with complete wart clearance 6 weeks
8/51 (16%) with clear duct tape occlusion
3/52 (6%) with placebo

P = 0.12
Not significant

RCT
90 adults Proportion of people with complete wart clearance 2 months
8/39 (21%) with clear duct tape occlusion
9/41 (22%) with placebo

P >0.99
Not significant

Wart recurrence

Duct tape occlusion compared with placebo We don't know whether duct tape occlusion is more effective at reducing the proportion of people with recurrence after 6 months in people who had previously had complete wart clearance with either duct tape occlusion or placebo (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart recurrence

RCT
17 adults who had complete wart clearance at 2 months
Subgroup analysis
Proportion of people with wart recurrence 6 months
6/8 (75%) with clear duct tape occlusion
3/9 (33%) with placebo

P = 0.15
Not significant

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
103 children aged 4–12 years Skin rash
7/47 (15%) with clear duct tape occlusion
0/52 (0%) with placebo

P = 0.14
Not significant

RCT
90 adults Adverse effects
with clear duct tape occlusion
with placebo

Duct tape occlusion versus cryotherapy:

We found one systematic review (search date 2005), which identified one RCT.

Wart clearance

Duct tape occlusion compared with cryotherapy We don't know how duct tape occlusion and cryotherapy compare at improving wart clearance after 2 months (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

RCT
61 people aged 3 to 22 years
In review
Proportion of people with complete resolution of warts 8 weeks
22/26 (85%) with duct tape occlusion for 6 days a week plus gentle debridement once a week
15/25 (60%) with cryotherapy for 10 seconds every 2 to 3 weeks plus gentle debridement up to 6 treatments

P = 0.05
RCT had methodological limitations; see further information on studies for details
Not significant

RCT
61 people aged 3 to 22 years
In review
Proportion of people with complete resolution of warts 8 weeks
22/30 (73%) with duct tape occlusion for 6 days a week plus gentle debridement once a week
15/31 (48%) with cryotherapy for 10 seconds every 2 to 3 weeks plus gentle debridement up to 6 treatments

RR 1.52 (calculated by review)
95% CI 0.99 to 2.31
Not significant

Wart recurrence

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
61 people aged 3 to 22 years
In review
Adverse effects
with duct tape occlusion for 6 days a week plus gentle debridement once a week
with cryotherapy for 10 seconds every 2 to 3 weeks plus gentle debridement up to 6 treatments

Further information on studies

Despite the careful randomisation and blinding in the RCT comparing duct tape occlusion with cryotherapy, the numbers were small. Furthermore, an unspecified number of outcome assessments were carried out over the telephone over the 2 months' follow-up, and it was not entirely clear how long after the treatment period these assessments were done.

Comment

There is insufficient evidence to indicate that duct tape occlusion is effective in wart clearance.

Substantive changes

Duct tape occlusion One systematic review and two RCTs (3 publications) added. The systematic review found no significant difference in wart clearance between duct tape occlusion and cryotherapy. The two RCTs found no significant difference in wart clearance between duct tape occlusion and placebo. One of the RCTs also found no significant difference in wart recurrence between duct tape occlusion and placebo. Categorisation unchanged (Unknown effectiveness).

2009; 2009: 1710.
Published online 2009 September 24.

Formaldehyde

Summary

We don't know whether formaldehyde increases cure rates compared with placebo, as no high-quality studies have been found.

Benefits and harms

Formaldehyde:

We found one systematic review (search date 2005) identifying no RCTs.

Comment

None.

Substantive changes

No new evidence

2009; 2009: 1710.
Published online 2009 September 24.

Glutaraldehyde

Summary

We don't know whether glutaraldehyde increases cure rates compared with placebo, as no high-quality studies have been found.

Benefits and harms

Glutaraldehyde:

We found one systematic review (search date 2005) identifying no RCTs.

Comment

None.

Substantive changes

No new evidence

2009; 2009: 1710.
Published online 2009 September 24.

Homeopathy

Summary

We don't know whether homeopathy increases cure rates compared with placebo, as few high-quality studies have been found.

Benefits and harms

Homeopathy versus placebo:

We found no systematic review but found two RCTs comparing homeopathy with placebo.

Wart clearance

Homeopathy compared with placebo We don't know whether homeopathy is more effective at increasing the proportion of people with wart clearance after 8 to 18 weeks (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

RCT
174 people Proportion of people with wart clearance 18 weeks
16/80 (20%) with oral homeopathy (Thuya 30CH plus antimony crudum 7CH plus nitricium acidum 7CH for 6 weeks)
20/82 (24%) with placebo

ARR +4%
95% CI –8% to +17%
Not significant

RCT
67 people Proportion of people with wart clearance 8 weeks
5/34 (15%) with oral homeopathy (individually selected regimen)
1/33 (3%) with placebo

RR 4.85
95% CI 0.60 to 39.35
Not significant

Wart recurrence

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
174 people Adverse effects
2/86 (2%) with oral homeopathy (Thuya 30CH plus antimony crudum 7CH plus nitricium acidum 7CH for 6 weeks)
4/88 (5%) with placebo

RR 0.51
95% CI 0.10 to 2.72
Not significant

No data from the following reference on this outcome.

