Topical treatments for cutaneous warts

Warts in pediatric oncology patients: A single-institution retrospective study

BACKGROUND

Pediatric oncology patients undergoing cancer treatment can often have numerous and recalcitrant cutaneous warts due to their underlying immunosuppression. There are little published data on the optimal management of warts in pediatric oncology patients undergoing active cancer treatment compared to patients having completed treatment. Our objective was to analyze the clinical course of warts treated within this patient population at Boston Children's Hospital over a 10-year period.

METHODS

This was a single-institution retrospective study of 72 pediatric oncology patients from 1 September 2011 to 1 September 2021 who were treated for warts at Boston Children's Hospital. All patients had a diagnosis of cutaneous warts with at least one follow-up visit and were receiving active treatment for cancer either during or after concurrent treatment of their warts. We examined the modality and effectiveness of wart treatments while both on and offactive treatment of their cancer.

RESULTS

The median age was 12 years (range 4-18). Fifty-four percent of patients were documented to have plantar warts. Sixty percent of patients with a documented number of warts had more than five warts at presentation. For cases in which outcomes were specified, treatment resulted in complete resolution of warts in only 24.0% of patients undergoing active cancer treatment compared to 63.3% of patients not on active treatment. Warts persisted or worsened in 56.0% of patients undergoing active cancer treatment compared to only 13.4% of patients not on active treatment.

CONCLUSION

These data may help guide clinicians in evaluating and treating warts in pediatric oncology patients.

Outcomes of nurse-led cryotherapy treatment for viral warts

Cryotherapy is a cost-effective treatment that can be performed by non-dermatologists for viral warts, which are very common.1,2 The National University Hospital, Singapore runs a nurse-led wart clinic where nurses are trained to administer cryotherapy. This study reviewed eradication rates and side effects in patients treated at the nurse-led wart clinic.

A Study of Comparison and Evaluation of Various Intralesional Therapies in Cutaneous Warts

Background

The study compares the efficacy of four immunotherapeutic agents, measles mumps and rubella (MMR), purified protein derivative (PPD), Candida extract, and vitamin D3, in the treatment of multiple cutaneous warts.

Aim and Objectives

To observe the clinical responses and safety of different intralesional immunotherapeutic agents and compare their efficacy.

Materials and Methods

Hundred patients with multiple (>5) cutaneous warts were enrolled in the study and randomized into four groups: Group A: MMR, Group B: PPD, Group C: Candida extract, and Group D: Vitamin D. Target wart was selected, and the intralesional injections were given at three weekly intervals for a maximum of three doses. Response was observed in target and distant warts three months after the last injection.

Results

Intralesional vitamin D3 had the highest efficacy, while MMR had the lowest efficacy in clearance of target wart. Intralesional Candida extract had the highest efficacy, while vitamin D3 had the lowest efficacy in clearance of distant warts. Intralesional Candida extract was the most effective treatment for both local and distant warts. Side effects were minimal and transitory in nature.

Conclusion

Intralesional immunotherapy is a safe, affordable, and efficacious treatment for warts.

Relevant Dermatoses Among U.S. Military Service Members: An Operational Review of Management Strategies and Telemedicine Utilization

Despite skin being the largest and most exposed organ of the human body, skin issues can be challenging to diagnose in deployed military service members. Common reasons deployed soldiers seek dermatological evaluation include infections, inflammatory skin conditions, and skin growth. Due to limited access to specialized care in deployed settings, dermatological conditions are undertreated and underdiagnosed. As a result, dermatological conditions are a leading contributor to decreased combat effectiveness among deployed medical forces. To lessen the burden of dermatological diseases, military providers should promptly identify operational skin diseases and alleviate modifiable barriers faced by service members. In a post-pandemic era with novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and monkeypox infections, the duty to effectively treat operational skin lesions is ever important. The need for military dermatologists continues to rise as the global landscape continues to evolve with unprecedented infections and increased bioterrorism threats. Teledermatology offers many solutions to mitigate the high demand for dermatologists during pandemics. Dermatological consultations account for the highest number of telemedicine visits in the US Military Health System (MHS). As such, increased utilization of teledermatology will reduce infection-related dermatological sequelae and prevent the medical evacuation of service members from military operations. This review collates and categorizes relevant dermatological conditions encountered among deployed personnel. This report outlines the standard of care and modified treatments recommended according to potential barriers faced in operational settings.

Use of Contact Immunotherapy in the Treatment of Skin Diseases Other than Alopecia Areata

For decades, contact immunotherapy with dinitrochlorobenzene, diphencyprone, and squaric acid dibutylester has played an important role in both clinical practice and scientific research. It is listed as the first-line treatment for extensive alopecia areata and was more recently approved for melanoma treatment as an orphan drug in the USA. Moreover, owing to the relative low cost and safety, topical immunotherapy has also been used in many infectious, neoplastic, and inflammatory dermatological diseases. It is especially valuable in vulnerable groups, for cosmetic/pain sensitive areas, or for multiple lesions. In this review, we summarize the current evidence supporting the use of contact immunotherapy for treatment of skin diseases, from articles collected from PubMed database. Owing to space limitation and already numerous studies focusing on alopecia areata, we include only skin diseases other than alopecia areata. In addition to diseases that have been reported to be treated by contact immunotherapy, the hypothesized mechanism, prognosis prediction, efficacy, and safety of these topical agents are discussed.

Aspects of Antiviral Strategies Based on Different Phototherapy Approaches: Hit by the Light

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which caused the COVID-19 pandemic spreading around the world from late 2019, served as a ruthless reminder of the threat viruses pose to global public health. The synthesis of new antiviral drugs, as well as repurposing existing products, is a long-term ongoing process which has challenged the scientific community. One solution could be an effective, accessible, and rapidly available antiviral treatment based on phototherapy (PT). PT has been used to treat several diseases, and relies on the absorption of light by endogenous molecules or exogenous photosensitizers (PS). PT has often been used in cancer treatment and prophylaxis, and as a complement to established chemotherapy and immunotherapy in combined therapeutic strategy. Besides significant applications in anticancer treatment, studies have demonstrated the beneficial impact of PT on respiratory, systemic, emerging, and oncogenic viral infections. The aim of this review was to highlight the potential of PT to combat viral infections by summarizing current progress in photodynamic, photothermal, and photoacoustic approaches. Attention is drawn to the virucidal effect of PT on systemic viruses such as the human immunodeficiency virus and human herpes viruses, including the causative agent of Kaposi sarcoma, human herpes virus (HHV8). PT has good potential for disinfection in anti-norovirus research and against pandemic viruses like SARS-CoV-2.

Oral florid papillomatosis: Topical treatment with 5% imiquimod in orabase

Background

Florid oral papillomatosis is characterized by its tendency to local recurrence that requires multiple treatments, leading to important functional sequelae.

