Everybody dislikes warts.  Warts are a challenge for both you as well as your patient.  Remember that the family of wart viruses is a lot smarter than we are.  Even after the wart is visibly gone, virus persists in the skin and may recur later.

Make sure that both you and your patient have realistic expectations for treatment.  Your goal is to minimize your patient's morbidity and encourage the immune system to control the infection.  Permanently ridding your patient of the wart virus is not possible.  Overly aggressive therapy is usually only rewarded with extra morbidity and is frequently not more likely to be successful.

Warts are passed between humans commonly in "communal" settings such as berthing compartments, recreational facilities, and equipment.  Wear shower shoes, T-shirts, and weight lifting gloves to avoid exposure and the spread of warts to others.

The most common encountered morbidity from warts (especially on the feet) is pain.  The pain is not caused by the wart itself, but rather by the mass effect of having a hard knot within and on top of the skin.  Gently paring the wart with a scalpel blade just barely to the point of pinpoint bleeding is an easy way to debulk it, thereby decreasing the patient's discomfort as well as preparing the site for other treatment.  Control any bleeding by applying Monsell's solution or 20% Aluminum chloride solution (DrySol).

Common treatments for warts whether chemical, electrical, or surgical are skin destructive in nature.

Chemical salicylic acid wart varnishes (e.g. Duofilm, Occlusal HP, Compound W, etc.) should be applied to the wart daily, preferably at bedtime.  Consider protecting the surrounding normal skin by applying petrolatum.  Place two or three coats on the wart, allowing each coat to dry; then apply a bandaid.  Salicylic acid plasters (e.g. Mediplast) should be cut to fit the wart and then applied at bedtime and overlaid with a bandaid.  The next day, the lesion can be pared or abraded with an Emory board or pumice stone.  Stop treatment if there is substantial pain, irritation, or ulceration.

Trichloroacetic acid solution (TCA) can be used similar to the salicylic acid preparations, but has a larger potential for tissue destruction.  Use it with respect.

Liquid nitrogen, if applied optimally, will induce a small blister allowing the wart to peel away from the underlying dermis.  Freeze the wart quickly to the point of turning it white with a 1 mm zone of normal skin.  A good method to minimize the damage to surrounding normal skin is to apply an appropriately sized otoscope speculum and spray the nitrogen through the open end.  Let the wart thaw slowly, then repeat the freeze.

After freezing, the lesion will follow this sequence over the next few days:  pink, red, purple, brown, and then maybe even black.  A blister will likely form and should be approached as any other blister.  Once the vesicle has opened and dried, pare off any remainder and see if any lesion remains.  Repeat treatment should be considered every 1-2 weeks or so if any lesion remains.

Electrosurgery should be used only if you have had some training in its use.  It can generate a fair degree of post-operative morbidity.  Areas over joints, near the nails, or over the bony prominences are particularly difficult to treat.

Chemical vesicants such as cantharidin are quite destructive and are not recommended as initial therapy.