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Original Article

Evaluating the Efficacy of 100% Trichloroacetic Acid Needling

in the Treatment of Palmoplantar Warts
Priyanka Bodar, Pooja Agarwal, Siddhartha Saikia, Tejansu Dalal, Ashish Jagati
Department of Skin and VD, Smt. NHL Municipal Medical College, Smt. SCL General Hospital, Ahmedabad, Gujarat, India

Abstract
Introduction: Warts are benign proliferations of skin and mucosa caused by the human papillomavirus (HPV). Palmoplantar warts are caused
any HPV types 1, 2, 4, 27, 57 and occurs mostly in children and young adults. Among the treatment modalities, trichloroacetic acid (TCA)
application along with needling after sufficient penetration causes coagulation of proteins of the infected cells of skin and causes necrosis. Aim:
To study the efficacy of 100%TCA needling in the treatment of palmoplantar warts. Study Design: Longitudinal study carried out at a tertiary
care center in Gujarat. Materials and Methods: Patients having palmoplantar warts between the age group of 4-50 years over a period of 8
months were included in the study as per our inclusion and exclusion criteria. 100% TCA application followed by needling using an insulin
syringe was done once per week after informed consent. The necrosed skin was pared on each follow-up and the procedure was repeated till
complete clearance of warts. Results: The total number of patients were 60 out of which 6 patients were irregular in follow up. In 4 patients,
the treatment modality was changed after 6 weeks because of lack or response. 50 patients had complete clearance of warts. The minimum and
maximum duration for complete clearance of warts were 3 weeks and 8 weeks respectively. Limitation: It gives varying results in different
individuals and average duration in clearance of wart is comparatively slower as compared to some other methods. Conclusion: TCA needling
is an effective treatment modality for palmoplantar warts.

Keywords: Children, trichloroacetic acid needling, warts

Introduction be caused by HPV‑1, 4, 27, and 57.[3] The incidence increases

during the school years to reach a peak in adolescence and early
Warts or verrucae are benign proliferations of the skin or mucosa
adulthood, then declines rapidly through the twenties and more
that are caused by infection with human papillomavirus (HPV).[1]
gradually thereafter. Currently, available treatment modalities
HPV is a double‑stranded DNA virus, and to date, over 118
for warts include topical agents, such as salicylic acid (12%–
types of HPV have been identified.[2] Warts are spread by direct
26%) with lactic acid paint, podophyllotoxin, trichloroacetic
or indirect contact. For infection to occur, the HPV virus particle
acid (TCA), 5‑fluorouracil, photodynamic therapy, and surgical
needs to come into contact with a stem cell in the basal layer
modalities such as cryosurgery, electrosurgery, laser ablation,
of the epidermis. Thus, impairment of the epithelial barrier
and surgical excision. Oral drugs such as levamisole, cimetidine,
function, by trauma (including mild abrasions), maceration,
zinc sulfate, and local immunotherapeutic agents, including
or both, greatly predisposes to inoculation of the virus and is
imiquimod, contact sensitizers, intralesional interferons, have
generally assumed to be required for infection at least in fully
also been used.[4] Treatment of warts is often difficult, and most
keratinized skin. Higher incidence of palmar warts in certain
of the commonly available treatments are destructive leading
occupations, such as handlers of meat and poultry and plantar
to trauma and scarring. Modalities such as electrocautery and
warts in people using common swimming pools and showers,
validates this theory.
Address for correspondence: Dr. Pooja Agarwal,
The time of acquisition of the infection can seldom be ascertained. Department of Skin and VD, Smt. SCL General Hospital, Smt. NHL Municipal
Palmoplantar warts are mainly caused by HPV‑2, but can also Medical College, Ahmedabad, Gujarat, India.
E‑mail: pooja.kgmc@gmail.com
Submitted: 25-Jun-2019 Revised: 04-Mar-2020 Accepted: 20-Apr-2020 Published: 23-Jun-2020

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DOI: How to cite this article: Bodar P, Agarwal P, Saikia S, Dalal T, Jagati A.
10.4103/ijdd.ijdd_38_19 Evaluating the efficacy of 100% trichloroacetic acid needling in the treatment
of palmoplantar warts. Indian J Drugs Dermatol 2020;6:13-6.

© 2020 Indian Journal of Drugs in Dermatology | Published by Wolters Kluwer - Medknow 13

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Bodar, et al.: Trichloroacetic acid needling in treatment of palmoplantar warts

cryotherapy are painful and are often difficult to use in children.

