* Flat warts may result in a considerable cosmetic concern and fear of spread and contagiousness.
* May represent a therapeutic challenge and occasionally dilemma especially in children with face involvement.
* Shaving and hair epilation should be abandoned if relevant areas are involved.
* Golden rule: with any treatment modality, at least 3 months of management is considered a reasonable therapeutic trial. So no treatment should be stopped too quickly.
* Put in mind that flat warts frequently undergo spontaneous remission, so
avoid potentially scarring therapies.
* For few lesions you may consider:
1. Light cryotherapy.
2. Topical salicylic acid products (up to 20% concentration).
3. Tretinoin cream once or twice daily, in the highest concentration tolerated to produce mild erythema of the warts.
4. Tazarotene cream or gel.
5. Imiquimod 5% cream used up to once daily can be effective. If the warts fail to react initially to the imiquimod, tretinoin may be used in conjunction.
6. 5-FU cream 5%, applied twice daily, may be effective (in resistant cases).
* For refractory lesions:
1. laser therapy in very low fluences or photodynamic therapy (PDT) might be considered before electrodesiccation because of the reduced risk of scarring.
2. Immunomodulatory therapy: Ranitidine, 300 mg twice daily or Cimetidine (25–40 mg/kg).
3. Immunotherapy: using:
* Dinitrochlorobenzene (DNCB)
* Squaric acid
* Intralesional Candida or other antigens
These can be used on limited areas of flat warts, with the hope that the immune response will clear distant warts.
4. Oral isotretinoin therapy at 30 mg/day/ 3 months might be considered when the previous topical approaches have failed.