What's New

This pathway has been produced by representatives from both primary and secondary care to support the management of dermatological conditions. These guidelines accompany the publication of new referral criteria from GHFT. The pathway is based on both PCDS guidance on the management of dermatological conditions, GHFT guidelines and the current CCG commissioning policies and supports the local guidance agreed by experts throughout the healthcare system.

Warts and Verrucas Care Pathway Overview

  • Most people will have warts at some time in their life
  • They are usually harmless and go away on their own eventually, but may take months or many years
  • People who are immunosuppressed may have more numerous, and larger warts
  • Infection occurs by direct or indirect contact
  • A damaged epithelial barrier greatly increases the risk of inoculation:
    • Plantar warts transmitted from swimming pools due to the rough surfaces abrading the skin of the feet
    • Periungual warts in patients who bite their finger nails
    • Shaving spreads warts over the beard area
    • New warts may develop along the sites of trauma, this is known as the Koebner phenomenon
  • The incubation period ranges from a few weeks to over a year

Please click the relevant flowchart box to be taken directly to textual information 


Red Flags
A warty lesion near a nail which is causing destruction of the nail plate should be regarded as cancerous until proven otherwise. SCC near the nail can mimic warts and is commonly diagnosed late.
A flat warty lesion with irregular pigment in it on the sole of the foot should be regarded as suspicious for melanoma and must be assessed by a competent person with dermoscopy.
Differential Diagnosis
  • Naevi (particularly on the face)
  • Corns and calluses on the feet
  • SCC near nails and acral melanomas
Presentation / Assessment

Firm papules with a rough surface.

Most commonly found on the backs of the hands and fingers but can occur anywhere.

Mainly due to HPV 2.

Most plantar warts are found beneath pressure points.

There are two main types:

  • Sharply defined rounded lesions with a rough keratotic surface, often painful
  • Mosaic warts, which result from a plaque of closely grouped warts and tend not to be painful

Plantar warts can be confused with callosities or corns. Sometimes the two appear together. Callosities have a smooth surface in which the skin markings are maintained. Warts do not maintain the skin markings and when pared small bleeding points become evident. It is also said that warts are more painful when pinched, whereas callosities are more painful on pressure.

The face and backs of hands are the most common sites, lesions are often numerous.

Lesions are often small (under 5 mm), round, slightly elevated and have a smooth surface.

Koebnerisation (appearance of warts within scars) is relatively common.

Acrokeratosis verruciformis (of Hopf) is a rare inherited condition with an autosomal dominant mode of inheritance. It is a disorder of keratinisation characterised by multiple flat-topped, skin-coloured keratotic lesions resembling plane warts, observed most commonly on the dorsum of the hands and feet, and usually presenting in infancy.

Epidermodysplasia verruciformis is a rare inherited condition, mainly autosomal recessive, in which there is a widespread and persistent infection with the Human papilloma virus. The characteristic clinical features include plane warts, pityriasis versicolor-like lesions and red-brown plaques. Skin changes tend to begin in childhood. Dysplastic change, and malignant change into squamous cell carcinoma, is common in adults but metastasis is rare.

These are most commonly found on the face and neck in men, but they can occur on any part of the body.

They have a filiform appearance and may have a stalk.

Usually multiple.

The appearance depends on the type.

They may be difficult to distinguish from intraepithelial neoplasia or genital mucosal SCC, and indeed neoplasia may occur within an area of warty change on the genitals. If there is any diagnostic doubt, these patients should be referred to sexual health clinic.

Condylomata acuminata have the following features:

  • May cause discomfort, discharge or bleed
  • Lesions may appear pearly, filiform, fungating, cauliflower or plaque-like
  • They can be quite smooth (particularly on penile shaft), verrucous, or lobulated
  • Lesions can be skin-coloured, erythematous or hyperpigmented 
  • They predispose to cervical, penile and vulval cancer
  • Patients must be checked for other sexually transmitted infections 

Not all anogenital warts are sexually transmitted, however, in children a consideration has to be given to the possibility of sexual abuse. The possibility of non-sexual transmission is more likely if:

  • There are no other suspicious features
  • The warts are located on fully keratinised skin as opposed to the genital or anal mucosa 
  • There is a clinical resemblance to common warts
  • The child is very young, perhaps up to two years old - in such cases the warts may have been transmitted at birth from the mothers genital tract
Initial Primary Care Management

Warts do not need treating if they are not causing problems. Half will go away on their own within a year, and two thirds within 2 years. Even the best treatments have at best a 50-70% cure rate at 3 months (with 25% going away on their own in that timescale)

Warts are contagious but the risk of transmission is low

  • Covering the wart with a waterproof plaster when swimming
  • Wearing flip-flops in communal showers
  • Avoiding sharing shoes, socks and towels

  • Avoiding scratching lesions
  • Avoiding biting nails or sucking fingers that have warts
  • Keeping feet dry and changing socks daily


In general, plantar warts are very difficult to treat.

The pain caused by plantar warts results from thickening of the skin, accordingly the mainstay of treatment should be regular paring using an emery board on skin which has been softened in warm water first.

  • Cryotherapy is unlikely to help
  • On the occasions where cryotherapy does help many treatments are usually required
  • Cryotherapy of the feet is very likely to be painful and can cause blistering

All of the treatments below may be used for plantar or common warts. They should not be used for genital warts. 