TCA is a topical destructive agent and causes coagulation of
cellular proteins leading to cell death. It is effective in treating
common, cervical, genital, and anal warts in the concentrations of
70%–80% and has response rates comparable to cryotherapy.[5,6]
The advantage is the complete lack of systemic toxicity, less
pain, and earlier healing time. However, a few local side effects
such as pain, burning, hyperpigmentation, and rarely, a scar
formation may occur. This study was undertaken to study the
effectiveness of 100% TCA application followed by needling
in the treatment of palmoplantar warts.
Figure 1: Complete clearance of palmar warts at 5 weeks
Materials and Methods
This was a prospective study conducted over a period of
10  months from March 2018 to December 2018 in the
department of dermatology of a tertiary care center in Gujarat.
A total of 60 patients having palmoplantar warts in the age
group of 4–50 years were included in the study at their first
visit. The patients unwilling to follow‑up regularly, pregnant
and lactating women, immunosuppressed individuals, and
patients who had received any other treatment for warts in the
month prior were excluded from the study. After taking written
informed consent, the patient’s detailed history and clinical
examination were noted. Baseline characteristics of the wart
including site, size, and number were evaluated at the start of
Figure 2: Complete clearance of palmar warts at 6 weeks
the study and subsequently at weekly intervals till complete
clearance of the lesions. Photographic documentation was done
at the beginning and every follow‑up visit. Patients who had
complete clearance of lesions were followed up for further
3 months to note any recurrence. On first visit application of
100% TCA followed by needling with an insulin syringe on
each palmoplantar wart was done. Needling was done to up
to the appearance of pinpoint bleeding points. No paring was
done at the first visit. This was repeated weekly, and only the
necrosed tissue was pared on follow‑up without inducing any
bleeding points. This procedure was repeated until complete
clearance of warts. No other drugs like immune supplements
were given.
Figure 3: Complete clearance of plantar warts at 7 weeks
Results
A total of 60 patients were enrolled in the study. Six of them Plantar warts accounted for 25 (46.3%) cases, palmar warts
were lost to follow‑up at different stages, and 54  patients accounted for 19 (33.9%) cases, and both palmar and plantar
were available for evaluation. There was complete clearance warts were seen in 10 (18.5%) cases.
of warts in 50 (92.6%) patients [Figures 1‑3]. The treatment Thirty‑five  (64.8%) patients had  <5 warts, 17  (31.5%)
modality was changed after 6 weeks in 4 (7.4%) patients due patients had 5–10 warts, and only 2 (3.7%) had ≥10 warts.
to lack of response. Of 54 patients, 32 (59.3%) were males The patients who had  <5 warts  (n  =  35) had complete
and 22 (40.7%) were females. clearance in a mean duration of 4.3 weeks, the patients who
had 5–10 warts (n = 17) had complete clearance in a mean
Most of the patients belonged to the age group of <20 years,
duration of 4.9 weeks, and two patients who had ≥10 warts
accounting for 53.7% of cases followed by 20–40  years,
had complete clearance in a mean duration of 8 weeks. Thus,
which accounted for 31.5% of cases. The youngest patient
we observed that the mean duration needed for complete
was 4 years, and the oldest patient was 50 years (mean age:
clearance of warts increased with increase in number of warts
20.8 years).
at the baseline. Most of the patients (61%) had the disease
The majority of patients (48%) were students by occupation. duration of 3–6 months, 37% had warts for <3 months, and

