Received: 9 September 2019 Revised: 18 October 2019 Accepted: 26 October 2019

DOI: 10.1111/dth.13143

ORIGINAL PAPER

Real-life treatment of cutaneous warts with cantharidin

podophyllin salicylic acid solution

Anh Ly Nguyen1,2 | Koen D. Quint2,3 | Jan Nico Bouwes Bavinck2 |

Angelina Erceg1 | Wim J. A. de Kort1 | John E. M. Körver1

1
Department of Dermatology, Amphia
Hospital, Breda, The Netherlands Abstract
2
Department of Dermatology, Leiden Patients often request treatment of their burdensome cutaneous warts. However, a
University Medical Center, Leiden, The
safe and effective treatment for cutaneous warts is lacking. This study evaluates treat-
Netherlands
3
Department of Dermatology, Roosevelt ment outcome, side effects, and patient satisfaction after topical application of can-
Clinics, Leiden, The Netherlands tharidin 1% podophyllin 2% salicylic acid 30% (CPS1) solution in a large series of

Correspondence children and adults with cutaneous warts. Fifty-two children and 83 adults with warts,
Anh Ly Nguyen, Department of Dermatology, treated with CPS1 solution between October 2012 and October 2014, were included.
Leiden University Medical Center, P.O. Box
9600, 2300 RC Leiden, The Netherlands. Complete clearance of warts occurred in 86.5% of children and 62.7% of adults treated
Email: [Link].Nguyen2@[Link] with CPS1 solution (p < .01). Resolution of warts was partial in 3.9 and 24.1% and
absent in 9.6 and 13.2% of children and adults respectively. Side effects were present
in 41.2% of children and 46.3% of adults (p = .7). Most common side effects were blis-
tering, pain, and burning sensation. No serious adverse events occurred. On a 10-point
scale, median patient satisfaction score was 9.0 (interquartile range 7.8–10.0) and 8.0
(interquartile range 5.1–9.7) for children and adults respectively (p < .01). CPS1 solu-
tion is a safe and promising treatment modality with a high clearance and high patient
satisfaction rate for the management of cutaneous warts, particularly in children.

KEYWORDS

cantharidin podophyllin salicylic acid solution, clearance rate, patient satisfaction, treatment
outcome, warts

1 | I N T RO DU CT I O N However, patients often request treatment of warts due to pain, dis-

comfort, and/or social stigma. Treatment of warts is often painful, labor
Warts are a common viral infection of the skin caused by certain types intensive, time-consuming, and expensive. A safe and effective treat-
of the human papillomavirus (HPV; Bruggink et al., 2012). As a result of ment for cutaneous warts is still lacking (Sterling et al., 2014).
natural immunity, without treatment, warts tend to resolve spontane- A wide variation of treatment modalities is available for the man-
ously within months to years (Sterling, Gibbs, Haque Hussain, Mohd agement of warts. The range of topical treatment modalities includes
Mustapa, & Handfield-Jones, 2014). Prior research demonstrated that duct tape, topical salicylic acid, cryotherapy, silver nitrate, mono-
52% of warts in children cleared within 1 year and two thirds of the chloroacetic acid, podophyllin, cantharidin, and 5-fluorouracil (Bock,
warts resolved within 2 years, regardless of treatment of the warts 1965; Bruggink et al., 2010; Bruggink et al., 2015; Cockayne et al.,
(Bruggink, Eekhof, et al., 2013; Massing & Epstein, 1963). An expectant 2011; Duthie & McCallum, 1951; Ebrahimi, Dabiri, Jamshidnejad, &
approach is often advised for the management of the cutaneous warts. Sarkari, 2007; Epstein & Epstein, 1960; Gladsjo, Alió Sáenz, Bergman,

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2019 The Authors. Dermatologic Therapy published by Wiley Periodicals, Inc.

Dermatologic Therapy. 2019;32:e13143. [Link]/journal/dth 1 of 7

[Link]
2 of 7 NGUYEN ET AL.

