Patient Information
The study focused on a cohort of 17 participants suffering from refractory plantar warts (PWs). These patients represented a clinically challenging demographic, as all had previously failed standard-of-care treatments, including topical salicylic acid, cryotherapy, and laser interventions. The persistent nature of their lesions had resulted in significant physical discomfort and psychological distress. On average, the patients presented with multiple lesions (a total of 236 lesions across the 17 participants), indicating a high viral load or significant immune evasion by the human papillomavirus (HPV).
Diagnosis
Diagnosis was established through clinical examination by board-certified dermatologists. Key diagnostic features included the presence of hyperkeratotic papules on the plantar surface of the feet, disruption of normal skin lines (dermatoglyphics), and the presence of ‘seeds’ or thrombosed capillaries observed upon paring of the hyperkeratotic tissue. The refractory nature was confirmed by a documented history of non-responsiveness to at least two different destructive modalities over a period of six months or longer.
Differential Diagnosis
During the diagnostic phase, several conditions were considered and ruled out:
- Clavus (Corns): Ruled out by the presence of punctate hemorrhages upon debridement and the loss of skin striae, which are characteristic of warts but absent in corns.
- Callus: Ruled out as the lesions were focal and exhibited the classic cauliflower-like texture of verrucae rather than simple diffuse hyperkeratosis.
- Verrucous Carcinoma: Although rare, this was considered in cases of extreme recalcitrance; however, the clinical presentation and response to treatment favored a viral etiology.
- Molluscum Contagiosum: Ruled out due to the specific plantar location and hyperkeratotic morphology.
Treatment and Management
The intervention involved a daily, 30-minute immersion of the affected area in a saturated saline solution. Saturated saline was prepared by dissolving common salt (NaCl) in warm water until no more salt could be dissolved. The protocol was as follows:
- Preparation: Participants were instructed on how to prepare the saturated solution at home.
- Immersion: The feet were soaked for 30 minutes every evening for a duration of 8 weeks.
- Debridement: Gentle removal of softened hyperkeratotic tissue was permitted but not required as a primary mechanical intervention.
- Monitoring: Patients were monitored for adverse effects such as skin irritation, erosion, or pain. Notably, the treatment was described as painless and noninvasive, a significant departure from destructive methods like liquid nitrogen cryotherapy.
Outcome and Prognosis
The results of the 8-week trial were highly significant. At the lesion level, 98.3% (232 out of 236) of the warts cleared completely. At the participant level, 15 out of 17 (88.2%) achieved complete remission (95% CI 63.3% to 97.4%). All participants who achieved clearance remained lesion-free during a 6-month follow-up period, indicating a lack of short-term recurrence. The prognosis for these previously refractory cases was excellent, with high patient satisfaction due to the lack of treatment-induced pain or scarring.
Discussion
The management of plantar warts remains a therapeutic dilemma. Standard destructive treatments often cause pain and secondary infections, leading to poor patient compliance and high recurrence rates. This trial suggests that saturated saline immersion is a viable, low-cost, and painless alternative. The mechanism of action likely involves the osmotic effect of hypertonic saline, which may induce cellular dehydration in the HPV-infected keratinocytes, potentially disrupting the viral microenvironment and stimulating a local immune response.
Compared to existing literature, which cites success rates for cryotherapy between 50-70% often requiring multiple painful sessions, the 88.2% remission rate observed here is exceptional for a refractory population. The lack of recurrence over six months is particularly noteworthy, as HPV often remains latent in surrounding tissue. However, the study’s single-arm design and small sample size are limitations. Future randomized controlled trials (RCTs) are necessary to compare saline immersion directly against placebo or standard therapies to establish it as a primary clinical guideline.
References
1. Xu Y, Li T, Liang X, et al. Saturated saline immersion for the treatment of refractory plantar warts: An open-label, one-arm, single-center trial. J Am Acad Dermatol. 2026;94(2):525-529. doi:10.1016/j.jaad.2025.10.014.
2. Sterling JC, et al. British Association of Dermatologists’ guidelines for the management of cutaneous warts 2014. Br J Dermatol. 2014;171(4):696-712.
3. Kwok CS, et al. Topical treatments for cutaneous warts. Cochrane Database Syst Rev. 2012;9:CD001781.