‘Warts and All’ - Consider Even Definitive Salvage Radiotherapy for Recalcitrant Adult Viral Warts

Recalcitrant adult viral warts can cause significant functional and cosmetic impacts. A 60-year-old adult male with a five-year history of recurrent, recalcitrant, and progressive warts of both hands had failed prior treatments with laser, cryotherapy, and topical therapies. Salvage radiotherapy (RT) was considered. RT volumes were administered to gross disease only with the margin to field edge dependent on modality. Using superficial radiotherapy (SXRT) with beam quality of half value layer of 1.9 millimeters aluminium equivalent, an area on the dorsum of the non-dominant (left) hand measuring 4 x 3 centimetres (cm) received 19.8 Gray (Gy) to skin surface in 11 daily fractions of 1.8 Gy. When little reaction was noted, the fraction size was increased to 3 Gy, delivering another nine fractions to 27 Gy, giving a total dose of 46.8 Gy. Wart lysis, erythema, and desquamation healed over four weeks, this complete response (CR) continuing at more than two years. We then considered SXRT dose of 50 Gy in 20 fractions over four weeks to be the correct SXRT dose. A further 39 areas were treated with SXRT over a year with continuing CR, continuing for at least a year following the last area treated. A larger area of 11 × 4 cm on the dorsum of his dominant right hand received 60 Gy in 24 fractions using Volumetric Arc Therapy (VMAT) had CR also continuing at two years post treatment. Radiotherapy to a high dose may be considered for salvage of recalcitrant adult viral warts. More research is needed.