Kricorian, & Cunningham, 2009; Kartal Durmazlar, Atacan, & Eskioglu, Involving Human Subjects Act. Patients who received treatment with
2009; Kwok, Holland, & Gibbs, 2011; Rosenberg, Amonette, & Gard- topical application of CPS1 solution for cutaneous warts between
ner, 1977; Salk, Grogan, & Chang, 2006). A meta-analysis and pooled October 2012 and October 2014 were eligible for inclusion. Exclusion
analysis from randomized controlled trials reported cure rates ranging criteria were plane or anogenital warts, seborrheic keratoses, immune
from 30 to 58% following treatment of cutaneous warts with duct compromised patients, pregnant, or lactating women.
tape, cryotherapy, salicylic acid, topical 5-fluorouracil, and combined
therapy with salicylic acid and cryotherapy (Kwok et al., 2011). The
overall evidence for most of these treatments is weak, due to difficul- 2.2 | Treatment and definitions
ties in study design (Sterling et al., 2014).
In contrast to most wart treatments, the application of cantharidin Treatments were performed by trained health care professionals at
solution is painless. Cantharidin is a vesicant produced by blister beetles, our outpatient clinic, under the supervision of a physician. Self-
which has been used as a treatment of warts and molluscum conta- application of CPS1 solution was not allowed due to its toxicity and
giosum since the 1950s (Torbeck, Pan, DeMoll, & Levit, 2014). Combina- potential misuse, as it can be fatal if ingested (Torbeck et al., 2014).
tions of cantharidin 1% podophyllin 2% salicylic acid 30% (CPS1) Excessive callus was removed by using a curette or scalpel. The treat-
solution, cantharidin 1% podophyllotoxin 5% salicylic acid 30% (CPS2), ment regimen consisted of topical application of cantharidin 0.7%
and cantharidin 1% podophyllin 20% salicylic acid 30% (CPS3) solution solution followed by subsequent applications with CPS1 solution. For
are also available for the treatment of warts. Cure rates after topical the first treatment, cantharidin 0.7% solution was applied in order to
application of cantharidin solution for the treatment of cutaneous warts carefully assess the extent of blister formation and other side effects.
range from 64.0 to 100% (Bock, 1965; Epstein & Epstein, 1960; Kartal The solution was applied to the wart with a 1-mm surrounding rim of
Durmazlar et al., 2009; Rosenberg et al., 1977). Cure rates for the treat- normal skin. Treated warts were covered with occlusive tape. Patients
ment of plantar warts with topical application of CPS2 and CPS3 solu- were advised to rinse the solution off the treated warts 4–8 hr after
tion are even higher, ranging from 81.0 to 100.0% (Becerro de Bengoa application (in accordance with the product instruction), once a tin-
Vallejo, Losa Iglesias, Gómez-Martín, Sánchez Gómez, & Sáez Crespo, gling/burning sensation, or blister appeared. Application of the solu-
2008; Coskey, 1984; Ghonemy, 2017; Kaçar, Taşlı, Korkmaz, Ergin, & tions was performed at intervals of 3–4 weeks until complete

an, 2012; López López et al., 2016; López-López, Agrasar-Cruz,
Erdog clearance of all treated warts had occurred. Complete clearance was

