Warts on the bottom of feet can be very painful and can feel like one has a rock stuck to the bottom of the foot . They are very stubborn and difficult to treat . (psst! Skip to the end to discover an eventual happy ending to your wart saga.)

What is a Wart?

A wart is a small area of skin that has been infected with a virus . However if the warts spread, it can infect a much larger portion of skin and this is called a mosaic wart. A wart virus, called human papilloma virus infects the basal layer of the epidermis of one’s skin at junction of epidermis and dermis :

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

One way to distinguish a wart from a callus is the location. Calluses will form under a boney prominence and warts typically do not.

Although this post will focus on warts on bottom of feet, warts occur anywhere there is skin . On the foot, it can occur in the top of foot, around the toes, between toes, or even part of toenail . All of which are less likely to occur 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 from walking .

The bottom of the foot is more susceptible to punctures of skin allowing entry of the wart virus. But, the virus does not need a skin puncture to infect the skin.

The moist environment created by shoes and socks fosters growth of wart once established .

Feet that sweat a lot can allow the wart virus to travel to other parts of foot and infect there .

Younger age is a risk factor as children have not had exposure to wart virus . Therefore, these youth have not developed immunity to the virus yet.

Warts are highly contagious. A common place to pick up a wart is the swimming pool or public showers in locker rooms. If there is one child in a family who has a wart, chances are the other children in the family will eventually develop warts as well. I recommend a separate shower or bathtub, if possible, for a patient that has a wart or spraying the tub with Lysol after use of the tub. *** Also never touch a wart with ungloved finger because more than likely dealing with a wart on the finger next .

How to determine if it’s a wart?

Warts are very circumscribed and defined. There is a distinct difference between healthy skin and the wart .

The surface of the wart is lumpy and can look like cauliflower.

There is normally a lot of callus on the surface and underneath the callus are tiny stipples or pinpoint areas of dried blood from blood vessels growing up into wart. Therefore, your podiatrist will have to shave off the callus on top to see if there are areas of pinpoint bleeding from these blood vessels. The callus is dead skin with no nerve endings in it so the shaving does not hurt. We call this shaving debridement.

Treatment

Again, as with other healthcare problems and their treatment online, there is a lot of misinformation. I’m going to share with you what has worked for thousands of my patients with plantar warts and what doesn’t work to save you time and money.

* Tincture of Time.

Warts can spontaneously resolve in 2/3 of children within two years. It is slower in adults and can take several years according to British Association of dermatologist guidelines for management of cutaneous warts, 2014 in Br J dermatol. 2014 Oct;171(4):696-712 Epub 2014 Oct1. In other words, it takes time for your immune system to recognize this foreign invader of a wart virus, and eventually destroy it.

* Keratolytics

This term describes removing 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 that make callous / dead skin cells to be more active.

***Warning ** A word of caution concerning keratolytics, they can be very strong and lift up the top layer of your skin, and sometimes leave the raw skin exposed. Walking on this can be very sore. Also, it can become infected. I never recommend any salicylic acid to be used on certain diabetic patients, patients with numb feet (neuropathy)or poor circulation. A foot with a wart is better than no foot from an amputation .****

Salicylic acid is most commonly used. Most over-the-counter products contains 17% salicylic acid, which is not strong enough for a wart on the skin on the plantar surface (bottom) of the foot.

I have my patients try to get a 40% salicylic acid paste seen below:

Cost is $29.99.

https://www.amazon.com/dp/B0057BPE5S/?tag=drgaffneybestfoot-20

(As the Amazon associate, I earn from qualifying purchases.)

Important tip when using salicylic acid: it is important to keep the salicylic acid contained on the wart, and not on the healthy skin to prevent significant irritation. That is why the cut and paste type of padding in the ad forementioned curad product above is useful . Also, on the bottom of the feet, pads slide around, so using a paper tape to secure it as found in this link : https://www.amazon.com/dp/B003TXPZ64/?tag=drgaffneybestfoot-20 is helpful. 3 rolls for $5.99. I like paper tape because it normally does not cause skin tears and is breathable. The pad also can be secured with Coban, which is a self- adherent tape with no sticky portion to irritate skin. Again, I like the 3M product as seen in this link: https://www.amazon.com/dp/B01GU3QUJ0/?tag=drgaffneybestfoot-20. 3 rolls for $8.80. Coban is elastic, so care must be taken not to wrap too tight, which is very easy to do going circumferentially.

If the skin does get irritated from the salicylic acid, I usually have my patient discontinue the salicylic acid for a period of time until the skin is healed. We switch to an antibacterial ointment and a dressing to help achieve that..

** Continual occlusion of the wart with a dressing is important for success. One home remedy that I have seen work is taking an inside of a banana pill and cutting it to fit and applying it over top of the wart, securing it with tape or Coban. However, there is no scientific evidence to back this. Normally it is occluded with a dressing of a nonstick pad like telfa and paper tape or moleskin. https://www.amazon.com/dp/B001KYTYLQ/?tag=drgaffneybestfoot-20

*** Debridement of the wart on a regular basis. This is best done once a week by a healthcare professional, such as a podiatrist..

Back in the days before high deductible health insurance plans, and high co-pays, I would have my patients come to the office once a week for debridement/trimming of the dead tissue on the wart, followed by treatment with the 70% salicylic acid and an occlusive dressing to keep on and dry until the next week. This was quite effective at wart resolution due to the consistency of professional care over time. However, the exorbitant cost of healthcare has also made it very difficult to treat warts this way.