Methods

We present 74‐year‐old woman with oral florid papillomatosis (OFP) who refused a new surgical treatment, and was treated with imiquimod 5% in orabase on alternate days for 16 weeks. Treatment was complemented with application of hyaluronic acid gel.

Results

There were no side effects to the treatment, nor signs of local recurrence, in the treated area at 2 years of follow‐up.

Conclusions

After reviewing the literature and according to our knowledge, this is the first published case of oral florid papillomatosis treated topically with imiquimod 5% successfully. Topical treatment with imiquimod 5% in orabase may be a valid alternative for patients with recurrent OFP located in the anterior area of the oral cavity who refuse surgical treatment, although we must closely monitor the patient for the possibility of recurrence or malignant degeneration.

Sequential Use of CO2 Laser Prior to Nd:YAG and Dye Laser in the Management of Non-Facial Warts: A Retrospective Study

Background and Objectives: Warts are benign lesions of viral etiology characterized by a hyperkeratotic appearance tending to spread across the skin surface. Various treatments have been proposed to manage this condition, such as acids, imiquimod, photodynamic therapy, cryotherapy, and various lasers. Materials and Methods: In this paper, we describe a combination protocol using CO₂ laser prior to Nd:YAG laser for lesions interesting the palmoplantar areas or dye laser for lesions on other skin surfaces in the management of non-facial warts resistant to traditional therapies. In total, 34 patients with 103 warts suffering from wart infection resistant to traditional therapies treated from 1 January 2019 to 1 June 2020 were retrospectively enrolled at the Dermatological Unit of Magna Graecia University (Catanzaro, Italy). Two dermatologists measured clinical results, classifying lesions with complete resolution, partial resolution, or non-responding. Patients at four months follow-up were asked to evaluate their degree of satisfaction with a visual analog scale (VAS). Results: Almost all patients reported the complete resolution of lesions, with no patient reporting scarring. Five patients reported hypopigmentation in the treated areas. The mean satisfaction level was high. Only three patients experienced a relapse of the condition. Conclusions: Using a vascular laser following a CO₂ superficial ablation of warts may help reduce the risk of scarring and decrease the incidence of relapses for lesions resistant to traditional therapies. Therefore, more extensive studies will be necessary to confirm the obtained results.

Safety and Efficacy of FIT039 for Verruca Vulgaris: A Placebo-Controlled, Phase I/II Randomized Controlled Trial

Trial design

Human papillomavirus infection causes verruca vulgaris. CDK9 inhibitor FIT039 inhibits DNA virus proliferation in animal models. We conducted a multicenter, single-blind, placebo-controlled, randomized phase I/II clinical trial evaluating the safety and efficacy of FIT039 against verruca vulgaris.

Methods

Target lesions were treated with liquid nitrogen once, and a FIT039 patch or placebo patch was applied for 14 days. The primary endpoint was lesion disappearance. The secondary endpoints were safety and changes in dimension, cross-sectional area, and the number of petechial lesions.

Results

A total of 24 participants were randomly allocated to the FIT039 (n = 13, median age, 54 years) and placebo (n = 11, median age, 62 years) groups. Verruca vulgaris did not disappear. FIT039 decreased the dimension to 76% of the initial value on day 29, followed by an increase to 98% on day 57. Placebo showed a monotonic increase to 107% on day 57. Changes in the cross-sectional area and petechiae number were comparable between the groups.

Conclusions

No drug-related adverse reactions occurred. FIT039 efficacy was not determined in this study.

From the Cochrane Library: Topical Treatments for Cutaneous Warts

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Intralesional Bleomycin for the Treatment of Resistant Palmoplantar and Periungual Warts

INTRODUCTION

Periungual, palmar, and plantar warts are difficult to treat with poor treatment response. Intralesional (IL) bleomycin has shown promising results for their treatment in a few reports. However, we need further evidence before opting it for treating difficult sites and resistant warts. Hence, we conducted this study to assess the efficacy and safety of IL bleomycin for the treatment of resistant palmoplantar and periungual warts.

METHODS

In this retrospective study, we included all patients who were given IL bleomycin for warts over a year. Maximum three sittings of bleomycin (1 mg/ml) were given monthly, and they were followed up for 3 months after the procedure. The response was categorized as complete, near-complete, significant, moderate, mild, and no clearance for 100%, 75-99%, 50-74%, 25-49%, 1-25%, and 0% clearance, respectively.

RESULTS

Out of 29 patients, follow-up details were available only in 19 patients (53 warts). The mean duration was 2.5 ± 1.47 years. The number of past interventions ranged from 2-4. Wart clearance after the first intervention was complete in 36.84%, near-complete in 26.31%, significant in 26.31%, and moderate in 10.53%. Wart clearance after the last intervention was complete in 89.47% and near-complete in 10.52% of patients. However, during 3 months of follow-up after the last injection, 15.78% had a recurrence. None of them had severe local and systemic side effects.

CONCLUSIONS

IL bleomycin could be a better treatment option for the treatment of resistant and difficult warts. However, we observed a higher recurrence rate even in a shorter follow-up. Hence, we need further studies with larger samples.

Management of Difficult-to-Treat Warts: Traditional and New Approaches

Warts are regularly treated by dermatologists, and while many respond readily to first-line treatments, others may represent a therapeutic challenge. Large, deep, numerous, and extensive warts; treatment-resistant lesions with higher risk for side effects, such as hypopigmentation; or patients unable to tolerate or comply with our treatment regimen, may need alternative treatment options. In this work we review the characteristics of select modalities that should be considered for difficult-to-treat warts. We discuss efficacy and tolerability data as well as practical features that can guide us to select the best treatment for every scenario. Novel approaches, still in an investigational phase, are also discussed to illustrate potential future directions of wart treatment.

Update on human papillomavirus - Part II: complementary diagnosis, treatment and prophylaxis

In this nonsystematic review, the complementary diagnosis, treatment, prevention, and control of human papillomavirus are discussed. The histopathology is addressed regarding its indications, main findings and limitations, as a complementary diagnostic method largely used by dermatologists. Electron microscopy is briefly reviewed, along with its contribution to the accumulated knowledge on HPV, as well as the relevance of research in using this technology for future advances in diagnosis and treatment. Molecular information about the virus is continuously increasing, and the practical applications of HPV serology, molecular identification and genotyping are discussed. Vaccines are a valuable tool in primary HPV infection prevention and are now available in many countries; their composition, indications, and adverse effects are revisited. Local and systemic treatment options are reviewed and off-label prescriptions are discussed. Finally, health education focusing on HPV infection as a sexually transmitted infection of worldwide relevance and the many barriers to improve primary and secondary prevention are addressed.