Bautista-Casasnovas, & Alvarez-Castro, 2015). The study size and follow defined as resolution of all treated warts, noted by physician and/or
up period were often limited (Becerro de Bengoa Vallejo et al., 2008; patient. Clearance was considered partial when a section of treated
Bock, 1965; Coskey, 1984; Epstein & Epstein, 1960; Ghonemy, 2017; warts had disappeared or if treated warts became smaller compared
Kaçar et al., 2012; Kartal Durmazlar et al., 2009; López López et al., to baseline, based on patient's experience. Warts that initially cleared
2016; López-López et al., 2015; Rosenberg et al., 1977). “In some stud- with treatment, but reoccurred at the same location within 3 years of
ies, the associated predicting factors enhancing the resolution of warts treatment with CPS1 solution were noted as recurrences.
such as age of patients were not accounted for." (Becerro de Bengoa
Vallejo et al., 2008; Bock, 1965; Epstein & Epstein, 1960; Kartal
Durmazlar et al., 2009; Rosenberg et al., 1977). A previous study demon- 2.3 | Data collection
strated that resolution of warts was more likely at a younger age
(Bruggink, Eekhof, et al., 2013). Moreover, the fact that a patient-friendly Data were collected from a combination of electronic patient records
and effective treatment with painless application for warts in children is and a survey. The physician judged clearance of the warts during reg-
still lacking, calls for a study investigating treatment with topical applica- ular check-ups. In case of discrepancies between the electronic
tion of CPS1 solution for cutaneous warts in children versus adults. patient records and the survey, the information from the electronic
This study aimed to evaluate outcome, patient satisfaction, and patient records was used to minimize recall bias. Patients were
side effects of cutaneous warts treated with topical CPS1 solution in approached by post or telephone to complete the survey. The survey
a large series of children and adults. included questions regarding the time span of the warts before treat-
ment with CPS1 solution, reasons for desiring treatment of warts, any
wart treatment before and after treatment with CPS1 solution, side
2 | MATERIALS AND METHODS effects after application of CPS1 solution, clearance of all treated
warts, recurrences, and patient satisfaction regarding treatment with
2.1 | Study cohort CPS1 solution. The patient satisfaction score was measured on a
10-point scale; the higher the score, the higher the level patient satis-
This retrospective study was conducted at a secondary non-university faction. A serious adverse event was defined as a life-threatening
teaching hospital in Breda, The Netherlands. The ethics committee of adverse event, resulting in death, requiring inpatient hospitalization,
Medical Research Ethics Committees United exempted this study for prolongation of hospitalization or an event resulting in persistent or
review, as it was a survey-based retrospective study (W16.037). significant disability or incapacity. Upon request, an English translation
Therefore, this research was not subject to the Medical Research of the survey is available from the corresponding author. In reporting
NGUYEN ET AL. 3 of 7

