PLANTAR WART IN CHILDREN

Plantar wart in children, How can they be treated?

– “Plantar Wart”

How are they removed?

There are a wide variety of therapeutic alternativesdescribed and used to remove plantar warts. The choice depends on the number of lesions, the size of the lesions and the age of the patient. In general, these lesions frequently affect womenand children, especially in the medial area of the foot, theheel, the head ofthe first metatarsal and the ball of the hallux, which correspond to the areas of greatest pressure on the foot. (1-3) The first step before treating this pathology is always to explain very well to the patient the health problem that afflicts him/her as well as the existing treatment alternatives, including chemical, physical, medical, surgical and alternative therapies such as homeopathy or acupuncture. (4) (4)

Before explaining what each of these consist of, we will focus on the personal opinion based on the experience of professional podiatrists, who better to provide interesting data on their preferences when treating cases of plantar warts that are presented at the clinic. In 2014, a studywas carried out to compare the treatment of plantar warts by podiatrists in the Barcelona Metropolitan Area and studies published over the last ten years. The following interesting statistical results were obtained from 50 surveys: 76% of the responses state that the type of treatment most commonly used by podiatrists is chemical treatment(nitric acid combined with silver nitrate are the most commonly used), followed by 10% physical treatment (cryotherapy and laser), 8% homeopathic treatment, 4% drug treatment(intra-lesional bleomycin and anaesthetic with epinephrine) and 2% surgical treatment. It is striking that only 12% of respondents claim not to use combined treatments(5).

There is no unanimity among the authors to protocolise the treatment of plantar warts, therefore, after reviewing the scientific articles in the different databases, the following can be summarised about the existing treatment alternatives:

 

What kind of treatments are available?

Chemical treatments

Nitric acidand Verrutopare acids used in the treatment of plantar warts caused by the human papillomavirus (HPV). Nitric acid is one of the most commonly used treatments in podiatry practices in Spain (6). It is a corrosive and toxicsubstance that destroys the skin and mucous membranes, producing a yellowish burn in the area to be treated. (7) Verrutopis made up of 65% nitric acid which, together with other components (zinc, copper and organic acids), causes denaturation of the wart tissue and subsequent necrosis (8).

An analytical observational study carried out between 2014 and 2016 selected 36 patients with plantar warts in order to analyse the effectiveness of both treatments: 18 of them were treated with Nitric Acid and the remaining 18 with Verrutop, all on a weekly basis. The mean healing time in weeks of treatment with Nitric Acid was 12.3 ± 6.6 and with Verrutop 10.3 ±4, with a shorter healing time in weeks in those patients treated with Verrutop. (9)

Viennet et al. argue that healing is generally achieved with 2 or 3 sessions of Verrutop. (10) (10) Requeijo Constela, A et al. conducted a descriptive study in 2010 in which they reported an average of more than two months for healing of plantar warts with nitric acid. (11) (11)

Another chemical treatment used is salicylic acid. It is akeratolytic agentconsidered one of the best therapeutic methods asit does not cause pain or scarring. It produces an immune-mediated response by irritationand slowdestruction of the virus-infected epidermis.

Chicharro E et al wrote an article in 2007, a review of 13 studies using salicylic acid 15-60% versus placebo, demonstrating a 75% cure rate for salicylic acid versus 48% for the placebo group. They also concluded that this treatment combined with other treatments increases efficacy and reduces healing times. (12) (12)

Cantharidinis also commonly used as a chemical treatment. Cantharidin is a potent vesicant known since antiquity which, when applied to the lesion, interrupts the irrigation of the lesion. The vesicle is removed mechanically and leaves no scar. There is a magistral formula used in Spain consisting of Cantharidin 1%, Salicylic Acid 30%, Podophyllin 5% and Collodion flexible CSP 2 ml. It is normally used at concentrations of 0.7% or 1%, and must remain occluded for 24 hours after application.