Finding possible pharmacological effects of identified organic compounds in medicinal waters (BTEX and phenolic compounds)

Medicinal thermal waters consist of a mixture of different organic and inorganic compounds. Traditionally, these waters are only characterized and classified by their inorganic composition; however, the bioavailability of the majority of these inorganic compounds is limited. Many authors investigate the organic fractions of thermal waters. These authors propose that these compounds have a potential effect on health. To elucidate the underlying mechanisms, it is crucial to know the composition of the organic fractions. The absorption of these compounds on intact skin or mucosa is notable. Some of them have local anaesthetic effect or affect receptors in the central nervous system. In the knowledge of the chemical composition, we are able to estimate the possible pharmacological effect or might be able to assess possible toxicity risks. In the present article, we aim to review possible health effects of two of the identified organic fractions: benzene and alkylbenzenes and phenolic compounds that might correlate with the therapeutic effect on rheumatological or other diseases.

Topical 15% Zinc Oxide Ointment Significantly Reduces the Size of Common Warts After Four Weeks: A Randomized, Triple-blinded, Placebo-controlled Trial

Background: There are limited number of topical agents for the treatment of common warts. Few reports show efficacy of zinc oxide for such indication. Objectives: We sought to evaluate the efficacy of topical 15% zinc oxide ointment for the reduction in size of common warts. Materials and Methods: Sixteen patients with two comparable palmar warts or verruca vulgaris were randomized to receive either 15% zinc oxide ointment or placebo three times a day for four weeks. Diameter, surface area, and volume change of warts in both groups were used as objective assessments, while patient and physician assessments were also recorded. Results: At Week 4, zinc oxide significantly reduced the median surface area compared to baseline (P<0.037). However, when the median percent changes between groups were compared, there were no statistically significant differences. Conclusions: Zinc oxide can reduce the size of common hand warts after four weeks. We suggest that it can be used as an adjunctive therapy to enhance the efficacy of other treatments.

The efficacy of a cyclin dependent kinase 9 (CDK9) inhibitor, FIT039, on verruca vulgaris: study protocol for a randomized controlled trial

BACKGROUND

Human papilloma viruses (HPVs) infect squamous epithelial cells and form verrucous lesions, or warts. Besides the psychosocial problems caused by the disfiguring warts, a subset of HPVs can be the primary etiologic agent for malignancies such as cervical cancer. However, there is no curative antiviral therapy for HPV infection. We recently found that the viral RNA transcription of DNA viruses requires cyclin dependent kinase 9 (CDK9) in the host cells, and that FIT039, a specific inhibitor of CDK9, suppressed the proliferation of DNA viruses such as herpes simplex virus 1 (HSV-1), HSV-2, human adenovirus, human cytomegalovirus, hepatitis virus B, and HPVs. Here, we describe a protocol to evaluate the safety and antiviral effect of FIT039 on common warts in human skin.

METHODS AND DESIGN

A multi-institutional, single-blind, placebo-controlled randomized phase I/II clinical trial was designed to evaluate the safety and efficacy of FIT039 on common warts on the extremities. A total of 44 adults with a primary diagnosis of verruca vulgaris on the extremities without serious comorbidities will be randomized into either the intervention group with an FIT039-releasing transdermal patch or a control group for a duration of 14 days. Outcomes will be assessed at baseline and postintervention. Participants will be further assessed at 2 months follow-up. The primary endpoint for efficacy is the resolution of the warts. The safety endpoint is the incidence of adverse events and adverse drug reactions. The secondary endpoints are changes in the dimensions of the wart, the cross-sectional area of the wart, and the number of clots within the area of the wart.

DISCUSSION

This study is the first to assess the efficacy of FIT039 and will contribute to the development of antiviral agents that can cure refractory common warts in immunocompromised patients.

TRIAL REGISTRATION

UMIN Clinical Trials, UMIN000029695 . Registered on 1 November 2017.

Tattoos and human papilloma virus: A case report of tattoo-associated flat warts (verrucae planae)

The prevalence of tattoos is increasing and as such every physician must be aware of the potential adverse events associated with tattooing. Here we present a 36-year-old man with a recent history of skin-coloured papules appearing suddenly in a 20-year-old tattoo on the right forearm. Biopsy and histologic examination confirmed a diagnosis of verrucae planae or flat warts. Tattoo-associated human papilloma virus infections develop clinical manifestations after long latency periods and are often difficult to treat. The risk of tattoo-related human papilloma virus infection should be discussed when considering acquiring a tattoo.

Duct tape for warts in children: Should nature take its course?

Question I continue to see families in my practice with complaints of having common warts. Despite trying to convince them that no therapy is needed, children and parents ask for advice and therapy. Is duct tape truly effective for common warts, and how is it applied?Answer Common warts (verruca vulgaris) are extremely common in children and are caused by the human papillomavirus. These benign lesions will resolve spontaneously and no therapy is recommended. Evidence for duct tape effectiveness is limited, but because this therapy is safe and well tolerated, parents can try it at home, as well as try using salicylic acid patches. With duct tape therapy, apply a small piece of duct tape directly on the wart once every 4 to 7 days; then remove the tape, clean the area with soap and water, and remove the dead skin using an emery board. Apply another piece of tape 12 hours later. Repeat this cycle for 4 to 6 weeks.

Comparison of electrosurgery by electrodessication versus cryotherapy by liquid nitrogen spray technique in the treatment of plantar warts

Background

Warts or verrucae are benign proliferations of the skin and mucosa resulting from infection with papilloma viruses. Warts form a small subset of patients attending skin out-patient department (OPD), out of which the plantar warts are one of the common presentation. The present study is an attempt to compare two modalities of treatment that is electrosurgery and cryotherapy in patients with plantar warts. There are no studies available where comparison of complications between two modalities has been done in plantar warts thus making it one of unique studies of its kind.

Methods

A prospective, comparative study was conducted over a period of 6 years. After exclusion criteria, one hundred forty-seven male patients having plantar warts were included in the study. Selection of patients suffering from warts subjected to treatment was done by simple random selection. After treatment, 39 patients were lost to follow-up, and finally 48 patients treated by electrosurgery and 60 by cryotherapy were compared and analysed statistically for response to treatment and incidence of complications.

Results

The overall clearance rate was 75% in electrosurgery versus 73.3% in cryotherapy patients. The pain, delayed wound healing and scarring were observed significantly in more patients treated with electrosurgery than cryotherapy. In our study, recurrence at 24 weeks was observed in 21.9% of the electrosurgery patients which was slightly higher than cryotherapy, where it was 16.6%.

Conclusion

This study highlighted that cryotherapy is quick, safe and comparatively painless procedure with less complications with success almost similar to electrosurgery making it more suitable for plantar warts.

A randomized controlled proof-of-concept trial of digoxin and furosemide in adults with cutaneous warts

Background

Topical ionic contraviral therapy (ICVT) with digoxin and furosemide inhibits the potassium influx on which DNA viruses rely for replication. Therefore, ICVT was hypothesized to be a potential novel treatment for cutaneous warts.

Objectives

To assess the clinical efficacy, safety and tolerability of ICVT in adults with cutaneous warts. The secondary objective was to gain insight into the underlying working mechanism of ICVT.

