Intralesional antigen immunotherapy for the treatment of warts: current concepts and future prospects

Efficacy of Intralesional Candida Antigen Versus Measles, Mumps, and Rubella Vaccine Versus Topical Podophyllin in Treatment of Resistant Genital Warts

BACKGROUND

No single treatment is ideal for genital warts with high rate of resistance using conventional modalities as topical podophyllin; however, several intralesional immunotherapies are being tested nowadays, with variable results. In this study, we compared the safety and efficacy of treating resistant and recurrent genital warts by 2 intralesional immunotherapies [Candida antigen and measles, mumps, and rubella (MMR) vaccine] and compared them with topical podophyllin.

PATIENTS/METHODS

A total of 45 patients with resistant or recurrent genital warts were enrolled in this study. Size and number of warts were detected in each patient, patients were divided into 3 groups. Group A injected with intralesional Candida antigen. Group B with intralesional MMR vaccine. Group C were treated with topical 25% podophyllin. Patients received a session every 2 weeks for 3 treatment sessions.

RESULTS

With regard to the reduction in size and number of all warts, the best response was obtained in Candida antigen group where 46.7% showed complete clearance and 40% showed partial response followed by MMR group and the last was the podophyllin group, with no significant difference between them. Complete clearance of mother warts was noticed in 86.7% of Candida group, 53.3% in MMR group, and last 40% in podophyllin group, with a significantly better response in the Candida group (P = .027).

CONCLUSION

Both intralesional Candida antigen and MMR vaccine are simple, safe, and effective treatment options with comparable results and better response than topical podophyllin.

Intralesional Quadrivalent Human Papilloma Virus Vaccine Versus Candida Antigen in the Treatment of Multiple Recalcitrant Non-Genital Warts

INTRODUCTION

Warts are the most prevalent clinical manifestation of Human Papilloma Virus (HPV) infections, which vary in morphological pattern depending on the site of the body affected.

OBJECTIVES

To evaluate the safety and efficacy of intralesional quadrivalent HPV vaccine versus candida antigen in treatment of multiple recalcitrant non-genital warts.

METHODS

A randomized-control clinical trial included 60 cases with multiple recalcitrant warts who were randomly distributed into three groups; Group I included 20 patients who received intralesional candida antigen at a dose of 0.3 mL of 1/1000 solution, Group II included 20 patients who received intralesional quadrivalent HPV vaccine at a dose of 0.3ml and Group III included 20 patients who received intralesional injection 0.3 ml of normal saline 0.9% as a control group). Each agent was injected at the base of the largest wart every three weeks until it was completely cleared, or for a total of four sessions.

RESULTS

the highest response rate was detected in the quadrivalent HPV vaccine group (75% complete response) followed by the candida vaccine group (40% complete response and 15% partial response). Also, regarding the distant response rate, the highest response rate was detected in the quadrivalent HPV vaccine group (72.7% complete response and 27.3% partial response) followed by the candida vaccine group (33.3% complete response and 50% partial response).

CONCLUSIONS

Intralesional immunotherapy appears to be effective and safe in treating multiple recalcitrant non-genital warts, with intralesional quadrivalent HPV vaccine outperforming intralesional candida antigen.

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.

The efficacy and safety of intralesional Candida vaccine versus topical diphencyproprobenone in immunotherapy of verruca vulgaris: A randomized comparative study

Various therapeutic options are available for verruca. While physical destruction may be associated with scarring, immunotherapy may be effective in treating warts through stimulating body immune response. The objective of the study was to compare the efficacy, safety, and outcome of Candida antigen vs diphencyprone (DPCP) in the treatment of warts. Fifty patients were randomly assigned to receive either intralesional Candida antigen every 3 weeks or weekly DPCP application. Both treatments were applied only to the mother wart. Lesions' clearance and associated side effects were observed up to 4 weeks after treatment. Two blinded physicians evaluated photos of warts before and 4 weeks after the end of treatment. Both modalities granted wart clearance and/or improvement with no statistically significant difference; however, Candida antigen was significantly better in clearing adjacent untreated warts (p = 0.046). Fewer side effects were observed among the Candida antigen group. The response was duration associated in the Candida groups only. Intralesional Candida antigen injection and DPCP treatments for warts yielded improvement with superiority of Candida injection in eradicating distant lesions and fewer side effects. A shorter wart duration may be associated with a better therapeutic response with Candida antigen.

A prospective randomized controlled study of Mycobacterium Indicus Pranii vaccine, Measles Mumps Rubella vaccine and Vitamin D3 in extragenital cutaneous warts

DESIGN

Interventional, prospective, four arm randomized control.

SETTING

Outpatient department, Department of Dermatology, Venereology and Leprology, AIIMS Jodhpur (Rajasthan), India.

PARTICIPANTS

Two hundred patients.