Treatment options - over the counter

Practice Point

Topical treatments are best avoided on the face due to the risk of irritation and scarring

This is always an option if the warts are not causing any problems. The natural history of warts should also be considered. Up to 90% of warts in young children will resolve in two years. However warts in adults, those with a long history of infection and in immunosuppressed patients are less likely to resolve spontaneously and are more recalcitrant to treatment

The discomfort caused by warts results from thickened skin. Paring of warts reduces discomfort and helps improve the efficacy of the treatments discussed below. The technique for paring is as follows:

  • Soak in warm water for 5-10 minutes
  • Pare away the dead skin using a disposable emery board / nail file
  • Perform once to twice a week

There are various lotions and paints available over the counter. They work by dissolving the skin cells on the top layer of the wart. These need to be used every night for at least three months. As with other treatments it is important to make sure that warts are regularly pared down.

Salicylic acid plasters are also available over the counter. They can be cut to size and applied overnight to the surface of the wart. This may be repeated for 3 nights, then pare it down. It may be necessary to wait a few days before repeating – 3 consecutive nights a week for a few weeks is often quite effective.

An alternative to salicylic acid is glutaraldehyde (available over the counter and marketed at Glutarol), or formaldehyde (available over the counter and marketed as Verucar gel). 

May be effective but patients must be very careful not to get any on the surrounding skin. They may leave a permanent or long lasting black mark on the skin. They must be disposed of very carefully as they are caustic.

The wart is occluded with duct tape for six days after which time the wart should be soaked in warm water for five minutes and paired down. The wart is then left uncovered overnight and the duct tape put on the next day for a further six days. This should be continued until the wart resolves.

May be used but takes multiple treatments, at fortnightly intervals, is painful, and can cause scarring and damage to underlying structures. It is no more effective than salicylic acid, and is often not available in primary care. In between treatments of liquid nitrogen the use of other treatment modalities such as duct tape or salicylic acid may be of additional benefit

Can be useful for filiform warts, especially on the face. It can also be used for other warts that have failed to respond to other treatments. The main problem with this technique is that recurrence rates are up to 30%

Have been suggested as options but there is no scientific evidence for their effectiveness.

Is a technique where lots of small needles are stuck into the wart. This causes some damage and alerts the immune system to the presence of the wart so it can be cleared. Needling has been shown to be quite effective in early studies, and often treating one wart like this results in all the warts disappearing. It is offered at private beauty salons and clinics.

Prescribable treatments where over the counter therapies have failed

(salicylic acid and lactic acid) and posalfilin ointment (salicylic acid and podophyllin) may both be prescribed on FP10. 

(cantharidin, podophyllum resin, salicylic acid) is an unlicensed preparation on the Glos joint formulary for warts. This needs to be bought by the surgery and applied by the doctor or nurse, only for people over 12 years old. This is applied to the wart surface and a 1 to 3mm margin around it, allowed to dry for a few minutes, then covered with a piece of non-porous adhesive tape for at least 8 hours. A blister appears within 24 hours which may be painful and inflamed. The blister (with the wart on top) may be removed by curettage the day after applying the cantharone plus.

This is not a commonly used method in primary care, and GPs need to have health and safety procedures and risk assessments in place before purchasing the substrate. 

Small studies have shown a number of other treatments to be of benefit in some patients. These treatments are off-label AND NOT ON THE JOINT FORMULARY FOR WARTS but appear to be safe:

Applied once a day at night under occlusion. Wash the hand thoroughly that was used to apply the cream. Wash the treated area the following morning. Review after four weeks. This is only available on prescription, and should be reserved for cases where treatment with over the counter remedies has failed.

May help in cases of persistent facial warts. Apply three nights a week (eg Monday, Wednesday, Friday) until the wart resolves. Wash off the following morning. This is only on prescription and is expensive, and may cause significant skin irritation and a flu like illness, in which case it should be stopped.
When to Refer

Warts should only ever be referred to secondary care if there is diagnostic doubt, or if they are causing significant functional impairment and not responding to standard treatment.

Significant functional impairment may include facial warts obstructing vision, nasal warts obstructing breathing, or very large warts obstructing an orifice.

If there is doubt please refer via Advice and Guidance.


Individual Funding Requests

Surgical treatment for removal of skin lesions including warts is considered to be a procedure of low clinical priority and is listed on Gloucestershire CCG's Effective Clinical Commissioning Policy.  Please see this link for details of access criteria and funding arrangements.

Secondary Care Management - GHFT

Treatment options available in secondary care may include:

  • Liquid Nitrogen / cryotherapy - painful especially for children. May scar and rarely leads to cure from one application.
  • Hyfrecation or curettage & cautery under LA ( very rarely)
  • Keratolytics with regular paring( eg. occlusal, salactol, bazooka)

Patient Resources

Please see the Patient & Carer Information & Leaflets section.

Resources for Professionals

National Standards

Please see the National and NICE Guidance section.

Other Online Resources

Pathway Leads





Zain Patel

Commissioning Manager


Gloucestershire Clinical Commissioning Group


Dr Chin Whybrew


Gloucestershire Clinical Commissioning Group


Dr James Milne

Consultant Dermatologist

Gloucestershire Hospitals Foundation Trust


Reason for Pathway Selection

This pathway has been produced by representatives from both primary and secondary care to support the management of dermatological conditions. These guidelines accompany the publication of new referral criteria from GHFT. The pathway is based on both PCDS guidance on the management of dermatological conditions, GHFT guidelines and the current CCG commissioning policies and supports the local guidance agreed by experts throughout the healthcare system.

Completion Date

December 2016

Review Date

December 2017