Therapeutic pearl: A simple thermo-sclero-keratolytic therapy for recalcitrant periungual viral warts

PROBLEM STATEMENT

Periungual warts with subungual infiltration are not uncommon over nail units. These warts are recalcitrant and represent a therapeutic challenge. Various modalities of treatment have proven effective with variability. Moreover, most of these therapies are costlier, painful and not easily available. The periungual and subungual warts, at times, are resistant to the given treatments. Hyperthermia (44°C for 30 minutes per day for 8 to 12 weeks) that works on micro-auto-immunization, is a good option for treating multiple viral warts.¹ However, it is a time consuming procedure. Intralesional hypertonic saline (15% NaCl) as sclerosing agent is effective in treating prolabial mucoceles,² and topical table salt (NaCl) has been used for treating pyogenic granuloma.³ The surfaces of the naturally resolving warts are seen studded with fine black dots which are thrombosed and sclerosed feeding capillaries of the warts. On this ground, hot (heat and auto-inoculation therapy) hypertonic solution (sclerotherapy) with keratolytic agent (wart debulking therapy) has been used as a fast, cost effective, less painful modality of treatment for chronic periungual wart.

RECOMMENDED SOLUTION

For treating the wart, the keratolytic agent (Lactic Acid 16.66% Salicylic Acid 16.66%) was applied once daily at night along with bearable hot saturated table salt solution (35.9 percent) twice daily with a cotton ball for 5 minutes for 4 weeks [Figure 1a]. The patient was followed up every 2 weeks for 12 weeks to observe the changes in the lesion . For finger periungual and subungual warts, the finger can be dipped in this solution for 5 minutes. The volume of the wart decreased, feeding capillaries got thrombosed (sclerosed) and were seen as black dots on the surface of residual lesions after 2 weeks [Figure 1b]. The lesion resolved within 4 weeks without sequelae [Figure 1c]. The treatment was well tolerated. There was no side effect or recurrence observed at the site. The saturated hypertonic saline solution (35.9%) is made by dissolving 40 to 50 gram table salt in 100 ml of tap water and its saturation can be judged by the residual undissolved salt at bottom of the container. This solution can be used till it is consumed in 10 to 15 days or more.

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Figure 1:

(a) A large periungual wart with nail involvement. (b) The wart after 2 weeks of therapy. (c) The wart got resolved in 4 weeks having no signs of wart lesions at 6 weeks.

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Thus hot home-made hypertonic saline with keratolytic agent seems to be a fast, effective, cheap and safe treatment modality for recalcitrant periungual warts. This combination could be useful for treating the common viral warts on other parts of the body. To judge its effectiveness, this combination therapy should be tried to a larger number of patients.