METHODS

The intervention administered in the groups were normal saline (A), vitamin D₃ (B), MIP (C), and MMR (D). The injections were given into the largest wart at 2-weekly intervals until complete clearance or for a maximum of seven sittings. Post-treatment clearance of the injected wart and the distant wart was compared on the basis of change in wart number, percentage clearance, and mean time to complete clearance. Side effects were recorded.

RESULTS

A total of 197 patients were recruited. The mean percentage improvement in the injected and non-injected warts was 68.4% and 66.8%, respectively. Intention to treat analysis (ITT) showed that complete clearance of lesions in injected wart occurred in placebo, vit D₃ , MMR, and MIP arms in 64%, 66%, 58%, and 55% patients, respectively (p > 0.05), while in the non-injected warts in 62%, 64%, 52%, and 53%, respectively (p > 0.05). The mean time to achieve complete clearance of wart was fastest in MIP at 7.1 weeks followed by MMR at 7.2 weeks, VIT D₃ at 7.4 weeks and in placebo group 7.8 weeks (p > 0.05). Side effects noted were fever, pain, erythema, and swelling which was highest in VIT D₃ group (p < 0.05).

CONCLUSION

The efficacy of immunotherapies was comparable to placebo with minimal side effects.

Efficacy of Cryotherapy Combined With Intralesional Purified Protein Derivative (PPD) Versus Intralesional PPD Monotherapy in the Treatment of Multiple Common Warts

INTRODUCTION

Intralesional antigen immunotherapy represents a promising therapeutic approach for the treatment of different types of warts, particularly if multiple and/or recalcitrant.

AIM

to investigate the efficacy and safety of combined cryotherapy with intralesional purified protein derivative (PPD) immunotherapy in the treatment of multiple common warts.

METHODS

Fifty patients were randomly divided into two groups (25 patients each): Group A: receiving intralesional PPD immunotherapy for the largest wart, while group B: receiving cryotherapy for all warts plus intralesional PPD for the largest wart. Treatments were performed every 2 weeks for a maximum of four sessions. Photographs were taken at baseline and at each visit and clinical response was evaluated by the reduction in number and size of warts. Adverse effects were recorded.

RESULTS

There was a significant reduction in size and number of warts in both groups (P < .001), with no significant difference between the two groups. Complete clearance of the lesions was observed in 48% of patients in group A and 44% in group B (P = .39). Higher rates of near complete/complete response were achieved after fewer sessions (2, 3 sessions) in group B (P = .002). Blistering was common after cryotherapy. Higher rate of hypopigmentation was noticed after combined treatment than after PPD monotherapy (56%, 8% respectively; P < .001), which resolved gradually.

CONCLUSION

Both intralesional PPD alone and combined cryotherapy with PPD are safe and effective in clearing of common warts. Cryotherapy may be a successful adjunct to intralesional PPD immunotherapy that helps in reducing the number of treatment sessions.The study protocol was registered at ClinicalTrials.gov with ID: NCT04288817.

A comparative clinico-dermoscopic study of intralesional injection of combined digoxin and furosemide, Candida antigen, and vitamin D3 for multiple warts

BACKGROUND

Immunostimulatory and antiproliferative therapies have been widely used for the treatment of multiple warts. Recently, anti-HPV activity of ionic contra viral therapy (ICVT) which is comprised of combined digoxin and furosemide has been demonstrated.

AIM

To evaluate and compare the effectiveness and safety of intralesional injection of Candida antigen, vitamin D3, and combined digoxin and furosemide in the treatment of multiple warts.

PATIENTS AND METHODS

Seventy-five patients with numerous warts were randomly assigned to one of three equal groups: Candida antigen, vitamin D3, or a combination of digoxin and furosemide. In the Candida antigen group, injections into the biggest wart were done. In the vitamin D3 and combined digoxin/furosemide groups, the agent was injected into each wart with a maximum of five injected warts. Injections were repeated every 2 weeks until clearance or for a total of five sessions.

RESULTS

There was a statistically significant difference in the overall therapeutic response among the studied groups in favor of the intralesional Candida antigen group (60%), followed by the vitamin D3 group (48%) and the ionic contraviral therapy group (28%) (p = 0.02). However, the difference between both Candida antigen and vitamin D groups was not significant (p = 0.59).

CONCLUSIONS

Intralesional Candida antigen immunotherapy and vitamin D3 antiproliferative therapy are significantly more effective than ICVT.

LIMITATIONS

Short follow-up period and relatively small sample size.