this study, we adhered to the Strengthening the Reporting of Obser- 3.9% (95% CI: 1.1%; 13.0%) and 24.1% (95% CI: 16.2%; 34.3%) and
vational Studies in Epidemiology statement. ineffective in 9.6% (95% CI: 4.2%; 20.6%) and 13.2% (95% CI: 7.6%;
22.2%) of children and adults respectively (p < .01). Children required
significantly fewer treatments with CPS1 solution compared to adults:
2.4 | Statistical analysis 65.4% of children received 1–3 treatments with CPS1 solution as
opposed to 37.3% of adults (p < .01). A majority of the adults (62.7%)
Continuous variables with a non-normal distribution were summarized required ≥4 treatments with CPS1 solution for their warts. Children
as median with a corresponding interquartile range (IQR). Categorical were completely cleared from their warts at a median of 3.0 months
variables were summarized as frequencies and percentages. Statistical (IQR 1.6–6.0) after onset of treatment with CPS1 solution, while for
analysis of continuous variables was performed using the Pearson chi- adults complete clearance occurred at a median of 5.0 months (IQR
square test and for statistical analysis of two independent groups on a 3.0–6.0; p = .02). Of the warts that initially cleared with CPS1 solu-
continuous variable, the Mann–Whitney U test was performed. In tion, recurrence of the warts occurred in 10.6% of children and 19.4%
case of categorical variables with three or more categories, the of adults (p = .3) (Table 1).
Kruskal–Wallis test was applied. Outcomes were considered statisti- A majority of children and adults rated the effect of treatment
cally significant if p < .05. In case of missing data, pairwise deletion with CPS1 solution as good, very good or excellent (88.2 vs. 68.7%
was performed. The data analyses were performed with SPSS Statis- respectively, p = .01). The median patient satisfaction score was
tics Pack version 25.0 (IBM, Armonk, NY). higher for children than adults, namely 9.0 (IQR 7.8–10.0) versus 8.0
(IQR 5.1–9.7), respectively, (p < .01; Table 1).
Side effects of treatment with CPS1 solution were present in
3 | RESULTS 41.2% of the children and 46.3% of adults (p = .7). The most common
side effects were blistering, pain, and burning sensation. No serious
3.1 | Patient characteristics adverse events occurred (Table 2).
Subgroup analysis based on location of the warts (plantar warts,
A total of 147 patients were treated with topical application of CPS1 common warts, combined plantar, and common warts) showed no sig-
solution for cutaneous warts between October 2012 and October nificant difference in terms of treatment outcomes.
2014. Five patients declined to participate in the survey and six
patients were lost to follow-up. One patient was excluded as the sur-
vey was completed anonymously. A total of 52 children 4 | DI SCU SSION
(age < 18 years) with the help of their parents and 83 adults
(age ≥ 18 years) completed the survey and were included in the This study reports the largest series of patients with warts treated
analyses. with CPS1 solution to date. This study demonstrated a high complete
Overall, a majority of the patients were adults (61.5%), female clearance rate (86.5 and 62.7%, p < .01) with only mild side effects
(53.3%), and had more than one wart (69.2%). Adults more often had and a high degree of patient satisfaction (88.2 and 68.7%, p < .01) of
plantar warts in comparison to children (61.4 vs. 44.2%, p = .05). The cutaneous warts treated with CPS1 solution in children and adults,
majority of children had common warts. Warts in children were twice respectively.
as likely to have been present for <12 months at first presentation Previous studies reported somewhat higher clearance rates rang-
compared to adults (46.0 vs. 23.4%, p < .01). Children more frequently ing from 81.0 to 100.0% after treatment of plantar warts with topical
had multiple reasons for desiring treatment in comparison to adults application of CPS2 and CPS3 solution. However, there are some
(74.5 and 54.2%, respectively, p = .05). Children experienced social and clear differences in treatment design and secondary outcomes among
cosmetic inconveniences of the warts twice as often as adults. Only these studies. For one, the duration of occlusion in these studies was
3.8% of children and 4.8% of adults had not received previous treat- significantly longer and varied from 24 to 48 hr with weekly to
ment for their warts. There were no significant differences between monthly applications with CPS2 or CPS3 solution (Table 3). Further-
children and adults in terms of number of treatments prior, during, or more, podophyllotoxin 5% and podophyllin 20% were used as a com-
after therapy with CPS1 solution (Supplementary Table). The median ponent of the CPS2 and CPS3 solution respectively as opposed to
follow-up period was 28.3 months with IQR of 18.8–32.5 months. podophyllin 2% in the CPS1 solution we applied in this study (Becerro
de Bengoa Vallejo et al., 2008; Coskey, 1984; Ghonemy, 2017; Kaçar
et al., 2012; López López et al., 2016; López-López et al., 2015). It is
3.2 | Treatment outcome, patient satisfaction and likely that longer duration of occlusion, shorter treatment intervals
side effects and higher concentration of the components of the CPS2 and CPS3
solution somewhat enhanced resolution of the warts. However, this
Clearance of warts was complete in 86.5% (95% confidence interval relatively modest increase in clearance rate did come at a cost. The
[CI]: 74.7%; 93.3%) of children and 62.7% (95% CI: 51.9%; 72.3%) of studies using CPS2 solution reported significantly more severe side
adults treated with CPS1 solution. Resolution of warts was partial in effects and higher toxicity than our study, using CPS1 solution
4 of 7 NGUYEN ET AL.

TABLE 1 Treatment outcome and patient satisfaction after topical application of CPS1 solution for cutaneous warts