In their 2011 study, Alcalá J et al. Present a case study of 144 patients (52 of them previously treated recurrent patients) followed for six months. They achieved a cure rate of 86.6% in a single application and 100% in four treatments.(13) (13)

Some studies show cure rates of over 80% for vulgaris, plantar and periungual warts. (14) (14) Although cantharidinapplicationis not painful, the subsequent vesiculation that occurs may be accompanied by erythema, pain, pruritus and post-inflammatory hyperpigmentation. Other more severe but less frequent adverse reactions described include lymphangitis, bacterial cellulitis and scar formation. (15) (15)

Physical treatments

Cryotherapy: Method consisting of the application of cold to the skin (-57º), freezing the wart with a cryogen for 10 to 20 seconds, the freezing produces local irritation allowing the host to have an immune reaction against the virus. Its major drawback is the painduring application and subsequent blistering, as well as the possibility of residual scarringand hyper/hypo pigmentation. (16) (16)

It is considered second-line therapy for the treatment of plantar warts. (17) (17)

According to published studies, four different cryogens stand out (liquid nitrogen, nitrous oxide, carbon dioxide and dimethyl ether-propane) between which the difference is based on the boiling temperature. They are most effective on small superficial warts. (18,19) As for the application schedule, in most cases it is every 2 weeks (18,20) and with regard to the healing time, a period of between 3 and 12 weeks is established (18,21).

An article was written in 2008, which reported healing rates of between 70-80%. They observed a greater effectiveness in lesions of less than 6 months of evolution 84% compared to 39% of more than 6 months of evolution. (22) (22)

Laser: This technique is painful and can leave scars. . The pulsed light laser causes damage directlyon the microvasculatureof the wart. Its mechanism of action depends on the absorption of energy within the capillaries of the wart, and thus localised tissue necrosis.

There are 3 different types of laser (LP-Nd:YAG, CO2 laser and pulsed dye laser FPDL) (23-26) which differ in terms of their components. Regarding the use of LP-Nd:YAG, it is stated in the article that it is applied once every 4 weeks and has an average healing time of 6 months. (23) (23) The application pattern and average healing time of the other two types of laser are not detailed in the studies found. (24-26) (24-26)

Studies show superior therapeutic efficacy in plantar warts treated with laser (78.3%-81.80% cure rate) (27-28) compared to those treated with cryotherapy (29.73%-41.67%). (29-31) (29-31)

Drug treatments

Antiviral treatments such as oralValacyclovirare observed, with a once-daily application pattern and an average healing time of 4-5 weeks.(32) Also immunomodulators such as topicalImiquimodapplied 3 times a week alternately. (33-34) (33-34)

Regarding the mechanism of action of Imiquimod, it is presumed that it is carried out through the activation of different immune mechanisms such as the migration of Langerhans cells towards lymph nodes to facilitate the production of specific cytotoxic T-lymphocytes against the virus. (35-37) (35-37)

In a study on recalcitrant subungual and periungual recalcitrant warts, a salicylic acid preparationfollowed by 5% occlusiveImiquimod cream 5 times a week for 16 weeks was used. Eighty percent of patients had complete resolution of lesions. The most evident adverse reactions were local erythema, itching and stinging. (38) (38) As main advantages, the authors mentioned the possibility of self-treatment by the patient, good tolerance and the possibility that, being an immune response stimulator, immunological memory is produced with respect to the specific strain of HPV causing the lesions. (39). (39)

Surgical treatments

El tratamiento quirúrgico de las verrugas plantares está indicado cuando han fracasado tratamientos conservadores, y se debe ser empleado como tratamiento de tercera línea. (6)

La escisión quirúrgica consistirá en eliminar la lesión radicalmente mediante cirugía convencional, electrocirugía o curetaje. En verrugas aisladas puede ser beneficioso al ser un método rápido, pero estos procedimientos normalmente están asociados a elevadas tasas de sangrado, cicatrices e infecciones bacterianas y una tasa de recurrencia de un 20% aproximadamente. (40)

Alternative Therapies: Homeopathy and Acupuncture

No scientific studiescan be found that demonstrate the effectiveness of such therapies.

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