Intralesional Candida albicans antigen versus intralesional zinc sulfate in treatment of cutaneous warts

Immunotherapy represents a promising therapeutic option for treatment of warts. Different concentrations of Candida antigen (1/100 and 1/1000) and zinc sulfate 2% were not previously compared regarding their efficacy in treatment of cutaneous warts. The present study compared the safety and efficacy of intralesional candida antigen versus intralesional 2% zinc sulfate for treatment of cutaneous warts. This prospective controlled clinical trial included one hundred and five patients presented with common, plantar, and plane warts. Patients were divided randomly into three groups, each group included 35 patients. Group 1 were treated with intralesional candida antigen (Ag) 1/100, Group 2 were treated with intralesional candida Ag 1/1000, and Group 3 were treated with intralesional zinc sulfate 2%. This study found that target warts of group 1 displayed higher rate of complete clearance compared to group 2 and group 3 (94.3%, 77.1, 74.2%), respectively. The present study concluded that intralesional immunotherapy with Candida antigen was more effective than Intralesional 2% zinc sulfate in treatment of cutaneous warts and less painful. Clinical trial registration number is (Clinical Trials.gov Identifier: NCT03158168).

Systemic immunotherapy for the treatment of warts: A literature review

BACKGROUND

Immunotherapy has emerged as a critical therapeutic tool for the treatment of warts. Immunotherapy for warts is currently restricted to recalcitrant lesions. A small number of regimens appear to be extremely effective. Furthermore, there is a scarcity of evidence-based research.

OBJECTIVE

Furthermore, in the majority of cases, their safety and effectiveness have not been evaluated in double-blind, controlled clinical trials, making the reproducibility of many of the listed treatments difficult to analyze and a possible placebo effect difficult to rule out.

METHODS

Analyzing and discussing different types of systemic immunotherapy. The different types of immunotherapy for warts are mentioned in this report.

RESULTS

Systemic immunotherapeutic modalities commonly used in the treatment Echinacea, propolis, oral retinoids, glycyrrhizinic acid, levamisole, cimetidine, and zinc sulfate have all been reported as effective treatment modalities for different types of warts.

CONCLUSION

Immunotherapy has emerged as one of the most important therapeutic modalities for warts. Such treatment is required not only for recalcitrant or multiple lesions, but also in the majority of treated cases.

Intralesional Versus Intramuscular Hepatitis B Virus Vaccine in the Treatment of Multiple Common Warts

BACKGROUND

Hepatitis B virus (HBV) vaccination is associated with stimulation of humoral and cell-mediated immunity. Intralesional HBV vaccine has been recently used as an immunotherapy of common warts with relatively low success rate.

AIM

To assess the efficacy and safety of intralesional versus intramuscular (IM) HBV vaccine in the treatment of multiple common warts.

PATIENTS AND METHODS

The study included 60 patients with multiple common warts who were randomly assigned to 2 groups: intralesional HBV vaccine or IM HBV vaccine. In the intralesional HBV vaccine group, the vaccine was injected into the largest wart at 2-week intervals until complete clearance or for a maximum of 5 sessions. Intramuscular HBV vaccine group received 3 injections in the deltoid muscle at 0, 1, and 6 months.

RESULTS

Complete wart clearance was reported in 7 patients (23.3%) of the intralesional HBV vaccine group and 15 patients (50%) of the IM HBV vaccine group. The difference was statistically significant in favor of the IM group ( p = .0479). Adverse effects were mild and insignificant in the 2 groups.

CONCLUSION

HBV vaccine, particularly the IM form seems to be a promising, well-tolerated therapeutic option for the treatment of warts.

LIMITATIONS

Short follow-up period and small sample size.

Combined intralesional injection of tuberculin purified protein derivative (PPD) plus cryotherapy versus each alone in the treatment of multiple common warts

Different modalities are used for treatment of common warts, but none of them had been proved to be the best in achieving complete cure. We aim to compare the effect of cryotherapy, intralesional injection of tuberculin PPD and cryotherapy combined with intralesional injection of tuberculin PPD in the treatment of multiple common warts. This study is a randomized clinical trial in which the patients were randomly divided into three groups; group (A) included 25 patients subjected to cryotherapy, group (B) included 25 patients subjected to intralesional injection of tuberculin PPD and group (C) included 25 patients subjected to cryotherapy plus intralesional injection of tuberculin PPD. All the three groups showed a significant clinical improvement (p < 0.001) with statistically significant difference between cryotherapy group (A) and intralesional injection of tuberculin PPD group (B) (p < 0.001) & between cryotherapy group (A) and cryotherapy plus intralesional injection of tuberculin PPD group (C) (p < 0.001). However, there was no statistically significant difference between both intralesional injection of tuberculin PPD group alone (B) and cryotherapy plus intralesional injection of tuberculin PPD group (C) (p = 0.213). In Conclusion the cryotherapy combined with intralesional injection of PPD and intralesional injection of PPD alone are better than cryotherapy alone in treatment of multiple common warts. However, better response could be reached in combination of both cryotherapy and intralesional PPD with fewer number of sessions.