Weekly debridement is best. However, professional debridement weekly is not financially feasible for many. In which case, using disposable Emory boards to sand down the overlying callus would be helpful once a week . Anything that touches the wart will be contaminated with wart virus, so anything used to debride the wart needs to be thrown away after use. I do not recommend patients trying to dig out the wart with any sharp instrument. Infections and painful scars can occur.

So why can’t warts just be numbed and removed ? If this is done, a painful scar can develop, when there is weightbearing after excision. Therefore, it is recommended to be nonweightbearing on the area of removal for two weeks . Also, the microscopic wart virus is still around in the area and can reinfect the skin. If it infects the scar, it can be exquisitely painful, and nearly impossible to resolve at that point. So , if you have excision done, it is normally coupled with a prescription antiviral topical to treat any virus that is still in the area and prevent recurrence of the wart.

*Immunotherapy:

Immunotherapy is the process of activating one’s immune system to eradicate skin tumors and cancers.

1. Over the counter topical medication:

Vircin

This contains salicylic acid and immune modulator and an antiviral component. This trifecta approach is effective in resolving warts overtime. Apply once a day up to 12 weeks. Let the product dry on the wart before applying a sock. It is designed not to require a dressing however, I always recommend in an occlusive dressing to enhance results. Success rate has been claimed to be 88%. I like this product about as much as I like the prescription topical Aldara listed below. I have found it very effective in my experience especially for multiple warts. It can be purchased via link below:

https://www.elcentrodermatology.com/store/p20/vircin-wart-treatment-containing-an-immunomodulator-salicylic-acid-antiviral.html

Cost is $45.

2. Prescription, topical treatments:

Efudex cream:

Efudex ( 5-fluorouracil) is a cream that can interfere with DNA formation and stop growth of wart . It is also used to treat some skin cancers. This can be used twice a day applying with the Q-tip to the wart, and under an occlusive dressing. This would need to be used for approximately 8-12 weeks . The debridement of the wart should be done at least once a month during the treatment as well..

Cost is around $35.

I would use this in combination with salicylic acid and an occlusive dressing. My patient would be advised to apply the salicylic acid and the Efudex as well as keeping an occlusive dressing on the wart. I would recommend sharp debridement in the office once a month.

Aldara ointment ( imiquimod)

This activates the immune cells and the inflammatory process to attack the wart. It can directly kill the wart virus. It was developed to treat genital warts, but is used commonly for plantar warts. It comes in packets and is applied to the wart five days a week or every other day under an occlusive dressing. I typically have my patient supply salicylic acid on the days when Aldara is not used. Again, I will have the patient return once a month for a sharp debridement.

Cost is about $56-$64 for a pack of 30 cream packets. They are small packets but maybe able to use one packet to treat 2-3 times.

I have found much more favorable results with the Aldara vs. Efudex .

For treating warts which are extremely stubborn, it normally takes consistent, faithful treatment for at least two -three months to see results .

3. Swift microwave treatment

This is a new treatment and uses low microwave energy to trigger the immune system to eradicate the wart. It takes a few minutes in the doctor’s office. Multiple treatments are needed. It is recommended that treatment is done monthly up to three treatments. After this, the claims are that the wart gradually shrinks over a period of six weeks to nine months. It appears to be a promising treatment about 83% success rate. I do not have experience with this device. It is an extremely expensive machine for a doctor to purchase. It costs around $28,000 and does not have health insurance coverage as of now. Therefore treatments are expensive and run between $250-$295 per session.

If I had a stubborn wart, I would first try vircin or the prescription topicals plus 40% salicylic acid for 8 weeks, if the wart is not resolving, then I would look into the swift microwave treatment or curettage and laser.

3. Surgical Curettage with pulsed dye laser

The wart is numbed with local anesthesia and scooped out with a dermal curette. Then a laser is used. The light heats up the blood vessels in the wart destroying what’s left of the wart . There will be a wound and non-weightbearing for 2-3 weeks is recommended to prevent a scar.

I always use Aldara or Efudex for at least a month afterward to prevent any wart virus hanging around from setting up shop again.

This treatment is highly effective and I think in my entire career I’ve only had 2 recurrences after this treatment. The problem is that a laser device is very expensive so many doctors cannot afford it . Therefore, this is done many times in a surgical center or hospital that has a laser. Sometimes small community hospitals do not have this laser .

Pictures of warts as they are being treated :

Adjunctive treatment: For sweaty feet with warts, I will order drysol to dry this up. Sweaty feet foster growth of the wart and carries the virus to other parts of the foot . One can use underarm antiperspirant on the foot as well.

Other Treatments:

This is not an all inclusive list of available treatments just what I found has worked over the years. I used Bleomycin a few times . This is a chemotherapy drug that is injected directly into the wart and is like the immunotherapy wart medications mentioned above . It was very effective in irradicating the warts. But the treatment is expensive and very painful . Other topical chemicals like canthrone and trichloroacetic acid work well but are also painful.

Treatments that have not worked:

Lastly, I do not recommend freezing warts off ( liquid nitrogen) . I have never seen this work on foot warts and is painful to have done. It creates a blister which is painful when walking and I just couldn’t justify using it . The liquid nitrogen over the counter, in my opinion, is just a waste of money. I think the ineffectiveness is due to the thickness of the skin on the foot. This method seems to work elsewhere on the body.

Over my career, I have curated my offered treatments to the least painful , most effective, and as cost effective possible. However , patients are individuals and treatment plans also must be flexible and personalized not to mention all the obstacles that health insurance throw up .

To end on a positive note, once warts are effectively treated and your body mounted an immune response to them, it will recognize and destroy the virus should it ever try to infect the foot again. So, recurrence is highly unlikely. Hip Hip -Hooray!

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

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Thank-you!

Melissa Gaffney, DPM

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