Methods

Treatment with ICVT was assessed for efficacy, safety and tolerability in a single‐ centre, randomized, double‐blind, placebo‐controlled phase IIA trial. Eighty adult patients with at least two cutaneous warts (plantar or common) were randomized to one of four treatments: digoxin + furosemide (0·125%), digoxin (0·125%), furosemide (0·125%) or placebo. The gel was administered once daily for 42 consecutive days. Predefined statistical analysis was performed with a mixed‐model ancova. The trial was registered at ClinicalTrials.gov with number NCT02333643.

Results

Wart size and human papillomavirus (HPV) load reduction was achieved in all active treatment groups. A statistically significant reduction in wart diameter of all treated warts was shown in the digoxin + furosemide treatment group vs. placebo (−3·0 mm, 95% confidence interval −4·9 to −1·1, P = 0·002). There was a statistically significant reduction in the HPV load of all treated warts in the digoxin + furosemide group vs. placebo (−94%, 95% confidence interval −100 to −19, P = 0·03). With wart size reduction, histologically and immunohistochemically defined viral characteristics disappeared from partial and total responding warts.

Conclusions

This study demonstrates the proof of concept for the efficacy of topical ICVT in adults with cutaneous warts.

What's already known about this topic?

Cutaneous warts are caused by the human papillomavirus (HPV).

Ionic contraviral therapy (ICVT) might be a potential treatment for cutaneous warts.

A previous phase I/II open‐label study demonstrated the safety and efficacy of ICVT.

What does this study add?

Proof of concept for the efficacy of topical ICVT in adults with cutaneous warts.

Topical ICVT demonstrates a favourable safety profile, with the effects most pronounced when it is combined in a formulation for common warts.

Wart size reduction was related to HPV load reduction measured by quantitative polymerase chain reaction (qPCR) in swabs.

qPCR is a valuable disease biomarker for drug development in cutaneous warts.

https://doi.org/10.1111/bjd.17803 available online

https://www.bjdonline.com/article/

The Effectiveness of Cutaneous Wart Resolution with Current Treatment Modalities

Non-venereal warts are a frequent dermatological presentation with potential spontaneous regression in immunocompetent adults and children within 2 years. Evidence shows that conventional wart treatments are not a guaranteed treatment modality and can carry concerns regarding safety. The aim of this literature review was to identify the most effective treatments for wart resolution to guide clinical practice while identifying areas for further research.

A systematic literature review was performed to determine the current treatment modalities for non-anogenital cutaneous warts in immunocompetent individuals and their effectiveness. Articles were categorized into one of eight groups depending on anatomical location, population age, or recalcitrant status with ranked levels of evidence.

This literature review highlights a variety of treatments for non-venereal warts shown to be effective. In this instance where optimal evidence-based treatments are not available, clinical experience determines the most appropriate clinical practice.

Further reproducible immunotherapy research on wart resolution is required to enable clear comparisons of these treatment modalities to conventional methods. Future clinical practice will require the human papillomavirus type to target the wart treatment accordingly; however, further research is required to determine these correlations.

Sinecatechins ointment for the treatment of warts in children

BACKGROUND

Sinecatechins ointment, a green tea derivative, is a novel agent approved for the treatment of anogenital warts in immunocompetent adults and has been reported to be effective in treating extragenital warts as well. Data are lacking in children. We sought to determine the efficacy and tolerability of sinecatechins ointment for treating warts in children.

METHODS

A retrospective cohort study was conducted of children with anogenital and/or extragenital warts treated with sinecatechins ointment for at least 1 month. The primary outcome was frequency of complete response (total resolution of warts at follow-up). Secondary outcomes included frequency of partial response (reduction in number and/or size of warts) and adverse events. There was no control group for comparison.

RESULTS

Of 24 patients who met the inclusion criteria, 14 (58.3%) had anogenital warts, 7 (29.2%) had extragenital warts, and 3 (12.5%) had both anogenital and extragenital warts. Mean age at treatment initiation was 8.0 years (SD = 3.9). Median duration of warts at treatment initiation was 1.2 years (range 0.09-12.62). Sixteen patients (66.7%) experienced a reduction in the number and/or size of the warts. Four patients (16.7%) had complete resolution. Median treatment duration was 4.5 months (range 0.6-21.8) overall. Median time to complete resolution was 2.9 months (range 1.3-7.7). Fifty-four percent of patients used sinecatechins ointment as prescribed. Adverse events were limited to mild local irritation (7 patients; 29.2%).

CONCLUSION

Sinecatechins ointment is a promising therapy for warts in children, and its use should be evaluated in prospective controlled clinical trials.

Efficacy and Safety of Topical Cantharidin Treatment for Molluscum Contagiosum and Warts: A Systematic Review

BACKGROUND AND OBJECTIVE

Topical cantharidin is routinely used for the treatment of molluscum contagiosum and warts. The objective of this systematic review is to assess the efficacy and safety of topical cantharidin treatment for molluscum contagiosum and warts.

METHODS

We performed a systematic review of studies assessing topical cantharidin treatment of molluscum contagiosum or warts. We searched the databases of Cochrane, EMBASE, GREAT, LILACS, MEDLINE, and Scopus. Two authors performed the study selection and data extraction.

RESULTS

Twenty studies (1958-2018) met inclusion/exclusion criteria. Twelve studies assessed warts, and eight studies assessed molluscum contagiosum. Overall, 1752 patients were included (range 0.3-62 years; specified in 15 studies). Clearance rates with topical cantharidin for molluscum contagiosum were variable (range 15.4-100%). Significant clearance of warts with maintenance of clearance was demonstrated with topical cantharidin alone. Topical cantharidin in combination with podophyllotoxin and salicylic acid demonstrated efficacy for plantar warts (pediatric and adult; clearance rate range 81-100%; four studies had 100% clearance), with the majority clearing after a single treatment. Satisfaction with cantharidin therapy was high, especially in molluscum contagiosum. Pain (7-85.7%), blistering (10-100%), and hyper-/hypopigmentation (1.8-53.3%) were the most commonly occurring adverse effects with cantharidin treatment.

CONCLUSION

Topical cantharidin demonstrated clearance of warts, particularly in combination with podophyllotixin and salicylic acid, and modest benefit for pediatric molluscum contagiosum with good tolerability and safety.

Opportunities and challenges for human papillomavirus vaccination in cancer

The discovery of genotype 16 as the prototype oncogenic human papillomavirus (HPV) initiated a quarter century of laboratory and epidemiological studies that demonstrated their necessary, but not sufficient, aetiological role in cervical and several other anogenital and oropharyngeal cancers. Early virus-induced immune deviation can lead to persistent subclinical infection that brings the risk of progression to cancer. Effective secondary prevention of cervical cancer through cytological and/or HPV screening depends on regular and widespread use in the general population, but coverage is inadequate in low-resource settings. The discovery that the major capsid antigen L1 could self-assemble into empty virus-like particles (VLPs) that are both highly immunogenic and protective led to the licensure of several prophylactic VLP-based HPV vaccines for the prevention of cervical cancer. The implementation of vaccination programmes in adolescent females is underway in many countries, but their impact critically depends on the population coverage and is improved by herd immunity. This Review considers how our expanding knowledge of the virology and immunology of HPV infection can be exploited to improve vaccine technologies and delivery of such preventive strategies to maximize reductions in HPV-associated disease, including incorporation of an HPV vaccine covering oncogenic types within a standard multitarget paediatric vaccine.