Predictors of the Therapeutic Response to Intralesional Bivalent HPV Vaccine in Wart Immunotherapy

Variable intralesional immunotherapies have recently been proposed as a means of achieving a successful eradication of recurrent and recalcitrant human papillomavirus (HPV)-induced cutaneous and anogenital warts. The bivalent HPV vaccine is one of the newly proposed immunotherapeutic agents. We investigated the role of interleukin-4 (IL-4) and interferon-gamma (IFN-γ) as ex vivo immunologic predictors to estimate the response to the bivalent HPV vaccine as a potential immunotherapy for cutaneous and anogenital warts. Heparinized blood samples were withdrawn from forty patients with multiple recurrent recalcitrant cutaneous and anogenital warts and forty matched healthy control subjects. Whole blood cultures were prepared with and without bivalent HPV vaccine stimulation. Culture supernatants were harvested and stored for IL-4 and IFN-γ measurements using an enzyme-linked immunosorbent assay. A comparative analysis of IL-4 and IFN-γ levels in culture supernatants revealed a non-significant change between the patient and control groups. The bivalent HPV vaccine stimulated cultures exhibited a non-significant reduction in IL-4 levels within both groups. IFN-γ was markedly induced in both groups in response to bivalent HPV vaccine stimulation. The bivalent HPV vaccine can give a sensitive IFN-γ immune response ex vivo, superior to IL-4 and sufficient to predict both the successful eradication of HPV infection and the ultimate clearance of cutaneous and anogenital warts when the bivalent HPV vaccine immunotherapy is applied.

Psoriasis Exacerbation after Candida Antigen Immunotherapy Injection

Background

Immunotherapy as wart treatment has been proposed as a successful and well-tolerated treatment option. However, as their action is not confined to the site of injection, the activation of the immune system in a way may alter the immune state of the patient.

Case Presentation

A case of 29-year-old patient who experienced psoriasis exacerbation and psoriatic arthritis within days following Candida antigen immunotherapy injection for resistant filiform wart management.

Conclusion

Candida antigen injection may cause psoriasis exacerbation, as TNFα and subsequent T-helper 1 induction is crossroad in both psoriasis and Candida antigen immunotherapy. Therefore, we report this case to state that besides the effectiveness of Candida antigen for wart therapy, caution should be considered if used in patients who are susceptible to psoriasis with meticulous follow-up or better to apply an alternative treatment option.

Autoimplantation – An Immunological Treatment For Multiple Warts

Introduction. Warts are benign epithelial lesions that involve skin and mucosa. Successful management depends on the patient’s immunity, site and type of wart. In spite of huge therapeutic armory available, no treatment has been found to be effective so far.

Objective. To evaluate the effectiveness of autoimplantation in the management of multiple warts.

Material and Methods. This is a hospital based prospective study of forty patients with multiple warts. A prospective, hospital-based study included forty cases of multiple warts for autoimplantation. Resolution of warts within three months was taken as complete clearance; the follow up of any recurrence lasted six months.

Results. The majority of patients were males (69.7%), belonging to 21–30 years age group (57.6%). Complete resolution was observed in 25 patients, partial response was achieved in 5 patients and there was no response in 3 patients. The majority of patients did not have any complication or recurrence

Conclusion. Autoimplantation is a simple, daycare, effective procedure. It provides resistance by inducing cell mediated immunity and also prevents recurrence to a great extent.

Intralesional Measles, Mumps, and Rubella Vaccine Versus Intralesional Candida Antigen in the Treatment of Common and Plantar Warts

BACKGROUND

Intralesional immunotherapy has been effectively used in the treatment of warts; however, comparative studies between different antigens are limited.

OBJECTIVE

To evaluate the efficacy and safety of intralesional measles, mumps, and rubella (MMR) vaccine compared with intralesional Candida antigen for the treatment of multiple common and plantar warts.

METHODS

Sixty-eight adult patients with multiple common and plantar warts were randomly assigned into two groups, each containing 34 patients. The first group received intralesional MMR vaccine, while the second group received intralesional Candida antigen. Each treatment was injected into the largest wart at 2-week intervals until complete clearance or for a maximum of 5 sessions.

RESULTS

The overall therapeutic response was higher in the Candida antigen group (73.5%) compared with the MMR group (67.7%); however, the difference was not statistically significant. Complete clearance of common warts was higher in the Candida antigen group, while that of plantar warts was higher in the MMR group. Adverse effects were transient and well tolerated in both groups. No recurrence was detected during the 6-month follow-up period.

CONCLUSION

Intralesional MMR and intralesional Candida antigen showed comparable efficacy and safety in the treatment of common and plantar warts.

Intralesional Antigen Immunotherapy in the Treatment of Periungual Warts

BACKGROUND

Intralesional immunotherapy using different types of antigens is considered an effective and safe treatment option for different types of warts. However, there are few studies that illustrate the use of these antigens in the treatment of periungual warts as a distinct type of warts.

OBJECTIVE

To evaluate the efficacy and safety of three antigens: measles, mumps, rubella (MMR) vaccine, Candida antigen, and purified protein derivative (PPD) in the treatment of periungual warts.

METHODS

The study included 150 patients who were randomly assigned to 3 groups with 50 patients in each. Each agent was injected intralesionally at a dose of 0.1 mL into the largest wart at 2-week intervals until complete clearance or for a maximum of 5 sessions.