Children (age <18) Adults (age ≥18) Total p Value

Clearance of warts# n = 52 n = 83 n = 135 <.01*
Complete 45 (86.5) 52 (62.7) 97 (71.9)
Partial 2 (3.9) 20 (24.1) 22 (16.3)
None 5 (9.6) 11 (13.2) 16 (11.8)
Number of treatments with CPS1 solution~ n = 52 n = 83 n = 135 <.01*
1–3 34 (65.4) 31 (37.3) 65 (48.1)
≥4 18 (34.6) 52 (62.7) 70 (51.9)
Number of treatments with CPS1 solution~, median (IQR) 3.0 (2.0–4.0) 4.0 (3.0–5.0) 4.0 (2.0–5.0) <.01*
Duration before clearance of warts after onset treatment 3.0 (1.6–6.0) 5.0 (3.0–6.0) 4.0 (2.5–6.0) .02*
with CPS1 in months#, median (IQR)
Recurrence of warts# n = 47 n = 72 n = 119 .3
Yes (complete/partial) 5 (10.6) 14 (19.4) 19 (16.0)
No 42 (89.4) 58 (80.6) 100 (84.0)
Patient global assessment of treatment effect∞ n = 51 n = 83 n = 134 .01*
Good, very good or excellent 45 (88.2) 57 (68.7) 102 (76.1)
Bad or reasonable 6 (11.8) 26 (31.3) 32 (23.9)
Patient satisfaction score∞, median (IQR) 9.0 (7.8–10.0) 8.0 (5.1–9.7) 8.5 (6.0–9.95) <.01*

Note: Data are n (%) unless stated otherwise. Abbreviations: CPS1, cantharidin 1% podophyllin 2% salicylic acid 30%; IQR, interquartile range; n, total
number of patients; *, p value <.05; ~, data obtained from patients' electronic record; #, data obtained from patients' electronic record and survey; ∞, data
obtained from survey.

T A B L E 2 Side effects due to topical

Children (age < 18) Adults (age ≥ 18) Total p value
application of CPS1 solution for
Number of side effects# n = 51 n = 82 n = 133 .7 cutaneous warts
None 30 (58.8) 44 (53.7) 74 (55.6)
1 11 (21.6) 17 (20.7) 28 (21.1)
2 4 (7.8) 12 (14.6) 16 (12.0)
≥3 6 (11.8) 9 (11.0) 15 (11.3)
Type of side effects#^ n = 50 n = 81 n = 131 NC
Blistering 44 (88.0) 77 (95.1) 121 (92.4)
n = 51 n = 82 n = 133 NC
Pain 12 (23.5) 32 (39.0) 44 (33.1)
Burning sensation 6 (11.8) 19 (23.2) 25 (18.8)
Irritation of skin 4 (7.8) 7 (8.5) 11 (8.3)
Erythema 6 (11.8) 4 (4.9) 10 (7.5)
Pigmentation of skin 2 (3.9) 5 (6.1) 7 (5.3)
Itching 3 (5.9) 1 (1.2) 4 (3.0)
Scarring 2 (3.9) 0 (0.0) 2 (1.5)
Infection of skin 0 (0.0) 0 (0.0) 0 (0.0)
Other 4 (7.8) 7 (8.5) 11 (8.3)

Note: Data are n (%). Abbreviations: CPS1, cantharidin 1% podophyllin 2% salicylic acid 30%; n, total
number of patients; NC, not calculable due to multiple answer options; #, data obtained from patients'
electronic record and survey; ^, Multiple answers are possible.

(Becerro de Bengoa Vallejo et al., 2008; Coskey, 1984; Kaçar et al., 1984). Another study more frequently reported pain following treat-
2012; López López et al., 2016; López-López et al., 2015). One study ment of the warts with the CPS2 solution as opposed to the CPS1
reported cellulitis in 3.3% of children treated with topical application solution in our study (85.7 vs. 33.1%; Kaçar et al., 2012). Treatment of
of CPS2 solution followed by an occlusion period of 24 hr (Coskey, plantar warts with CPS3 solution caused complications of pain, bulla,
NGUYEN ET AL. 5 of 7

and hemorrhagic bulla in 26.7, 60, and 13.3% of the patients

6–12 months

8–40 months
(Ghonemy, 2017). We adhered to the product instruction of CPS1

Follow-up

6 months

6 months
solution, which advised an occlusion period of 4–8 hr. Our study

period

Note: Data are n (%) unless stated otherwise. Abbreviations: CPS1, cantharidin 1% podophyllin 2% salicylic acid 30%; CPS2, cantharidin 1% podophyllotoxin 5% salicylic acid 30%; CPS3, cantharidin 1%
reported only mild side effects, no secondary infections, or serious

NR
NR
adverse events. Furthermore, these mild side effects in our study also
Recurrences

coincided with a high patient satisfaction rate. Therefore, we consider

n patients

0/144 (0) topical application of CPS1 solution followed by an occlusion period

0/14 (0)

(16.0)
19/119
of 4–8 hr as an effective, safe, and well-tolerated treatment for cuta-
NR

NR

NR
(%)

neous warts, especially in children.