Models and applications for measuring the impact of health research: update of a systematic review for the Health Technology Assessment programme

BACKGROUND

This report reviews approaches and tools for measuring the impact of research programmes, building on, and extending, a 2007 review.

OBJECTIVES

(1) To identify the range of theoretical models and empirical approaches for measuring the impact of health research programmes; (2) to develop a taxonomy of models and approaches; (3) to summarise the evidence on the application and use of these models; and (4) to evaluate the different options for the Health Technology Assessment (HTA) programme.

DATA SOURCES

We searched databases including Ovid MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and The Cochrane Library from January 2005 to August 2014.

REVIEW METHODS

This narrative systematic literature review comprised an update, extension and analysis/discussion. We systematically searched eight databases, supplemented by personal knowledge, in August 2014 through to March 2015.

RESULTS

The literature on impact assessment has much expanded. The Payback Framework, with adaptations, remains the most widely used approach. It draws on different philosophical traditions, enhancing an underlying logic model with an interpretative case study element and attention to context. Besides the logic model, other ideal type approaches included constructionist, realist, critical and performative. Most models in practice drew pragmatically on elements of several ideal types. Monetisation of impact, an increasingly popular approach, shows a high return from research but relies heavily on assumptions about the extent to which health gains depend on research. Despite usually requiring systematic reviews before funding trials, the HTA programme does not routinely examine the impact of those trials on subsequent systematic reviews. The York/Patient-Centered Outcomes Research Institute and the Grading of Recommendations Assessment, Development and Evaluation toolkits provide ways of assessing such impact, but need to be evaluated. The literature, as reviewed here, provides very few instances of a randomised trial playing a major role in stopping the use of a new technology. The few trials funded by the HTA programme that may have played such a role were outliers.

DISCUSSION

The findings of this review support the continued use of the Payback Framework by the HTA programme. Changes in the structure of the NHS, the development of NHS England and changes in the National Institute for Health and Care Excellence's remit pose new challenges for identifying and meeting current and future research needs. Future assessments of the impact of the HTA programme will have to take account of wider changes, especially as the Research Excellence Framework (REF), which assesses the quality of universities' research, seems likely to continue to rely on case studies to measure impact. The HTA programme should consider how the format and selection of case studies might be improved to aid more systematic assessment. The selection of case studies, such as in the REF, but also more generally, tends to be biased towards high-impact rather than low-impact stories. Experience for other industries indicate that much can be learnt from the latter. The adoption of researchfish^® (researchfish Ltd, Cambridge, UK) by most major UK research funders has implications for future assessments of impact. Although the routine capture of indexed research publications has merit, the degree to which researchfish will succeed in collecting other, non-indexed outputs and activities remains to be established.

LIMITATIONS

There were limitations in how far we could address challenges that faced us as we extended the focus beyond that of the 2007 review, and well beyond a narrow focus just on the HTA programme.

CONCLUSIONS

Research funders can benefit from continuing to monitor and evaluate the impacts of the studies they fund. They should also review the contribution of case studies and expand work on linking trials to meta-analyses and to guidelines.

FUNDING

The National Institute for Health Research HTA programme.

The Diagnosis and Treatment of Nail Disorders

BACKGROUND

Nail disorders can arise at any age. About half of all nail disorders are of infectious origin, 15% are due to inflammatory or metabolic conditions, and 5% are due to malignancies and pigment disturbances. The differential diagnosis of nail disorders is often an area of uncertainty.

METHODS

This review is based on publications and guidelines retrieved by a selective search in PubMed, including Cochrane reviews, meta-analyses, and AWMF guidelines.

RESULTS

Nail disorders are a common reason for derma - tologic consultation. They are assessed by clinical inspection, dermatoscopy, diagnostic imaging, microbiological (including mycological) testing, and histopathological examination. Some 10% of the overall population suffers from onychomycosis, with a point prevalence of around 15%. Bacterial infections of the nails are rarer than fungal colonization. High-risk groups for nail disorders include diabetics, dialysis patients, transplant recipients, and cancer patients. Malignant tumors of the nails are often not correctly diagnosed at first. For subungual melanoma, the mean time from the initial symptom to the correct diagnosis is approximately 2 years; this delay is partly responsible for the low 10-year survival rate of only 43%.

CONCLUSION

Evaluation of the nail organ is an important diagnostic instrument. Aside from onychomycosis, which is a common nail disorder, important differential diagnoses such as malignant diseases, drug side effects, and bacterial infections must be considered.

Efficacy of pulsed dye laser treatment for common warts is not influenced by the causative HPV type: a prospective study

Verruca vulgaris (VV) is a prevalent skin condition caused by various subtypes of human papilloma virus (HPV). The most common causes of non-genital lesions are HPV types 2 and 4, and to a lesser extent types 1, 3, 26, 29, and 57. Although numerous therapeutic modalities exist, none is universally effective or without adverse events (AE). Pulsed dye laser (PDL) is a favorable option due to its observed efficacy and relatively low AE rate. However, it is not known which verrucae are most likely to respond to PDL, or whether the causative viral subtype influences this response. The objective of this prospective blinded study was to assess whether the HPV subtype was predictive of response to PDL. For that matter, 26 verrucae from 26 immunocompetent patients were biopsied prior to treatment by PDL. HPV coding sequences were isolated and genotyped using PCR analysis. Patients were treated by PDL (595 nm wavelength, 5 mm spot size, 1.5 ms pulse duration, 12 J/cm² fluence) once a month for up to 6 months, and clinical response was assessed. Binary logistic regression analysis and linear logistic regression analysis were used in order to evaluate statistical significance. Different types of HPV were identified in 22 of 26 tissue samples. Response to treatment did not correlate with HPV type, age, or gender. As no association between HPV type and response to PDL therapy could be established, it is therefore equally effective for all HPV types and remains a favorable treatment option for all VV.

Topical ionic contra-viral therapy comprised of digoxin and furosemide as a potential novel treatment approach for common warts

Background

DNA viruses such as HPV rely on K⁺ influx for replication. Both digoxin and furosemide inhibit the K⁺ influx by interacting with cell membrane ion co‐transporters (Na⁺/K⁺‐ATPase and Na⁺‐K⁺‐2Cl⁻ co‐transporter‐1, respectively). We therefore hypothesized that these two compounds in a topical formulation may be valuable in the treatment of HPV‐induced warts. This new approach is called Ionic Contra‐Viral Therapy (ICVT).