RESULTS

Complete clearance of warts was observed in 70%, 80%, and 74% in PPD, Candida antigen, and MMR vaccine groups, respectively. There was no statistically significant difference regarding the therapeutic response between the 3 studied groups. Adverse effects were transient and insignificant in the 3 groups. No recurrence of the lesions was reported in any of the studied groups.

CONCLUSIONS

Intralesional antigen immunotherapy seems to be an effective therapeutic option for the treatment of periungual warts.

Immunotherapy in cutaneous warts: comparative clinical Study between MMR vaccine, tuberculin, and BCG Vaccine

BACKGROUND

Warts are common viral infection of the skin. Treating warts are still an ongoing challenge and no general agreement is reached, on the best treatment, despite different therapeutic approaches. Intralesional (IL) immunotherapy has recently been shown to be effective in treating various wart forms.

AIMS

To assess the efficacy and safety of IL tuberculin, IL MMR vaccine, and intradermal (ID) BCG vaccination in treating viral warts.

PATIENTS AND METHODS

Sixty patients with single or multiple warts were divided equally into three groups. Group A received IL MMR vaccine, and group B received IL tuberculin every 3 weeks (maximum 3 times). Group C received ID BCG vaccination in the arm with one month interval (maximum 3 times). Recurrence was followed up for 6 months.

RESULTS

In group A, complete response occurred in 30%, partial response in 5%, and no response in 65%. In group B, complete response occurred in 45%, partial response in 20%, minimal response in 10% and no response in 25%. In group C, complete response occurred in 70%, partial response in 5%, minimal response in 5%, and no response in 20%. No recurrence was observed in group A and B but occurred in one patient in group C with the same lesion.

CONCLUSIONS

Immunotherapy by IL tuberculin and ID BCG vaccination are safe, effective, and inexpensive techniques in treating all types of warts even if recalcitrant or multiple but immunotherapy by IL MMR vaccine has shown less effectiveness and less safety technique.

Changes in Cytokine Profile with Immunotherapy in Viral Warts using Purified Protein Derivative, Mumps Measles Rubella Vaccine, and Mycobacterium w Vaccine

Background

Immunotherapy for wart employs ability of immune system to recognize certain viral, bacterial, and fungal antigens in previously sensitized individual inducing Type IV delayed-type hypersensitivity reaction (up-regulated Th1 cytokines IL-1, TNF-α, IFN-γ; down-regulated Th2 cytokines IL-10), not only to injected antigen but also against wart virus.

Aims

To evaluate and compare the pattern of production of Th1 cytokines (IL-1, TNF-α, IFN-γ) and Th2 cytokines (IL-10) in patients receiving immunotherapy with purified-protein-derivative (PPD), Mycobacterium w (Mw), or mumps-measles-rubella (MMR) vaccine.

Methods

The cohort study conducted on patients receiving immunotherapy with PPD, Mw, or MMR which was injected intradermally at baseline, repeated every 2 weeks for 6 doses?. Five-millilit?e?r blood was collected for evaluation of cytokines at baseline and 12 weeks of treatment. Blood was centrifuged to separate serum, stored at -80°C. Cytokines were measured by ELISA using a standard kit.

Results

Nine participants in PPD group, 11 in Mw group, and 12 in MMR group completed the study. IL-1 was raised from baseline in all study arms and was significant in PPD group (P = 0.008). There was a predicted increase in IFN-γ in Mw and MMR groups but not in the PPD group. In the PPD group, IFN-γ was found to be down regulated. IL-10, a Th 2 cytokine was down regulated in all the groups at the study end from baseline, significantly so in the PPD group (P = 0.027) and MMR group (P = 0.001). TNF-α, being a Th1 cytokine was down regulated in all groups instead of an increase. In PPD group, IL-10 was significantly low at study end in patients who had complete resolution of warts.

Limitations

Longer follow-up could not be done due to logistic issues.

Conclusion

IL-1, TNF-α upregulation and IL-10 downregulation confirm that cytokine milieu plays an important role in wart immunotherapy. TNF-α has no contributory role. IL-10 can be used as a biomarker of complete response in PPD therapy.

Role of intralesional vitamin D3 in the treatment of cutaneous warts

Background:

Cutaneous warts are common benign skin lesions caused by human papillomavirus. Various treatment options are available for these but immunotherapy is becoming more and more popular over the past few years. It stimulates cell-mediated immunity causing clearance of warts.

Aims and Objectives:

The aim is to determine the role of intralesional vitamin D3 in the treatment of warts.

Materials and Methods:

Consecutive patients with verruca vulgaris attending OPD were included. Around two to three warts were injected first with 0.2 mL of lignocaine (20 mg/mL). After a few minutes, the same warts were injected with 0.2 mL (4 U) of vitamin D3 (15 mg/mL). The injections were given2 weeks apart for a maximum of six sessions, and the patient was followed up 3 months after the last injection.