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Bodar, et al.: Trichloroacetic acid needling in treatment of palmoplantar warts
the remaining had warts for  ≥6  months. The mean disease
duration was 3.2 months.
The minimum duration for complete clearance of warts was
3  weeks, and the maximum duration was 8  weeks  (mean
duration for complete clearance – 4.6 weeks).
Side effects noticed included burning sensation on application
of TCA which lasted only for the duration of the procedure.
Postinflammatory hyperpigmentation after healing was also
noted in two patients. No other postprocedural complications
were noted.
Fifty patients who had complete clearance of warts were
followed up for further 3  months, and no recurrence was
observed in any of the patients.
Discussion
A multitude of therapies is available for the treatment of
common warts, with varying degrees of success ranging from
the old‑age destructive treatment to cryotherapy and the newly
emerging therapies such as pulsed dye laser, intralesional
immunotherapy, and autoinoculation therapy.[5,7,8] One of the
most important shortcomings of most of these methods is that
many of them are not 100% successful.
Chemical cauterization provides a useful approach in the
treatment of warts in patients where pain is a major limiting
factor. TCA causes destruction of tissue by causing coagulation
of proteins in the cells and thus destroying the cells. It has the
added advantage of not being absorbed systemically, and white
frosting develops within a few minutes of the application,
which indicates the end point. Burning and itching sensations
are often accompanied by the application of TCA, whereas
ulceration leading to secondary infection and subsequent
scarring are the rare side effects of TCA application.[9]
Falknor first explained a direct needling procedure as a
treatment modality for warts in the form of inciting physical
trauma without use of any chemicals  (excluding the use of
local anesthesia).[10] His method consisted of anesthetizing
the verruca, then thrusting a needle in “dart fashion,” so as
to penetrate the full depth of the verruca and exiting through
the base of the capsule into the fat to induce a controlled
inflammatory response. He claimed only two recurrences of
126 lesions treated with this technique. Subsequent published
research using this method has been sparse. Skilton and Mehar
published a case series of 14 patients with painful verrucae
who were treated with the needling technique wherein
they claimed complete resolution in 50% of the cases after
an 8‑week review.[11] In our study, we have combined the
application of 100% TCA with needling method with the
intention of combining two different mechanisms with which
the palmoplantar warts may be cleared and thereby increase
the rate of clearance of warts.
In the study by Nischal et al., 55% patients were females and
[12]
45% were males. In our study, 59.3% were males and 40.7%
Indian Journal of Drugs in Dermatology  ¦  Volume 6 ¦ Issue 1 ¦ January-June 2020
were females. This slight male preponderance could be due to
more outdoor exposures (occupation, sports etc.).
The mean age in that study was 8.32 ± 1.54 years as compared
to our study where it was 20.8 years.[12]
In a study done by Pezeshkpoor et al., patients with verruca
vulgaris were treated with either 80% TCA (group A) or 35%
TCA (group B) once per week until complete clearance of the
lesions or for a maximum duration of 6 weeks. The results
showed a significant difference in improvement between the
two treatment groups, and the improvement was greater with
higher concentration of the solution (80% TCA).[6]
Salicylic acid is a keratolytic agent which causes the cells of
the epidermis to shed more readily and allows room for new
cell growth. Various studies have compared cryotherapy with
salicylic acid for the treatment of plantar and hand warts.
They showed that cryotherapy is equally effective as salicylic
acid in the treatment of warts.[13,14] However, on reviewing the
literature, we were unable to find a study which compared
salicylic acid with TCA for palmoplantar warts. Cryotherapy
was found to be more effective than 90% TCA for the treatment
of common warts in a study done by Abdel et al. However,
90% TCA had lesser complications than cryotherapy.[15] The
scenario on the other hand differed when a similar study was
done for plantar warts. In a study done by Cengiz et al., in
which the effectiveness and safety profile of 40% TCA and
cryotherapy were compared for plantar warts, they found that
40% TCA was more effective for clearance of plantar warts
with a better safety profile.[16]
The British Association of Dermatologist’s guidelines suggests
50%–80% TCA weekly application for 8 weeks for treating
hand warts.[17]
Ten percent of KOH has been found to be effective in the
treatment of plane warts by Khan et al.[18] However, due to the
