How to Get Rid of a Wart

Plantar Warts: A Podiatrist's Guide to Treatment

Warts on the bottom of the feet can be very painful and can feel like you have a rock stuck to the bottom of your foot. They are very stubborn and difficult to resolve . 

 

What Is a Wart?

A wart is an area of skin infected with a virus. This wart virus, called human papillomavirus (HPV), infects the basal layer of the epidermis at the junction of the epidermis and dermis.  If the wart spreads, it can infect a much larger portion of skin  called a mosaic wart. 

 

On the bottom of the foot, there is a thicker dead skin layer (the stratum corneum), and the skin overall is thicker. This adds to the challenge of treating plantar warts. The wart is often covered over with callus, which is why warts and calluses are often confused for one another.

One way to distinguish a wart from a callus is location. Calluses form under a bony prominence; warts typically do not.

The following is a callus overlying a tailor’s bunion:

Although this post focuses on warts on the bottom of the feet, warts can occur anywhere there is skin. On the foot, they can occur on the top of the foot, around the toes, between the toes, or even under the toenail. Warts in these areas are less likely than the bottom of the foot. 

Risk Factors

• The bottom of the foot has a higher probability of developing a wart due to the shear forces of walking.
• Skin punctures to the bottom of the foot allow entry of the wart virus.  But,  the virus doesn't need a puncture to infect the skin.
• The moist environment created by shoes and socks fosters growth of a wart once established.
• Feet that sweat a lot can allow the wart virus to spread to other parts of the foot.
• Younger age is a risk factor, since children haven't had prior exposure to the wart virus and therefore haven't developed immunity yet.

Warts are highly contagious. A common place to pick one up is the swimming pool or public showers in locker rooms. If one child in a family has a wart, chances are the other children will eventually develop one too. I recommend a separate shower or bathtub, if possible, for a family member who has a wart — or spraying the tub with Lysol after use.

Never touch a wart with an ungloved finger — more than likely, you'll end up dealing with a wart on your finger next. Warts can show up anywhere there is skin. 

How to Determine If It's a Wart

Warts are very circumscribed and defined. There's a distinct difference between healthy skin and the wart. The surface of a wart is lumpy and can look like cauliflower.

There's normally a lot of callus on the surface, and underneath that callus are tiny stipples — pinpoint areas of dried blood from blood vessels growing up into the wart. Your podiatrist will shave off the callus on top to check for these pinpoint bleeding spots. The callus is dead skin with no nerve endings, so the shaving (called debridement) doesn't hurt.

Treatment

As with other healthcare topics online, there's a lot of misinformation about wart treatment. Here's what has worked for thousands of my patients — and what hasn't. I do this in order to help you save you time and money.

Tincture of Time

Warts can spontaneously resolve in two-thirds of children within two years. Resolution is slower in adults and can take several years, according to the British Association of Dermatologists' guidelines for management of cutaneous warts (Br J Dermatol, 2014 Oct;171(4):696-712, Epub 2014 Oct 1). In other words, it takes time for your immune system to recognize this foreign invader and eventually destroy it.

Keratolytics

These a topical medications that temporarily remove the callus off the surface of the wart. The callus protects the wart — it's like the wart's house. The wart stimulates the keratinocytes to make callus/dead skin cells. 

A word of caution: Keratolytics can be very strong and lift up the top layer of your skin, sometimes leaving raw skin exposed. Walking on this can be very sore, and it can become infected. I never recommend salicylic acid for certain diabetic patients, patients with numb feet (neuropathy), or those with poor circulation.

Salicylic acid is the most common keratolytic. Most over-the-counter products contain 17% salicylic acid, which isn't strong enough for a wart on the plantar (bottom) surface of the foot. I have my patients try to get a 40% salicylic acid paste such as

An important tip when using salicylic acid: keep it contained on the wart and off the healthy skin to prevent significant irritation.
Adhesive  padding such as adhesive callus  pads

or corn pads

are useful to keep the medication contained to the wart and away from healthy skin .On the bottom of the feet, pads tend to slide around, so securing them with paper tape is helpful.
I like paper tape because it typically doesn't cause skin tears and is breathable. The pad can also be secured with Coban, a self-adherent tape with no sticky portion to irritate the skin. Coban is elastic, so care must be taken not to wrap it too tight, which is easy to do when wrapping circumferentially.

If the skin becomes irritated from the salicylic acid, I usually have the patient discontinue it until the skin heals, switching to an antibacterial ointment and a dressing.

Continual occlusion of the wart with a dressing is important for success. Normally, occlusion is done with a nonstick pad (like Telfa) and paper tape or moleskin.
One home remedy I've seen work is taking the inside of a banana peel, cutting it to fit, and applying it over the wart, secured with tape or Coban — though there's no scientific evidence behind this. 

 

Debridement of the wart on a regular basis — ideally weekly, by a healthcare professional such as a podiatrist — is also important.

Before high-deductible health plans and high co-pays became the norm, I would have patients come to the office weekly for debridement, followed by treatment with 70% salicylic acid and an occlusive dressing to keep on until the next visit. This was quite effective due to the consistency of professional care over time. However, the rising cost of healthcare has made this approach difficult for many patients today.