Results:

A total of 41 patients of cutaneous warts completed the study. Complete clearance was seen in 27 (65.85%) patients, partial response was seen in 11 (26.83%) patients, and three patients (7.32%) showed no response at all. The mean number of injections required for complete response was four. Recurrence was seen in two patients (4.88%) and one patient had keloid formation at the sight of injection.

Limitation:

This is a small sample sized study and lacks a control group.

Conclusion:

Intralesional vitamin D3 is an effective treatment option for common warts.

Complement component 3c and tumor necrosis factor-α systemic assessment after Candida antigen immunotherapy in cutaneous warts

BACKGROUND

Cutaneous warts are the commonest benign lesion produced by human papillomavirus. Lesions often regress spontaneously yet have a high rate of recurrence. They impair patients' quality of life and carry the potential risk of cancer. Nowadays, Candida antigen immunotherapy has become an encouraging therapeutic modality for warts. We tried to assess the role of the complement pathway and T helper 1 immune response in clinical response to Candida antigen immunotherapy via complement component 3c (C3c) and tumor necrosis factor (TNF)-α, respectively.

METHODS

A total of 44 patients with cutaneous warts were enrolled in the study. Patients were injected with Candida antigen at 2-week interval until complete clearance of the lesion or for a maximum of 5 sessions. Blood samples were collected before initiation and after completion of immunotherapy. C3 and C4 were measured using an automated turbidimetric method. Mannose-binding lectin (MBL), C3c, and TNF-α were measured using enzyme-linked immune sorbent assay.

RESULTS

A total of 56.4%, 17.9%, and 25.7% of the patients showed complete, partial, and no response to immunotherapy, respectively. Lesions on the dorsum of the foot and sole showed significant clearance (p value = 0.037). All patients had no deficient C3, C4, and MBL serum levels. C3c and TNF-α serum levels were significantly higher in non-responder group (p value < 0.001 and < 0.001, respectively). C3c and TNF-α serum levels were strongly correlated in all the studied patients (r = 0.8, p value < 0.001).

CONCLUSIONS

Candida antigen immunotherapy is an effective therapeutic modality for cutaneous warts. C3c and TNF-α serum levels were higher in patients who failed to respond to immunotherapy.

CLINICAL TRIAL REGISTRY NUMBER

NCT04399577 , May 2020 "retrospectively registered".

Efficacy and safety of homologous autoinoculation in treatment of multiple recalcitrant warts of different types

BACKGROUND

Homologous autoinoculation is a novel minimally invasive procedure that treats warts by stimulating specific immune response.

AIM

To evaluate the efficacy and safety of autoinoculation in treatment of multiple recalcitrant warts of different types in relation to patient's age, gender, type, number, size, and duration of warts.

PATIENTS AND METHODS

Two hundred patients with multiple recalcitrant warts of different types were treated with one autoinoculation session. Each patient was subjected to history taking, general and dermatological examination, and photographic documentation before and after treatment. Patients were followed up after 1 week, 2, 12, and 16 weeks to assess possible side effects, treatment response, and recurrence rate, respectively. Evaluation of treatment response was done through physician assessment according to change in size or number of warts or both.

RESULTS

After 12 weeks of procedure, 66% of patients showed complete clearance, 26% showed moderate clearance, and 4% showed mild clearance while only 1.5% of patients showed treatment failure, with negligible side effects and no recurrence. There was negative correlation between treatment response and wart duration (P < .001).

CONCLUSION

Autoinoculation is effective in treating multiple recalcitrant warts irrespective of their type, number or size, with minimal complications and no recurrence. The longer wart duration is, the less treatment response will be achieved.

Intralesional immunotherapy for molluscum contagiosum: A review

Molluscum contagiosum (MC) is a common cutaneous viral infection with no standard treatment. The virus responsible for MC is thought to be cleared by cell mediated immunity (CMI). Intralesional immunotherapy that stimulates CMI has been shown to be an effective treatment for other cutaneous viruses. In this review, we evaluate the efficacy and safety of intralesional immunotherapy in the treatment of MC. Articles met inclusion criteria if they examined the effects of intralesional immunotherapy as a treatment for MC, with a clear outcome and reproducible methodology. 228 studies were screened and 10 studies met criteria for inclusion. Intralesional immunotherapies investigated included candida, combined measles, mumps, rubella vaccine, tuberculin purified protein derivative, vitamin D3, interferon α, and Streptococcal substrain OK-432. Studies demonstrated clearance of MC lesions following intralesional immunotherapy, with complete response rates between 36% and 100%. No serious adverse effects were noted. Intralesional immunotherapy is a safe and effective treatment option for MC in pediatric and adult patients.