difference in the HPV type between plane warts and palmoplantar
warts, and the lack of a similar study of 10% KOH application
done for palmoplantar warts, it would not be fair to compare these
two modalities until further studies are established.
In our present study, 92.6% of patients had complete clearance
of warts with from 3rd week onward. We also observed that
patients having a greater number of warts required increased
the duration for complete clearance of warts. The only side
effect which we noticed was burning sensation during the
procedure itself which lasted only for the duration that the TCA
needling was done. No recurrence of warts was seen during
the 3‑month follow‑up period after complete clearance of
lesions. To the best of our knowledge, no similar study which
evaluates the efficacy of 100% TCA with needling in palmar
and plantar warts has been published to date in the literature.
Conclusion
This study has shown that 100% TCA needling is a highly
effective and relatively painless procedure for the treatment of
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Bodar, et al.: Trichloroacetic acid needling in treatment of palmoplantar warts
palmoplantar warts. This may be used as a primary treatment
modality in palmar and plantar warts in children where
intralesional injections or electrosurgery are limited due to the
pain. Further studies are warranted with a larger sample size.
Limitations
A control group with Falknor’s needling method alone
could have been taken to compare the efficacies of the two
methods. Furthermore, it gives varying results in different
individuals, and the average duration in the clearance of wart
is comparatively slower as compared to some other methods.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Lowy DR, Androphy EJ. Warts. In: Freedberg IM, Eisen AZ, Wolf K,
Austen KF, Goldsmith LA, Katz SI, editors. Fitzpatrick's Dermatology
in General Medicine. Vol. 4, 6th ed. New York: McGraw-Hill; 2003.
p. 2119-30.
2. de Villiers  EM, Fauquet  C, Broker  TR, Bernard  HU, zur Hausen  H.
Classification of papillomaviruses. Virology 2004;324:17‑27.
3. Sterling JC. Virus infections. In: Burns T, Breathnach S, Cox
N, Griffiths  C, editors. Rook's Textbook of Dermatology. 8th ed.
Massachuesttes: Blackwell Science; 2010. p. 33.1-33.78.
4. Dasher DA, Burkhart CN, Morrell DS. Immunotherapy for childhood
warts. Pediatr Ann 2009;38:373‑9.
5. Godley MJ, Bradbeer CS, Gellan M, Thin RN. Cryotherapy compared
with trichloroacetic acid in treating genital warts. Genitourin Med
1987;63:390‑2.
6. Pezeshkpoor  F, Banihashemi  M, Yazdanpanah  MJ, Yousefzadeh  H,
16 Indian Journal of Drugs in Dermatology  ¦  Volume 6  ¦  Issue 1  ¦  January-June 2020
Sharghi  M, Hoseinzadeh  H. Comparative study of topical 80%
trichloroacetic acid with 35% trichloroacetic acid in the treatment of the
common wart. J Drugs Dermatol 2012;11:e66‑9.
7. Sharquie  KE, Al‑Rawi  JR, Al‑Nuaimy  AA, Radhy  SH. Bacille
Calmette‑Guerin immunotherapy of viral warts. Saudi Med J
2008;29:589‑93.
8. Lal  NR, Sil  A, Gayen  T, Bandyopadhyay  D, Das  NK. Safety and
effectiveness of autoinoculation therapy in cutaneous warts: A double—
blind, randomized, placebo‑controlled study. Indian J Dermatol Venereol
Leprol 2014;80:515‑20.
9. Damstra  RJ, van Vloten  WA. Cryotherapy in the treatment of
condylomata acuminata: A controlled study of 64 patients. J Dermatol
Surg Oncol 1991;17:273‑6.
10. Falknor  GW. Needling  – A new technique in verruca therapy. A  case
report. J Am Podiatry Assoc 1969;59:51‑2.
11. Skilton  B., Mehar  Z. Needling: A  treatment option for recalcitrant
verrucae pedis. Podiatry Now 2011;14:21‑5.
12. Nischal  KC, Sowmya  CS, Swaroop  MR, Agrawal  DP, Basavaraj  HB,
Sathyanarayana  BD. A  novel modification of the autoimplantation
therapy for the treatment of multiple, recurrent and palmoplantar warts.
J Cutan Aesthet Surg 2012;5:26‑9.
13. Bunney MH, Nolan MW, Williams DA. An assessment of methods of
treating viral warts by comparative treatment trials based on a standard
design. Br J Dermatol 1976;94:667‑79.
14. Steele K, Irwin WG. Liquid nitrogen and salicylic/lactic acid paint in
the treatment of cutaneous warts in general practice. J R Coll Gen Pract
1988;38:256‑8.
15. Abdel Meguid AM, Abdel Motaleb AA, Abdel Sadek AMI. Cryotherapy
vs trichloroacetic acid 90% in treatment of common warts. J  Cosmet
Dermatol 2019;18:608‑13.
16. Cengiz  FP, Emiroglu  N, Su  O, Onsun  N. Effectiveness and safety
profile of 40% trichloroacetic acid and cryotherapy for plantar warts.
J Dermatol 2016;43:1059‑61.
17. Sterling  JC, Handfield‑Jones  S, Hudson  PM, British Association of
Dermatologists. Guidelines for the management of cutaneous warts. Br
J Dermatol 2001;144:4‑11.
18. Khan S, Zeeshan HM, Mushtaq F. Efficacy of 10% KOH in palmoplantar
warts. Pak J Med Health Sci 2017;11:553‑5.