Verruca needling: what it involves, who it is for and how well it works

A verruca is a wart on the sole of the foot caused by human papillomavirus (HPV). NICE's Clinical Knowledge Summary describes warts as growths caused by infection of skin cells with the virus, which may clear spontaneously at any time or persist for years. Needling is one of several treatments aimed at the ones that persist or hurt.

In needling, a podiatrist or other trained clinician numbs the foot, then uses a sterile needle to puncture the verruca many times. The NHS Grampian leaflet explains that this physically breaks down the verruca tissue and prompts an immune response. In plain terms, the aim is to damage the wart and draw the body's defences to it, so that the virus is recognised and cleared.

Needling is not usually the starting point. The Grampian leaflet says you may need it if you have painful or long-standing verrucae which have not responded to any other treatment, such as treatment with acids. NICE CKS similarly places topical salicylic acid and cryotherapy (freezing) as the standard options in primary care, and lists referral to a dermatologist for persistent warts that do not respond.

Guy's and St Thomas' notes that there are no guaranteed treatments for verrucae, that painless verrucae are best left untreated since some treatments can cause pain, especially in children, and that people with diabetes or low immunity should not self-treat and should see a podiatrist. It lists cryotherapy, needling and Swift therapy as the more invasive options that a registered podiatrist can discuss.

Availability is not something these leaflets can answer for your area, so ask your GP or local podiatry service whether needling is offered, and by whom, before assuming it is.

The NHS Grampian leaflet gives the outline. The clinician administers a local anaesthetic so that the area is completely numb, then repeatedly punctures the verruca with a sterile needle. A sterile dressing is placed over the area afterwards.

The leaflet asks you to stop taking any anti-inflammatory medication for 3 days before and 3 days after treatment, which is a point worth confirming with the clinician who is treating you, since practices differ and you should not stop prescribed medicines without advice.

The leaflet says that if the area becomes uncomfortable, the sterile dressing can be removed and replaced with an adhesive plaster. A red or brown discolouration may appear under the skin, which it describes as dried blood and completely normal.

Other aftercare, such as how long to keep the dressing on and when to return to exercise, comes from the clinician who treated you and varies. Infection is one of the listed risks, so if the area becomes increasingly painful, red or starts to discharge, contact the clinic or your GP.

The Grampian leaflet lists the potential risks as infection affecting the site of injection or needling, an adverse reaction to the local anaesthetic, and the procedure not curing the verrucae. It frames the potential benefit as destroying the verruca, which may reduce the risk of it spreading.

It also sets out what can happen if a verruca is left untreated: increased pain from the hard skin over it, spread to other sites on the feet, and spread to other family members. Whether that is a reason to treat depends on how much it troubles you, which is why the decision is made with the clinician rather than by rule.

The best-known UK trial is EVerT2, a single-centre randomised trial published in the British Journal of Dermatology in 2017. It recruited 60 adults with a plantar verruca and compared needling with debridement of the overlying callus. Fifty-three were included in the main analysis.

At 12 weeks the index verruca had cleared in 4 of 28 people in the needling group (14.3%) and 4 of 25 in the debridement group (16.0%). The authors concluded there was no evidence that needling was more clinically or cost effective than callus debridement, although pain outcomes were significantly better after needling.

Two cautions apply. The trial was small and run in one centre, so it cannot settle the question, and clearance rates were low in both groups, which fits the general message that verrucae are stubborn. The better pain outcome is a reason some people consider needling, but the trial did not show that it clears verrucae faster.

Guy's and St Thomas' recommends salicylic acid preparations from a pharmacy for painful or spreading verrucae, protecting the surrounding skin and stopping if the skin becomes sore. It suggests that gently rubbing down overlying hard skin may ease discomfort, and advises covering a verruca with a waterproof plaster for swimming, wearing flip-flops in communal showers, and not sharing socks or towels.

The Grampian leaflet notes that if you decide against needling, other options may include managing the verrucae yourself using ointments and gels from your local pharmacist.