Photodynamic therapy versus candida antigen immunotherapy in plane wart treatment: a comparative controlled study

INTRODUCTION

Plane warts, mostly found on the face, present a challenge to treat as most destructive methods can lead to unpleasant cosmetic outcome. Alternative therapeutic methods should be evaluated. The aim of this study is to evaluate the clinical efficacy and adverse effects of photodynamic therapy with methylene blue and intense pulsed light in comparison to candida antigen immunotherapy in the treatment of plane warts.

METHODS

The study included 39 patients with plane warts assigned into 3 groups. Group I received photodynamic therapy using methylene blue followed by IPL illumination, group II received immunotherapy using 0.1 ml of candida albicans antigen and group III received 0.1 ml saline as a control.

RESULTS

Complete response was detected in (46.1%) of patients in group I compared to (61.5%) in group II and no response in group III.

CONCLUSION

Candida antigen immunotherapy is superior to photodynamic therapy in plane warts treatment with absence of recurrence and comparable side effects in both groups.

Intralesional antigen immunotherapy for the treatment of plane warts: A comparative study

Intralesional immunotherapy by different antigens has shown promising efficacy and safety in the treatment of warts. However, the use of these antigens for the treatment of plane warts has been investigated in two studies only. To evaluate the efficacy and safety of three antigens; Measles Mumps, Rubella vaccine (MMR), Candida antigen, and purified protein derivative (PPD) in the treatment of multiple plane warts. The study included 120 patients who were randomly assigned to three groups, 40 patients in each group. Each agent was injected intralesionally at a dose of 0.1 mL into the largest wart at 2-week intervals until complete clearance or for a maximum of five sessions. Complete clearance of warts was observed in 55% of the PPD group, in 70% of the Candida antigen group, and in 62.5% of the MMR group. No statistically significant difference in the therapeutic response was found between the three groups. Intralesional antigen immunotherapy seems to be a promising well-tolerated and effective therapeutic option for the treatment of multiple plane warts, with relatively higher efficacy of Candida antigen.

Successful treatment of doughnut warts with intralesional Candida antigen immunotherapy

BACKGROUND

Doughnut warts, also called ring or annular warts, are a distinctive type of warts with central clearing and annular recurrence. There are very few studies illustrating this uncommon phenomenon and its treatment.

AIMS

To present 15 cases of doughnut warts and evaluate the efficacy and safety of Candida antigen intralesional immunotherapy in their treatment.

METHODS

The study included 15 patients presenting with doughnut warts who were previously treated with destructive modalities for their original warts. All patients were injected intralesionally by Candida antigen at a dose of 0.2 mL into the base of doughnut wart until complete clearance or for a maximum of 5 sessions.

RESULTS

Complete clearance was achieved in 12 patients (80%), partial response in 2 patients (13.3%), and no response in 1 patient (6.7%). Complete response was observed after two sessions in 5 patients, after three sessions in 4 patients, and after four sessions in 3 patients. Adverse effects were minimal and insignificant.

CONCLUSIONS

Doughnut warts represent a unique and rare type of wart recurrence. Intralesional Candida antigen immunotherapy seems to be a promising and effective therapeutic modality for the treatment of such a rare entity.

Efficacy of Intralesional Cryosurgery in the Treatment of Multiple Extragenital Cutaneous Warts: A Randomized Controlled Study

BACKGROUND

The efficacy of intralesional (IL) cryosurgery in the treatment of cutaneous warts has not been previously studied.

OBJECTIVE

To compare the efficacy and safety of IL cryosurgery versus electrosurgery in multiple extragenital warts and investigate their effect on serum interleukin (IL)-12 and interferon-gamma (IFN-γ).

MATERIALS AND METHODS

Thirty-one patients were included; 18 received IL cryosurgery, and 13 had electrosurgery. Treatment was performed for the largest or few (2-3) small warts (target) until cleared, leaving the remaining (distant) warts untreated. Clinical response of the target and distant warts and adverse effects were evaluated. Serum IL-12 and IFN-γ levels were assessed before and after treatment.

RESULTS

All patients had complete clearing of the treated wart in both groups. IL cryosurgery was well tolerated; infection, ulceration, and recurrence occurred only with electrosurgery. Complete/near-complete resolution of the distant untreated warts was seen in 33.3% versus none of patients in the IL cryosurgery and electrosurgery groups, respectively (p = .003). Furthermore, IL-12 and IFN-γ levels showed a tendency to increase after IL cryosurgery, and their increase correlated with distant wart response.

CONCLUSION

Intralesional cryosurgery is effective not only in clearing treated warts but also resolving untreated warts and possibly enhances human papillomavirus-directed immune response.

Role of mannose binding lectin in response to candida antigen immunotherapy of warts

BACKGROUND

Warts is the commonest cutaneous manifestation of human papillomavirus (HPV) infection. Intralesional Candida antigen immunotherapy is used for wart treatment.

AIM

To identify the role of mannose binding lectin (MBL) in susceptibility to HPV infection and to explore the relationship between MBL and response to intralesional Candida antigen immunotherapy of wart.