This was the first study evaluating treatment outcomes after
topical application of CPS1 solution for the management of cutane-
Efficacy
rate (%)

ous warts in children versus adults. As this study shows, children

100.0
100.0
81.0
95.8

93.3
71.9 more often than adults seek treatment for warts due to social and
cosmetic inconveniences. Children are more difficult to treat as pain-

podophyllin 20% salicylic acid 30%; N, number; NR, not reported; P, prospective cohort study; R, retrospective cohort study; RCT, randomized controlled trial.
ful treatments are poorly tolerated and should preferably be avoided
N patients with
cleared warts/

(Sterling et al., 2014). In daily practice, this can be challenging for

at follow up
N patients

138/144

both doctor and patient. Therefore, a distinction between children

reached

81/100

97/135
14/14
75/75

14/15

and adults is crucial in evaluating and choosing an adequate, satisfac-

Overview of studies regarding treatment of cutaneous warts with topical application of CPS1, CPS2, or CPS3 solution

tory, and effective topical treatment for cutaneous warts (Bruggink,

Eekhof, et al., 2013; Sterling et al., 2014). A review of the manage-
Every 2 weeks

Every 2 weeks
15–20 days
2–3 weeks

3–4 weeks
Once weekly

ment of cutaneous warts in children proposed salicylic acid 25–35%

as the preferred treatment for children with large, multiple, or peri-
Interval

Every

Every
After

ungual warts due to easy daily application at home and mild side
effects. Cryotherapy was viewed as another simple and easy treat-
ment, however often poorly tolerated by children due to pain, scar-
Duration of
occlusion

24–48 hr

24–48 hr

ring and post-inflammatory hyper- or hypopigmentation. They also

4–8 hr
24 hr

24 hr

24 hr

considered cantharidin to be a valuable option for the treatment of

cutaneous warts in children (Gerlero & Hernández-Martín, 2017).
The current study shows that CPS1 solution is a safe, rather quick,
Treatment

well tolerated and highly appreciated treatment for warts in children.

CPS2
CPS2

CPS2
CPS2

CPS3
CPS1

However, application of the CPS1 solution by trained health care

professionals is mandated (Torbeck et al., 2014). Still, costs for treat-
ment of warts could be greatly reduced, as only limited treatment
sessions (median number of 3) are needed to achieve complete reso-
N patients

lution of warts in children compared to cryotherapy. In addition, the

(N warts)
121 (NR)
144 (NR)

135 (NR)
75 (126)
14 (75)

15 (78)

recurrences reported for CPS1 solution (10.6 and 19.4% for children
and adults, respectively) are roughly lower or comparable to other
treatments of cutaneous warts with duct tape (75%), cryotherapy
Children and adults

Children and adults

(13.3–25%), 5% 5-fluorouracil (13–15%), and pulsed dye laser

Children versus

(0–36%; Dhar, Rashid, Islam, & Bhuiyan, 2009; Gladsjo et al., 2009;
Salk et al., 2006; Veitch, Kravvas, & Al-Niaimi, 2017; Wenner et al.,
Children

adults
Patient

2007; Youn, Kwon, Park, Kim, & Kim, 2011). Two studies reported
Adults

Adults
group

no recurrences after treatment of cutaneous warts with CPS2 solu-

tion (Table 3) (Becerro de Bengoa Vallejo et al., 2008; Kaçar et al.,
design
Study

2012). Recurrences of cutaneous warts after topical treatment with

RCT
R

R
P

salicylic acid are unknown. As the protocol for treatment with CPS1
solution is rather simple, one could wonder about the place of this
Vallejo et al. (2008)

treatment in the therapeutic arsenal of cutaneous warts. CPS1 solu-

Becerro de Bengoa

Kaçar et al. (2012)

López López et al.