Comment

Performing RCTs of homeopathic treatment is difficult because a major principle of homeopathy is to individualise treatment to the overall condition of the person. One RCT overcame this difficulty by allowing practitioners to evaluate all people before randomisation, and to select homeopathic regimens appropriate to each of their overall conditions. People were then randomised to their individually selected regimen (10 different regimens were used) or to placebo. We found one RCT comparing Thuja occidentalis (a homeopathic remedy) with placebo in patients with common warts, but we were unable to obtain the paper to assess it for inclusion in Clinical Evidence.

Substantive changes

No new evidence

2009; 2009: 1710.
Published online 2009 September 24.

Pulsed dye laser

Summary

We don't know whether pulsed dye laser increases cure rates compared with placebo, as few high-quality studies have been found.

Benefits and harms

Pulsed dye laser versus placebo:

We found one systematic review (search date 2005) and one subsequent RCT of pulsed dye laser. The systematic review found no RCTs comparing pulsed dye laser versus placebo.

Wart clearance

Pulsed dye laser compared with placebo We don't know whether pulsed dye laser is more effective at increasing the proportion of people with wart clearance after 14 weeks (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Wart clearance

RCT
37 people aged 19 to 70 years Proportion of people with complete wart clearance 14 weeks
6/19 (32%) with pulsed dye laser at 595 nm (spot size 5 mm, impulse duration 0.45 ms, flux 9 J/cm2 with 5 passes at a frequency of 1 Hz)
3/16 (19%) with placebo

P = 0.46
Results should be interpreted with caution; see further information on studies for full details
Not significant

Wart recurrence

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
37 people aged 19 to 70 years Incidence of crust and purpura
11% with pulsed dye laser at 595 nm (spot size 5 mm, impulse duration 0.45 ms, flux 9 J/cm2 with 5 passes at a frequency of 1 Hz)
0% with placebo
Absolute numbers not reported

Significance not assessed

RCT
37 people aged 19 to 70 years Pain levels (measured on a 10-point visual analogue scale)
4.7 with pulsed dye laser at 595 nm (spot size 5 mm, impulse duration 0.45 ms, flux 9 J/cm2 with 5 passes at a frequency of 1 Hz)
1.5 with placebo

Significance not assessed

RCT
37 people aged 19 to 70 years Tolerance (measured on a 10-point visual analogue scale)
8.31 with pulsed dye laser at 595 nm (spot size 5 mm, impulse duration 0.45 ms, flux 9 J/cm2 with 5 passes at a frequency of 1 Hz)
9.81 with placebo

Significance not assessed

Further information on studies

The results of the RCT should be interpreted with caution, as the clinical importance of the difference between treatments may not be detected owing to the small sample size. Important parameters, such as wart size and duration in each group, were also not mentioned.

Comment

None.

Substantive changes

Pulsed dye laser One RCT added, which found no significant difference in wart clearance between pulsed dye laser and placebo. Categorisation unchanged (Unknown effectiveness).

2009; 2009: 1710.
Published online 2009 September 24.

Surgical procedures

Summary

We don't know whether surgery increases cure rates compared with placebo, as no high-quality studies have been found.

Benefits and harms

Surgery:

We found one systematic review (search date 2005), which identified no RCTs.

Comment

None.

Substantive changes

No new evidence

2009; 2009: 1710.
Published online 2009 September 24.

Zinc sulphate (oral)

Summary

We don't know whether oral zinc sulphate increases cure rates compared with placebo, as no high-quality studies have been found.

Benefits and harms

Zinc sulphate versus placebo:

We found no systematic review and no RCTs of sufficient quality for inclusion (see comment).

Comment

We found one open-label RCT (80 people) comparing oral zinc sulphate (100 mg/kg/day in 3 divided doses up to a maximum of 600 mg/day) versus placebo (glucose solution 3 times daily) until warts resolved or for a maximum of 2 months. The open-label RCT did not meet Clinical Evidence criteria for inclusion, as less than 80% of people were followed up; 17/40 (43%) people taking zinc and 20/40 (50%) people taking placebo were lost to follow-up. The RCT had several other design flaws, including an inadequate randomisation procedure (a pseudo-randomisation scheme was used based on the time of consultation), a small sample size, and lack of observer blinding. In a per-protocol analysis, the open-label RCT found that zinc sulphate significantly increased the proportion of people who had complete resolution of their warts at 2 months compared with placebo. The RCT did not assess the significance of the difference between groups in the intention-to-treat population. The RCT followed up responders every 2 weeks for 2 to 6 months and found no recurrences. The control group event rate was also much lower (0% had resolution of warts) than that observed in most placebo-controlled wart trials. The RCT also found that zinc sulphate was associated with mild nausea (100% of people), vomiting (22%), and epigastric pain (13%). No-one taking placebo had adverse effects.

Substantive changes

No new evidence


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