Warts and all

Warts are usually a straightforward consultation. Diagnose, treat, move on.

This week a patient’s warts were different. I saw a 70-year-old man with eight warts on his fingers, present for several years and resistant to treatment. He’d already had multiple topical therapies and even curettage — which I tend to think of as the nuclear option for warts — but the warts had recurred after treatment.

At that point, the question isn’t what they are (clinically and dermoscopically they were warts), but why they were persisting.

I tend to think about wart treatment as working with the immune system. Warts can sit unchanged for years, and then suddenly the immune system recognises them and - BANG- they disappear within days. Many treatments people try — duct tape, salicylic acid, cider vinegar — are essentially attempts to irritate the skin enough to trigger that immune response. Prescription treatments such as imiquimod (Aldara) or 5-fluorouracil (Efudix) aim to stimulate the immune response directly.

But in this consultation my focus shifted from treatment to host factors: why was this patient not mounting an effective immune response?

We discussed screening for possible immunodeficiency. I arranged blood tests including full blood count, diabetes screening, HIV testing, and a paraprotein given his age. If these return normal but suspicion remains, lymphocyte subsets would be the next step.

Management options were narrowing. Aldara or Efudix alone would be reasonable, but I felt he might benefit from something more proactive. During my registrar years I presented a case series using combination therapy — gentle cryotherapy followed by imiquimod. The rationale is the cryotherapy initiates irritation and an initial immune response, followed by Aldara, which sustains the inflammation. I treated each lesion with 10 seconds of cryotherapy, followed by Aldara five times per week for six weeks.

Take-home: when warts are numerous, longstanding, and treatment-resistant — especially in older adults — it’s worth s

tepping back. Sometimes the key issue isn’t the virus, but the host.

I’ll be interested to see how he responds and will share an update in due course.

Originally published on substack: https://draaronhughes.substack.com/p/warts-and-all