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

Efficacy of Intralesional Candida Injection in the Treatment of Cutaneous Warts: A Systematic Review and Meta-Analysis

Recent studies that examined the treatment efficacy of Candida antigen injection for both non-genital and genital warts yield inconsistent results. To address this, a systematic review and meta-analysis was conducted, comparing the treatment response between Candida antigen injection therapy and other intralesional immunotherapies across all types of warts. PubMed, Cochrane Library, and Embase were searched for relevant randomized controlled trials (RCTs) from inception to 16 September 2023, and 24 eligible RCTs were identified. A protocol was developed using the PRISM A-P checklist. In terms of complete clearance, intralesional Candida injection therapy demonstrated a significant improvement compared with saline (risk ratio [RR] 5.39; 95% confidence interval [CI] 3.49-8.33; I2=0%). However, no statistically significant differences were observed when compared with other therapies such as mumps-measles-rubella vaccines, purified protein derivative, vitamin D3, bivalent human papillomavirus vaccine, and zinc sulphate. Adverse effects associated with intralesional Candida therapy were generally reported as mild and manageable. In conclusion, intralesional Candida injection therapy for cutaneous warts may exhibit a superior complete and distant response rate. Nevertheless, owing to a limited sample size and other limitations, future research should aim for larger studies to provide more conclusive evidence.

Successful Treatment of Generalized Facial Verrucae Vulgaris with a Combination of Curettage and Photodynamic Therapy in an Adolescent: A Case Report

Verrucae vulgaris are highly contagious keratotic lesions occurring on the skin caused by human papillomavirus. Generally, verrucae vulgaris are harmless to the body, but when they occur in specific areas such as the face or soles of the feet, they can profoundly impact an individual's quality of life and necessitate therapeutic intervention. Although several pharmacological and physical topical treatments are available, the results are often unsatisfactory in terms of efficacy and cosmetic outcome. Verrucae which typically occur widely on the face are usually Verrucae Planae. When Verrucae vulgaris does occur, it usually presents as single or occasional multiple lesions, rather than covering almost the entire face. In immunocompromised situations, verruca vulgaris can exhibit rare proliferative behavior. In this report, we present a 17-year-old male adolescent who was successfully treated for generalized facial verrucae vulgaris by using a combination of curettage and photodynamic therapy (PDT). The patient's prolonged use of topical corticosteroids and tacrolimus ointment on the face for eczema over several years is believed to have led to a localized immunosuppressive state of the facial skin, which is considered a significant factor in the outbreak of verrucae vulgaris. Additionally, the patient has a history of acne and frequently scratched face. The appearance of the Koebner phenomenon following scratching is considered another potential reason. This treatment achieved complete resolution and improved the patient's pre-existing acne problem, resulting in a satisfactory cosmetic outcome without any notable adverse effects or recurrence during the follow-up period. This highlighted that pre-treatment with curettage before PDT enhanced the efficiency of verrucae vulgaris treatment and reduced the cost.

Bacterial and viral infections of the nail unit: Tips for diagnosis and management

The nail unit is the most commonly affected area in hand infections, which can be primary infection or superinfection complicating other nail or skin disorders. Trauma, mechanical or chemical, is usually the trigger enabling infiltration of infectious organisms. Artificial nails and nail polish are also a possible cause of bacterial infection, harboring microorganisms. In severe acute bacterial infection, surgical intervention is often needed to prevent morbidity and disability. Abscess should always be drained, but viral infection such as herpetic whitlow, may mimic an abscess and, in contrast, requires non-operative treatment; to prevent sequelae. A more conservative approach is also generally advisable in less severe bacterial infection, other viral infections and in subacute or chronic nail infection. The present review deals with acute, subacute and chronic bacterial and viral infections of the nail unit, with a focus on diagnostic and treatment options. LEVEL OF EVIDENCE: III, systematic review of level III studies.

Photodynamic therapy and CO2 fractional laser combination therapy for verruca vulgaris caused by Koebner phenomenon - Two case reports

Verruca vulgaris, caused by the human papillomavirus (HPV), can profoundly impact an individual's quality of life and necessitate therapeutic intervention. The challenges associated with treating verruca vulgaris are particularly noteworthy when they manifest as the Koebner phenomenon (KP). In this report, we present two cases of verruca vulgaris that developed KP following cryotherapy. Some studies have suggested that pretreatment with laser therapy enhances the efficacy of Photodynamic Therapy (PDT). Given the inefficacy of cryotherapy and the emergence of KP in our patients, we opted for a treatment approach that combined PDT with CO2 fractional laser (CO2FL), resulting in complete resolution without any notable adverse effects or recurrence during the follow-up period. Our cases underscore the importance of considering KP when verruca vulgaris exhibit enlargement and proliferation post-cryotherapy. Furthermore, this combined treatment modality demonstrates its effectiveness and safety. Additionally, our experience highlights the need for a large-scale study to determine the optimal photosensitizer concentration for the treatment of thick, enlarged verruca vulgaris.

Intralesional cidofovir for the management of refractory cutaneous verrucae: a review of applications and opportunities

Viral warts - manifestations of cutaneous infection by human papilloma virus - can be a significant physical and emotional burden for patients when common treatments fail, particularly for individuals who are immunocompromised or with multiple lesions. Cidofovir, an antiviral agent typically used for the treatment of cytomegalovirus infection, has emerged as an alternative treatment option for viral warts when administered topically or intralesionally. In this review, we highlight the scientific rationale, published evidence, and practical clinical uses of intralesional cidofovir for the management of cutaneous warts as well as ongoing questions requiring further research and exploration of this emerging therapy for refractory verrucae.

Comparison of the Efficacy of Intralesional 5-Fluorouracil/Lidocaine/Epinephrine Injection with Cryotherapy to Treat Common and Palmoplantar warts: a Randomized, Controlled Trial

Cutaneous warts are treated by different treatments with various efficacy. Intralesional injection of 5-fluorouracil (IL 5-FU) has been compared with placebo and a few other wart treatments. Our objective was to compare the efficacy of IL 5-FU injection with cryotherapy to treat common and palmoplantar warts. Forty-five patients with common and palmoplantar warts were treated with either IL 5-FU admixed with lidocaine and epinephrine (5-FU+LE) or cryotherapy, once weekly for six sessions. The patients were assessed for clinical response score, the thickness of warts, pain score, and quality of life in treatment sessions, two weeks and eight weeks after the last session. Nine patients (64.3%) in the 5-FU+LE group, and 5 patients (35.7%) in cryotherapy group experienced complete response (p=0.285). Both treatments caused improvement of clinical response score in the patients during the treatment time (p<0.001), but the efficacy of treatments was not significantly different (p=0.793). Changes in wart thickness were significantly more marked in the 5-FU+LE group compared to the cryotherapy group (p=0.021). The patients in the cryotherapy group experienced more severe pain compared to the 5-FU+LE group (p=0.011). The quality of life better improved in the 5-FU+LE group compared to the cryotherapy group (p = 0.02). To conclude, most of the patients that experienced complete clinical response had received 5-FU+LE injection, though the difference was not significant. However, 5-FU+LE injection accompanied less pain and caused more reduction in wart thickness and more improvement in quality of life compared to the cryotherapy.