Mazandaran University of Medical Sciences

Warts caused by the human papillomavirus (HPV) are one of the most common skin conditions among children. The prevalence of warts in school-aged children ranges from 10 to 20 percent. Warts are more common among immunocompromised patients [1, 2]. Some studies also show that the prevalence of viral warts in the pediatric population increases with age, peaking in adolescence. HPV is a DNA virus that replicates only in fully differentiated epithelial cells. More than 80 types of HPV have been identified. Types 27, 57, 2, and 1 are the most common types of HPV in skin warts in the general population. Warts usually affect patients of different age groups and various parts of the body, causing physical and psychological complications for patients (such as pain, discomfort, and embarrassment), which in turn lead to functional impairment. Warts often affect pressure points on the soles of the feet. Although most warts are asymptomatic, plantar warts are often associated with pain while walking, causing physical and psychological stress [3].
Various treatments such as keratolytic agents, cryotherapy, laser, antimitotic treatments, contact sensitizers, and intralesional injection of antigen have been used. There is no evidence that one treatment is superior to others, and in many cases, treatment of viral warts requires a combination of treatments. Treatment selection for patients should be based on variables such as wart size, number of lesions, anatomical location, patient preference, cost, convenience, side effects, and operator experience. It is important to emphasize that good communication between the patient, parents, and dermatologist is essential for successful treatment in children [2, 4].
Despite having various treatment approaches, treating plantar warts is challenging. No single treatment is effective in most patients, treatments are often painful, and they are associated with a high recurrence rate. Although nearly 75 percent of warts can resolve spontaneously within two years, patients often seek treatment for cosmetic reasons and pain. Many studies have examined the use of vitamin D compounds (calcipotriol) and 5-fluorouracil in wart patients separately or in combination with other drugs, but only one recent case report that tested the combination of these two showed very positive efficacy results [5, 6].
In 2009, Gladsjo et al. conducted a randomized clinical trial to evaluate the therapeutic effect of 5% fluorouracil cream in children (4 to 18 years old) with skin warts. In this study, 40 children with skin warts, each having at least two warts on their hands, were enrolled. Patients were randomly assigned to one of two groups: once-daily application of the cream or twice-daily application. Patients and their parents were instructed to gently file each wart with an emery board before applying a small amount of 5% 5-FU cream with a cotton-tipped applicator. The primary outcome of the study was the complete clearance of study warts. Clinical evaluations were performed at baseline and after 1 week, 3 weeks, and 6 weeks of treatment. 88 percent of treated warts cleared after 6 weeks of treatment, and 41 percent of individuals cleared at least one wart. There was no difference in treatment response between once-daily and twice-daily application. No significant blood levels of 5-fluorouracil were detected in any subject. At the 6-month follow-up, 87 percent of complete responders had no wart recurrence. They concluded that 5% fluorouracil cream is a safe, effective, and well-tolerated treatment for warts in children [1].
To date, no clinical trial has evaluated the combination of calcipotriol and 5-fluorouracil. Additionally, given that common current treatments such as cryotherapy are painful for children, achieving an effective, pain-free intervention is necessary. This study aims to evaluate the efficacy and side effects of the combination of 5-fluorouracil and calcipotriol in children (ages 4 to 18) with palmar and plantar warts in a randomized, double-blind, placebo-controlled clinical trial.