Objective

To evaluate systemic exposure, safety and tolerability of ICVT with a combination of furosemide and digoxin after repeated topical application in subjects with common warts. Furthermore, we aimed to evaluate pharmacodynamics effects of ICVT.

Methods

Twelve healthy subjects with at least four common warts on their hands were included in the study and treated with a fixed dose of 980 mg topical gel containing 0.125% (w/w) digoxin and 0.125% (w/w) furosemide for 7 consecutive days on their lower back to assess safety and systemic exposure. Two warts were treated with 10 mg each and two served as negative controls to obtain preliminary evidence of treatment effect.

Results

ICVT was well tolerated topically, and there was no evidence of systemic exposure of digoxin or furosemide. There were no clinical relevant safety findings and no serious adverse events (SAEs). A rapid and statistically significant reduction in diameter, height and volume of the warts was already observed at day 14.

Conclusion

ICVT was found to be safe for administration to humans and 7 days of active treatment showed a statistical significant wart reduction compared to untreated control lesions, clearly indicating pharmacological activity.

Successful treatment of plantar warts with intralesional bleomycin and electroporation: pilot prospective study

BACKGROUND

Numerous studies have been performed to evaluate the efficacy of intralesional bleomycin for the treatment of warts with inconsistent result. Nevertheless, it is well known that the cytotoxicity of bleomycin can be enhanced in vivo by 300 to 700-fold by electroporation.

OBJECTIVE AND METHODS

In this article, we present an interventional, one-center, prospective case series, clinical trial of the effectiveness of intralesional bleomycin combined with electroporation for the treatment of plantar warts, in comparison to the use of intralesional bleomycin alone.

RESULTS

The study's cohort included 12 men and 10 women, with a mean age of 53.8 years. A total of 22 warts were treated. In dividing the patients in two groups (complete remission against all the others) and analyzing the different outcomes in the two arms of patients, a statistical significant difference was found (p=0.0015), proving a greater efficacy of the treatment with bleomycin combined with ECT as opposed to bleomycin alone. Electroporation was always well tolerated by the patients with no discomfort.

CONCLUSIONS

This study serves as a basis for the application of novel protocols in the treatment of different benign and locally malignant skin lesion by means of electroporation.

Real versus sham proximal biofield therapy in the treatment of warts of the hands and feet in adults: study protocol for a randomized controlled trial (MAGNETIK study)

Background

Despite the lack of scientific studies on biofield therapies, they are widely acclaimed by patients. The mechanisms of action are not explained by current allopathic medical approaches. Warts are common and contagious viral lesions that may be refractory to standard dermatologic treatments such as cryotherapy, laser therapy, and keratolytic ointments. Biofield therapies are efficient in various pathologies. Their ability to treat warts has never been demonstrated in a scientific study with a robust methodology. Patients with refractory warts often place their trust in these alternative therapies because of the poor results obtained from traditional medicine. We propose a prospective, randomized, single-blind, assessor-blind trial to evaluate the efficacy of treatment of warts by biofield therapy.

Methods/design

Subjects with warts on their feet or hands will be randomized into two groups: real biofield therapy versus sham therapy. The diagnosis will be made at the time of inclusion, and follow-up will take place in week 3. Comparison of pictures of the warts at baseline and after 3 weeks will be used as the primary outcome measure. The hypothesis is that the extent of the disappearance of the original wart in the group treated by real biofield therapy will be 70% and that it will be 30% in the group treated by sham therapy. Using 90% power and an alpha risk of 5%, 31 subjects are required in each group for a two-tailed proportion comparison test.

Discussion

To our knowledge, this is the first study to evaluate the efficacy of biofield therapy on warts. Therefore, the aim of this study is to extend knowledge of biofield therapy to another area of medicine such as dermatology and to propose complementary or alternative practices to improve patient well-being. The main strength of the study is that it is a randomized, single-blind, assessor-blind, placebo-controlled study.

Trial registration

ClinicalTrials.gov identifier: NCT02773719. Registered on 22 April 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1994-4) contains supplementary material, which is available to authorized users.

[Caustic necrosis due to topical formic acid 85% (Objectif ZeroVerrue(®))]

BACKGROUND

Formic acid 85% constitutes the active substance of a new wart removal agent marketed in France under the name of Objectif ZeroVerrue(®), a product sold over-the-counter for adults and children aged over four years, and on a doctor's recommendation for children aged under four years. Its mechanism of action may involve cellular destruction through dehydration.

PATIENTS AND METHODS

Herein we report two cases of cutaneous necrosis following application of formic acid 85%. One case was severe, affecting the extremity of the middle finger and involving the underlying extensor apparatus in a girl aged 3 and a half years. This necrosis required the creation of a pedicled fasciocutaneous flap and temporary arthroereisis.

DISCUSSION

The precautions for use set out in the information leaflet for this preparation based on formic acid must be strictly adhered to by patients. In particular, only one application should be made per week, taking care to avoid adjacent skin. It is essential to suspend treatment if the skin is still erythematous after the previous application, and the treated area must not be occluded with bandages. Doctors must be aware of the risk of necrosis, since their recommendation is required for children under the age of four years.

Promising New Wart Treatment: A Randomized, Placebo-Controlled, Clinical Trial

Background

Warts are common dermatological lesion caused by skin epithelial cells’ infection with human Papillomavirus (HPV).

Objectives

This study aimed to assess the efficacy of a new method for the treatment of dermal warts.

Patients and Methods

In this clinical trial study, 60 patients (older than 10 years) with dermal warts living in Baneh city, west of Iran, were allocated into the intervention and control groups using the block randomized method in 2012. In the intervention group, outer layers of the dermal wart carved using scalpel and HD tablet set on it and covered with adhesive. In the second and third days, it was repeated again. All stages in the intervention group were similar to the placebo group. Placebo was prepared by a pharmacologist, which was similar to the HD tablet. In both groups, patients were examined one week and one month after taking the last tablet by the physician in terms of improvement or lack of improvement. Data were analyzed by SPSS software version 18 using chi-square test, Fisher’s exact test, Mann-Whitney test and ANOVA for repeated measures.

Results

In the first week after the intervention, warts were changed in 93.3% of the cases; however, no changes were recorded in the control group. One month after follow-up, the mean was 0.4 ± 0.7 in the intervention group and 5.5 ± 4.9 in the control group (P = 0.0001). Based on ANOVA for repeated measures and t-test, the average number of warts, before, one week and one month after the intervention was statistically significant for both intervention (P = 0.009) and control groups (P = 0.0001).

Conclusions

This method is recommended for the treatment of dermal warts, owing to the effectiveness, short duration of treatment, and low cost of topical treatment for dermal warts using HD tablets.

