Maximizing the Effectiveness of Wart Removal in Children


Mr Monroe is a dermatology physician assistant at Dawkins Dermatology in Oklahoma City.


Photo Essay

While we can work near-miracles with many medical conditions, the humble wart continues to be one of the most frustrating ailments we are called on to treat. Many choices are available for treating warts—at last count, more than 20—and that alone indicates that there wouldn’t be so many therapies if any one of them were perfect. Alas, all of our treatment choices for warts are hampered by such problems as pain, scarring, and blistering, or worse yet, by relative ineffectiveness. In all likelihood, someday we’ll be able to prevent most warts by immunizing children against human papillomavirus (HPV), but until then, we have to work with the tools we have.

Cryotherapy with liquid nitrogen (LN2) is the mainstay of wart treatment in dermatology offices in the United States because of its definite advantages over a number of other treatment options. With LN2, there is no blood, no needles, little potential for scarring, a usually bearable level of pain, and excellent effectiveness. Nevertheless, the perception of pain is very much subjective: What some might call tolerable, others might find completely unacceptable, and what a 10-year-old might be able to tolerate, a 6-year-old may well not. (In fact, many adults find liquid nitrogen cryotherapy quite painful, and I’m one of them.)

Perhaps more importantly, even if a patient happily tolerates cryotherapy, by no means does cryotherapy guarantee clearance, and it certainly does not prevent the patient from developing new warts elsewhere. The HPV that causes warts finds some individuals to be more susceptible than others, flying under their immune system’s radar, persisting or multiplying despite most of our attempts at treatment. This susceptibility can be inherited and often is connected to the patient’s atopic state. Persons with atopy often have thin, sensitive skin that does a poor job of fighting most skin infections. Hyperhidrosis of the hands or feet also seem to put a patient at risk for the development of warts.


Figure 1 – A plantar wart on the right heel before removal with liquid nitrogen using a cryosurgery gun. Children with thicker plantar warts may have better therapeutic outcomes if the keratotic surface is pared down with a scalpel before cryotherapy.


Cryotherapy of warts with LN2 was introduced into common usage in the early 1970s and has since become an indispensible treatment choice. As with every treatment option for warts, however, LN2 has shortcomings, with pain and blistering chief among them. Moreover, as with every other wart treatment modality, therapeutic failures with LN2 are common.

A number of factors can affect treatment outcomes with LN2, including the thickness of the wart. Nevertheless, limitations imposed by pain outweigh most other factors. Here are a few tips to help minimize the pain and maximize the therapeutic effectiveness of cryotherapy for warts.


Figure 2 – While cryosurgery kits come with a shield with holes of various sizes to concentrate the liquid nitrogen for different sizes of warts, the same can be accomplished with an otoscope ear speculum. The tip of the disposable plastic speculum can be trimmed as much as needed to create a bigger hole. This allows targeting of only the wart and avoids overspray onto surrounding skin.


Handheld liquid nitrogen spray guns are far more effective and efficient at wart removal compared with applying LN2 with cotton swab and are no more painful if they are used correctly.


Using the gun correctly means concentrating the spray on its intended target and avoiding surrounding tissues. Cryosurgery guns come with a 4-inch round, plastic shield that has a variety of hole sizes to accommodate different sized warts. The appropriately sized hole is placed over the wart, pressing firmly to ensure a tight seal, and then LN2 is sprayed briskly through the hole onto the wart.

The same thing can be accomplished by holding an ear speculum onto the wart and spraying LN2 through it onto the skin (Figures 2 and 3). For larger warts, the speculum tip can be trimmed back to create a bigger orifice. For thicker plantar warts, the keratotic surface can be pared down with a No. 10 scalpel blade before cryotherapy.

Cryosurgery guns come with at least 3 different tip sizes to adjust the spray volume and a 3-inch wand tip for reaching difficult places such as around the eyes or nostrils.


Figure 3 – Each individual application of liquid nitrogen with a cryosurgery gun rarely last for more than 4 seconds. Still, those seconds can seem like an eternity for many children, so consider counting the seconds aloud to signal that there’s an end to their pain.


Using the template holes or specula as described, the duration of cryotherapy for a given lesion averages approximately 4 seconds and seldom exceeds 5 seconds, except for plantar warts, which tend to be thicker. With younger patients, consider counting the seconds out loud with the patients, so they know there is an end to the pain.

Consider treating plantar warts or other thicker lesions twice, a few seconds apart, to optimize effectiveness. I bring back most patients with plantar warts monthly to check and retreat as needed.


Figure 4 – Significant blistering is a likely adverse effect of cryosurgical wart therapy, and it likely will take several days for the skin to heal. Be sure to educate children and their parents about wart cryosurgery’s adverse effects and any possible activity restrictions that may be necessary before beginning the procedure. Let them know that treatment is optional, since most warts resolve with no treatment given enough time.


Before you begin to treat a child’s warts, consider spending some time educating the patient and his or her parents about the nature of the warts, the difficulty in treating them, and the risks and benefits involved. For example, make sure the child and family members understand that considerable blistering is likely to result and will take several days to resolve. Participation in activities such as sports may therefore need to be limited temporarily.

Finally, make sure everyone involved understands a very basic fact: Warts—especially minor warts—don’t have to be treated. Almost all of them eventually will go away on their own. They are not worth torturing a child over.