Weekly debridement is best, but when professional debridement isn't financially feasible, using disposable emery boards to sand down the overlying callus once a week can help. Anything that touches the wart becomes contaminated with the virus, so anything used to debride it should be thrown away after use. I don't recommend  self-treatment  with any sharp instrument because  infections and painful scars can result. 

So why can't warts just be numbed and removed?

Short answer : They can but there are a couple caveats .  
One, you have to take all weight off the surgical area / no weight bearing until it heals to prevent a painful scar on the bottom of the foot . 

Secondly,  the microscopic wart virus is often still present in the surrounding area even after complete wart removal and can reinfect the skin. If it infects the scar ( if one walks on the area before it’s healed) it can be exquisitely painful and nearly impossible to resolve.
That's why excision is normally paired with a prescription antiviral topical to treat any remaining virus and prevent recurrence.

Immunotherapy

Immunotherapy activates the immune system to eradicate skin tumors and growths, including warts.

1. Over-the-counter topical: Vircin

This contains salicylic acid, an immune modulator, and an antiviral component. This trifecta approach is effective in resolving warts over time. Apply once a day for up to 12 weeks, letting the product dry on the wart before applying a sock. It's designed not to require a dressing, but I always recommend an occlusive dressing to enhance results. Success rate is 88% according to their website . In my experience, I've found it very effective, especially for multiple warts. Vircin, in my opinion, is about as effective as the prescription topical Aldara described below.

2. Prescription topical treatments

Efudex cream (5-fluorouracil): Interferes with DNA formation to stop the wart's growth; it's also used to treat some skin cancers. Apply twice a day with a Q-tip under an occlusive dressing for approximately 8–12 weeks, with debridement at least once a month during treatment. I use this in combination with salicylic acid and an occlusive dressing, with sharp debridement in the office once a month.

Aldara ointment (imiquimod): Activates immune cells and the inflammatory process to attack  and directly kill  the wart virus. Originally developed for genital warts, it's commonly used for plantar warts too. It comes in packets, applied five days a week or every other day under an occlusive dressing, with salicylic acid on the off days and a monthly in-office debridement. I've found much more favorable results with Aldara than with Efudex.

 

For extremely stubborn warts, consistent, faithful treatment for at least two to three months is typically needed to see results.

3. Swift microwave treatment

A newer treatment that uses low microwave energy to trigger the immune system to eradicate the wart, done in the doctor's office in just a few minutes. Treatment is typically monthly for up to three sessions, with the wart gradually shrinking over six weeks to nine months afterward. Its claimed success rate is around 83%. I don't have personal experience with this device — it's an expensive machine for a practice to purchase (around $28,000) and currently isn't covered by insurance, so sessions run $250–$295 each.

If I had a stubborn wart myself, I'd first try Vircin or a prescription topical plus 40% salicylic acid for 8 weeks. If it wasn't resolving, I'd look into Swift microwave treatment or curettage and laser.

Surgical Curettage with Pulsed Dye Laser

The wart is numbed with local anesthesia and scooped out with a dermal curette, then treated with a laser that heats up the blood vessels in the wart, destroying what's left of it. This leaves a wound, and non-weightbearing for 2–3 weeks is recommended to prevent scarring. I always follow up with Aldara or Efudex for at least a month afterward to prevent any remaining virus from setting up shop again.

This treatment is highly effective. In my entire career, I've only had two recurrences after this procedure. The downside is that laser devices are very expensive, so many practices can't afford one. It's often done at a surgical center or hospital, and even some smaller community hospitals may not have this equipment.

 

Warts responding to treatment will start looking darker, then take on a scab-like appearance as they begin to die — a good sign that resolution is near. A dark scab indicates successful treatment; the wart has died and is separating from the skin. Pink and swelling around the area is a sign of inflammation — your body's immune system mounting a response to the virus.

Adjunctive Treatment

For sweaty feet with warts, I'll often prescribe Drysol to help dry things up, since sweaty feet foster wart growth and can carry the virus to other parts of the foot. An over-the-counter underarm antiperspirant can work on the foot as well.

Other Treatments

This isn't an all-inclusive list — just what I've found works based on my own experience. I've used Bleomycin a few times, a chemotherapy drug injected directly into the wart, similar in concept to the immunotherapy treatments above. It was very effective at eradicating warts, but the treatment is expensive and quite painful. Other topical chemicals like cantharidin and trichloroacetic acid work well but are also painful.

Treatments That Haven't Worked

I do not recommend freezing warts off (liquid nitrogen). I've never seen this work on foot warts, and it's painful. It creates a blister that hurts to walk on. Over-the-counter liquid nitrogen products, in my opinion, are a waste of money. I believe the ineffectiveness comes down to the increased thickness of the skin on the foot; this method does seem to work better elsewhere on the body.

Over my career, I've curated my recommended treatments to be the least painful, most effective, and as cost-effective as possible. That said, patients are individuals, and treatment plans need to stay flexible and personalized — not to mention navigating whatever obstacles health insurance throws up.

The Good News

Once a wart is effectively treated and your body has mounted an immune response to it, your immune system will recognize and destroy the virus should it ever try to infect the foot again. Recurrence is highly unlikely. Hip hip — hooray!

Thanks for reading. I hope this helps you navigate treatment with your doctor.

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