EVerT2-needling versus non-surgical debridement for the treatment of verrucae: study protocol for a single-centre randomised controlled trial

INTRODUCTION

Verrucae are extremely common, and are experienced by most people at some time during their lives. Although most verrucae will spontaneously disappear without treatment, many patients seek treatment, often because they have persisted for many years, are unsightly or painful or prevent them from doing sports or other activities. There are many different treatments available; including the Falknor's needling procedure. To date, there has only been one small trial evaluating the clinical effectiveness of this treatment and no health economic analysis has been undertaken. The Effective Verruca Treatments (EVerT2) trial aims to evaluate the clinical and cost-effectiveness of the needling procedure for the treatment of verrucae.

METHODS AND ANALYSIS

This single-centre randomised controlled trial will recruit 58 participants (aged 18 years and over with a plantar verruca) from Salford Podiatry Clinic patient lists and the surrounding area. If the participant presents with multiple verrucae, an 'index' verruca (largest and thickest lesion) will be identified and patients will be randomised 1:1 to the intervention group to receive the needling treatment or the control group to have the callus overlying the verruca debrided. The primary outcome is complete clearance of the index verruca at 12 weeks after randomisation. Secondary outcomes include clearance and recurrence of the treated verruca, clearance of all verrucae, number of verrucae remaining, change in size of the index verruca, pain, and participant satisfaction. A cost-effectiveness analysis of the needling versus callus debridement will be carried out from the perspective of health services over a time horizon of 12 weeks.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the University of Salford, Department of Health Sciences Ethical Approval Committee (HSCR15/24) and the University of York, Department of Health Sciences Research Governance Committee (HSRGC/2014/98/B). Findings will be disseminated through publication and conference presentations.

TRIAL REGISTRATION NUMBER

ISRCTN16429440.

Topical pyruvic acid (70%) versus topical salicylic acid (16.7%) compound in treatment of plantar warts: A randomized controlled trial

Background:

Recurrence rate is considerable with current topical treatments of plantar warts. We compared the efficacy of topical pyruvic acid (70%) with salicylic acid (16.7%) compound in treating multiple plantar warts.

Materials and Methods:

In this randomized controlled trial, 60 patients with multiple plantar warts were equally randomized to receive either pyruvic acid 70% or compound salicylic acid solution (salicylic acid 16.7%, lactic acid 16.7%, and collodion 100%) that was topically applied twice a day for 4 weeks. Patients were visited every 2 weeks for 1 month after starting treatment and then every 1 month for another 2 months. The number and size of warts, treatment complications (pain, burning, scar, pigmentation, and crust), and recurrence were evaluated.

Results:

Warts’ number was decreased by −13.12 ± 25.6% with pyruvic acid and by −23.0 ± 28.0% with compound salicylic acid (P = 0.159) after treatment. Warts’ size was decreased by −43.47 ± 57.0% with pyruvic acid and by −37.40 ± 32.76% with compound salicylic acid (P = 0.615) after treatment. There was no difference between the two groups in cumulative incidence of treatment complications (P > 0.05). Also, there was no difference between the two groups in recurrence rate at 2 months (10 vs. 16.7%, P = 0.500) or at 3 months after treatment (3.3 vs. 6.7%, P = 0.335).

Conclusion:

Topical pyruvic acid and compound salicylic acid had the same efficacy and complications in treating plantar warts. Decision for choosing the treatment can be made based on the costs and individual factors as well as patients preferences.

Mucocutaneous warts in Middle Anatolia, Turkey: clinical presentations and therapeutic approaches

Introduction

Viral warts are common skin condition caused by the human papilloma virus.

Aim

To determine the clinical features of warts and therapeutic approaches to warts and compare them with the literature.

Material and methods

A cross-sectional survey was conducted on 362 consecutive patients presenting to a dermatology clinic in Ankara, Middle Anatolia, Turkey. Age, gender, anatomic localization, clinical types, number of warts, and medical therapy histories were recorded.

Results

In our study 139 (38.4%) children and 223 (61.6%) adults had warts. Warts were seen in 191 men, and 171 women. The mean age was 24.7 ±13.5. In all groups the incidence and the number of warts were higher in men. Clinical types of warts were vulgar, anogenital, plantar, verruca plana, filiform, and mosaic. Thirty-six (9.9%) of 362 cases had more than one type. The locations of warts were as follows extremities (n = 233, 64.4%), anogenital (n = 86, 23.7%) and head and neck (n = 73, 20.2%). The incidence of anogenital warts was statistically higher in men than women (p < 0.05). Topical medical treatment was the first choice (n = 60, 57.1%).

Conclusions

In our study, the incidence and the number of warts were higher in men, which is different than in previous reports. The anogenital wart (AW) was ranked second in all types of warts. According to this finding, we can say that the frequency of AW has been increased in Turkey. To our knowledge recently there have been no studies investigating the clinical features of viral warts in all ages in the literature.

Advancements in Pharmacotherapy for Noncancerous Manifestations of HPV

Human papillomavirus (HPV) is the most common sexually transmitted disease. Via infection of the basal epithelial cells, HPV causes numerous malignancies and noncancerous cutaneous manifestations. Noncancerous cutaneous manifestations of HPV, including common, plantar, plane, and anogenital warts, are among the most common reasons for an office visit. Although there are various therapies available, they are notoriously difficult to treat. HPV treatments can be grouped into destructive (cantharidin, salicylic acid), virucidal (cidofovir, interferon-α), antimitotic (bleomycin, podophyllotoxin, 5-fluorouracil), immunotherapy (Candida antigen, contact allergen immunotherapy, imiquimod) or miscellaneous (trichloroacetic acid, polyphenon E). The mechanism of action, recent efficacy data, safety profile and recommended regimen for each of these treatment modalities is discussed.

A case of recalcitrant plantar warts associated with statin use

Background. Plantar warts are a common presenting skin complaint caused by the human papillomavirus. 1st line therapies include cryotherapy and topical salicylic acid. Where there is resistance to these treatments, consideration is made for 2nd line therapies, including intralesional bleomycin, imiquimod, 5-fluorouracil, and photodynamic therapy. We present a case of bilateral persistent plantar warts, resistant to treatment with repeated cryotherapy and topical salicylic acid over a 6-year period. Following a patient initiated decision to discontinue their statin medication, we observed rapid clearance of plantar warts without change to standard therapy or their environment. This case correlates with emerging literature demonstrating a link between statin medication and proliferation of HPV through increased levels of FOXP3+ regulatory T cells.

Topical adapalene in the treatment of plantar warts; randomized comparative open trial in comparison with cryo-therapy

Background:

Various therapeutic modalities, which are available for treating plantar wart, have not been successful every time.

Aims:

To evaluate topical adapalene under occlusion in the treatment of plantar warts and compare it with cryo-therapy.

Materials and Methods:

50 patients with 424 plantar warts were included in this single center, two arm, prospective, randomized, control, open study. Patients were allocated randomly into two groups consisting of 25 patients each. Group A patients having 299 plantar warts were treated using adapalene gel 0.1% under occlusion while Group B patients having 125 warts were treated using cryo-therapy. All the patients were evaluated weekly till the clearance of all the warts and the results compared.