Ghonemy (2017)

tion could be a promising second line treatment for cutaneous warts

Coskey (1984)

Current study

in hospitals (and primary care) following ineffective first line treat-

TABLE 3

(2016)

ment with salicylic acid, particularly in children.

The results in this study are real-life, generalizable, and represen-
tative for a population of patients in a secondary hospital, as this
6 of 7 NGUYEN ET AL.

study included a large non-selected sample of patients with burden- Bruggink, S. C., Gussekloo, J., de Koning, M. N. C., Feltkamp, M. C.,
some recalcitrant warts in a single center secondary hospital. Bavinck, J. N., … Eekhof, J. A. (2013). HPV type in plantar warts influ-
ences natural course and treatment response: Secondary analysis of a
Limitations of this study include its retrospective nature, lack of a
randomized controlled trial. Journal of Clinical Virology, 57(3),
placebo group, and potential recall bias due to long follow-up period. 227–232.
In this study, we tried to limit the recall bias by relying on electronic Bruggink, S. C., Gussekloo, J., Egberts, P. F., Bavinck, J. N. B., de
patients' records in case of discrepancies. Selection bias might also Waal, M. W. M., Assendelft, W. J. J., & Eekhof, J. A. H. (2015). Mono-
chloroacetic acid application is an effective alternative to cryotherapy
have been present, as it was probable that patients with painful or
for common and plantar warts in primary care: A randomized con-
recalcitrant warts were more frequently referred to our secondary trolled trial. The Journal of Investigative Dermatology, 135(5),
hospital than treated in primary care. These results might underesti- 1261–1267.
mate the true clearance rate, if the CPS1 solution were to be applied Cockayne, S., Hewitt, C., Hicks, K., Jayakody, S., Kang'ombe, A. R., …
Watt, I. (2011). Cryotherapy versus salicylic acid for the treatment of
in patients with warts in a primary care setting. Additionally, previous
plantar warts (verrucae): A randomised controlled trial. BMJ, 342,
research established that the HPV type in warts can also predict the d3271.
response to certain treatments (Bruggink, Gussekloo, et al., 2013). In Coskey, R. J. (1984). Treatment of plantar warts in children with salicylic
this retrospective study, the HPV types in warts were not tested and acid-podophyllin-cantharidin product. Pediatric Dermatology, 2(1),
71–73.
therefore the role of HPV type on clearance of warts in this study
Dhar, S. B., Rashid, M. M., Islam, A., & Bhuiyan, M. (2009). Intralesional
population remains unknown.
bleomycin in the treatment of cutaneous warts: A randomized clinical
trial comparing it with cryotherapy. Indian Journal of Dermatology,
Venereology and Leprology, 75(3), 262–267.
5 | C O N CL U S I O N Duthie, D. A., & McCallum, D. I. (1951). Treatment of plantar warts with
elastoplast and podophyllin. British Medical Journal, 2(4725),
216–218.
This study established topical application of CPS1 solution as a safe, Ebrahimi, S., Dabiri, N., Jamshidnejad, E., & Sarkari, B. (2007). Efficacy of
effective, and promising treatment modality for the management of 10% silver nitrate solution in the treatment of common warts: A
cutaneous warts, especially in children. A large prospective (placebo placebo-controlled, randomized, clinical trial. International Journal of
Dermatology, 46(2), 215–217.
controlled) randomized trial is indicated to further assess this promis-
Epstein, J. H., & Epstein, W. L. (1960). Cantharidin treatment of digital and
ing safe and effective treatment for cutaneous warts. periungual warts. California Medicine, 93, 11–12.
Gerlero, P., & Hernández-Martín, A. (2017). Treatment of warts in children:
ACKNOWLEDGMENT An update. Actas Dermo-Sifiliográficas, 107(7), 551–558.
Ghonemy, S. (2017). Treatment of recalcitrant plantar warts with long-
We thank Dr. R.E.J. Roach for the English language editing of this
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