PATIENTS AND METHODS

A case-control study was enrolled with 96 participants; 48 wart cases and 48 healthy controls. MBL serum level assay baseline and after six settings of intralesional candida antigen injection was done by ELISA technique. MBL2 gene exon 1 codon 54 polymorphism was detected by using restriction fragment length polymorphism-polymerase chain reaction (RFLP-PCR).

RESULTS

A statistically significant difference in MBL serum level between wart cases and controls was found. An association between MBL2 exon1 codon 54 polymorphism and susceptibility to HPV infection and development of warts was proved. Carriage of genotype AB was more frequent wart cases (95.8%) than in controls (20.8%). No statistical significance association could be found between the therapeutic response to Candida antigen immunotherapy in wart cases and MBL as regards its serum level and genotypes.

CONCLUSIONS

MBL play an important role in host defense against HPV infection.

Peripheral blood toll-like receptor 4 correlates response to candida immunotherapy of warts

Human papilloma virus infection may be self-limiting; however, some cases may spread. There are no factors predicting the prognosis of such infections. The present study aimed to evaluate the significance of TLR4 expression in predicting the response of warts to candida immunotherapy. A total of 60 patients with different types of warts were included in the present study. A total volume of 2 ml venous blood was collected and real-time polymerase chain reaction was used to determine expression of TLR4. Patients were subjected to intralesional injection of Candida antigen into the largest wart at 2-week intervals until complete clearance or for a maximum of six sessions. Of the total 58 patients available for analysis of study results, 44 patients (75.9%) showed complete resolution with better response in younger ages. The TLR4 expression in patients with complete and partial response was significantly higher than that in patients who had no response (p = .006). Among our patients, 48.3% showed no side effects, 44.8% showed local reactions, and 6.9% showed systemic side effects. Only four patients showed recurrence after 6 months. Using receiver operating characteristic curve analysis, at cutoff of expression level >12 is accompanied by 100% specificity of TLR4 in predicting treatment response to candida immunotherapy. Candida immunotherapy is an effective warts treatment, especially in young patients. Higher PMBC TLR4 levels can predict response to candida immunotherapy.

Intralesional Vitamin D3 Injection in the Treatment of Recalcitrant Warts: A Novel Proposition

Background:

Verruca vulgaris (viral warts) is a fairly common condition with a plethora of treatment options having variable success rates. Recalcitrant warts are refractory to treatment with often disappointing response and high recurrence rates. Lately, treatment with intralesional injections has gained momentum due to its effectiveness in clearing warts by stimulating the cell-mediated immunity. Vitamin D, when applied topically, regulates epidermal cell proliferation and is involved in the formation of antimicrobial peptides. We have attempted to use vitamin D3 to exploit its reported action as an immunotherapeutic molecule in addition to its topical effects. To our knowledge, there are no reports of intralesional vitamin D3 injections used in the treatment of extragenital recalcitrant warts.

Methods:

Sixty-four patients with recalcitrant warts of varying sizes and duration were included in the study. About 0.2- to 0.5-mL vitamin D3 solution (600,000 IU, 15 mg/mL) was injected to the base of the wart. A maximum of 5 warts were injected per session at 3-week intervals until resolution or for a maximum of 4 treatments. Patients were followed up for 6 months after the last injection to detect any recurrence.

Results:

Sixty patients completed the study. Complete response was seen in 54 of 60 (90%), partial response in 4 of 60 (6.66%), and no response in 2 of 60 (3.33%). The average number of injections required to achieve a complete resolution was 3.66. Complete resolution of distant warts was noticed in all patients.

Conclusions:

Intralesional vitamin D3 is a safe, effective, and an inexpensive treatment option for recalcitrant warts.

Efficacy of intralesional immunotherapy for the treatment of warts: A review of the literature

Warts are common epidermal growths caused by human papillomavirus that often cause significant discomfort and embarrassment. Current treatment options include topical therapies, cryotherapy, laser vaporization, and surgical excision. Many of these options are destructive and may result in scarring, while less aggressive approaches can lead to lesion recurrence. Additionally, these local modalities are not practical for patients with a large number of warts. Systemic approaches such as immunotherapy have demonstrated success in treating multiple lesions by combining a targeted approach with upregulation of the host immune system. An extensive literature review was performed to evaluate the various vaccine antigens that have been used intralesionally to treat cutaneous and anogenital warts. The specific intralesional immunotherapies that have been studied include: Candida albicans; measles, mumps, and rubella; Trichophyton; and tuberculin antigens such as purified protein derivative, Mycobacterium w vaccine, and Bacillus Calmette-Guerin. Intralesional vaccine injection represents a safe, effective, and tolerable treatment for warts, including recalcitrant and anogenital warts. This approach has been somewhat overlooked in the past despite substantial evidence of high response rates with a low side effect profile. Large comparative trials are necessary to determine the most effective immunotherapy treatment option as well as the most appropriate dosing parameters.