Result:

All the warts of 25 patients of Group A that were treated using adapalene gel 0.1% cleared in 36.71 ± 19.24 (55.95-17.47) days except those in one patient. In Group B, warts in all except one treated by cryo-therapy cleared in 52.17 ± 30.06 (82.23-22.11) days. There were no side effects like scar formation, irritation, erythema, or infections with adapalene group while in the cryo group scar was seen in 2 patients, pain in 24, erythema in 10, and infection in 3 patients.

Conclusion:

Adapalene gel 0.1% under occlusion is an effective, safe and easy to use treatment for plantar warts and may help clear lesions faster than cryo-therapy.

Monochloroacetic acid application is an effective alternative to cryotherapy for common and plantar warts in primary care: a randomized controlled trial

Cryotherapy and salicylic acid (SA) often fail as treatments for skin warts. We examined the effectiveness of monochloroacetic acid (MCA) for patients with common or plantar warts. Consecutive patients aged 4 years and older with one or more newly diagnosed common or plantar warts were recruited in 53 Dutch general practices. We randomly allocated eligible patients to 13-week treatment protocols of office-applied MCA versus liquid nitrogen cryotherapy every 2 weeks for patients with common warts (n=188), and MCA versus cryotherapy combined with daily SA self-application for patients with plantar warts (n=227). The primary outcome was the proportion of patients whose warts were all cured at 13 weeks. In the common wart group, cure rates were 40/92 (43%, 95% confidence interval 34-54) for MCA and 50/93 (54%, 44-64) for cryotherapy (risk difference (RD) -10%, -25-4.0, P=0.16). In the plantar wart group, cure rates were 49/106 (46%, 37-56) for MCA and 45/115 (39%, 31-48) for cryotherapy combined with SA (RD 7.1, 5.9-20, P=0.29). For common warts, MCA is an effective alternative to cryotherapy to avoid pain during the treatment, although pain after the treatment is similar. For plantar warts, office-applied MCA may be preferred over cryotherapy combined with SA, on the basis of comparable effectiveness, less treatment pain, and less treatment burden.

Imiquimod for anogenital warts in non-immunocompromised adults

BACKGROUND

30% of people with anogenital warts (AGW) have spontaneous regression of lesions but there is no way to determine whether a specific lesion will remain. There are a wide range of options available for treating people with AGW and selection is based on clinician's experience, patient preferences and adverse effects. The imiquimod could offer the advantages of patient-applied therapies without incurring the limitations of provider-administered treatments.

OBJECTIVES

To assess the effectiveness and safety of imiquimod for the treatment of AGW in non-immunocompromised adults.

SEARCH METHODS

We searched the Cochrane Sexually Transmitted Infections Group Specialized Register (15 April 2014), CENTRAL (1991 to 15 April 2014), MEDLINE (1946 to 15 April 2014), EMBASE (1947 to 15 April 2014), LILACS (1982 to 15 April 2014), World Health Organization International Clinical Trials Registry (ICTRP) (15 April 2014), ClinicalTrials.gov (15 April 2014), Web of Science (2001 to 15 April 2014) and OpenGrey (15 April 2014). We also handsearched conference proceedings, contacted trial authors and reviewed the reference lists of retrieved studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing the use of imiquimod with placebo, any other patient-applied or any other provider-administered treatment (excluding interferon and 5-fluorouracil which are assessed in other Cochrane Reviews) for the treatment of AGW in non-immunocompromised adults.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. We resolved any disagreements through consensus. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

Ten RCTs (1734 participants) met our inclusion criteria of which six were funded by industry. We judged the risk of bias of the included trials as high. Six trials (1294 participants) compared the use of imiquimod versus placebo. There was very low quality evidence that imiquimod was superior to placebo in achieving complete and partial regression (RR 4.03, 95% CI 2.03 to 7.99; RR 2.56, 95% CI 2.05 to 3.20, respectively). When compared with placebo, the effects of imiquimod on recurrence (RR 2.76, 95% CI 0.70 to 10.91), appearance of new warts (RR 0.76, 95% CI 0.58 to 1.00) and frequency of systemic adverse reactions (RR 0.91, 95% CI 0.63 to 1.32) were imprecise. We downgraded the quality of evidence to low or very low. There was low quality evidence that imiquimod led to more local adverse reactions (RR 1.73, 95% CI 1.18 to 2.53) and pain (RR 11.84, 95% CI 3.36 to 41.63).Two trials (105 participants) compared the use of imiquimod versus any other patient-applied treatment (podophyllotoxin and podophyllin). The estimated effects of imiquimod on complete regression (RR 1.09, 95% CI 0.80 to 1.48), partial regression (RR 0.77, 95% CI 0.40 to 1.47), recurrence (RR 0.49, 95% CI 0.21 to 1.11) or the presence of local adverse reactions (RR 1.24, 95% CI 1.00 to 1.54) were imprecise (very low quality evidence). There was low quality evidence that systemic adverse reactions were less frequent with imiquimod (RR 0.30, 95% CI 0.09 to 0.98).Finally, two trials (335 participants) compared imiquimod with any other provider-administered treatment (ablative methods and cryotherapy). There was very low quality of evidence that imiquimod did not have a lower frequency of complete regression (RR 0.84, 95% CI 0.56 to 1.28). There was very low quality evidence that imiquimod led to a lower rate of recurrence during six-month follow-up (RR 0.24, 95% CI 0.10 to 0.56) but this did not translate in to a lower recurrence from six to 12 months (RR 0.71, 95% CI 0.40 to 1.25; very low quality evidence). There was very low quality evidence that imiquimod was associated with less pain (RR 0.30, 95% CI 0.17 to 0.54) and fewer local reactions (RR 0.55, 95% CI 0.40 to 0.74).

AUTHORS' CONCLUSIONS

The benefits and harms of imiquimod compared with placebo should be regarded with caution due to the risk of bias, imprecision and inconsistency for many of the outcomes we assessed in this Cochrane Review. The evidence for many of the outcomes that show imiquimod and patient-applied treatment (podophyllotoxin or podophyllin) confer similar benefits but fewer systematic reactions with the Imiquimod, is of low or very low quality. The quality of evidence for the outcomes assessing imiquimod and other provider-administered treatment were of very low quality.

Resolution of cutaneous leishmaniasis after acute eczema due to intralesional meglumine antimoniate

We report a case of a 42 year-old female, who came to a leishmaniasis reference center in Rio de Janeiro, Brazil, presenting a cutaneous leishmaniasis lesion in the right forearm. Treatment with low-dose intramuscular meglumine antimoniate (MA) (5 mg Sb⁵⁺/kg/day) was initiated, with improvement after 28 days, although with the development of generalized eczema. After 87 days, the lesion worsened. Patient refused treatment with amphotericin B. MA was then infiltrated in the lesion, in two sessions, resulting in local eczema, with bullae formation; however, twenty days after, both the ulcer and eczema receded. Intralesional administration of MA should be used carefully when previous cutaneous hypersensitivity is detected.