Cutaneous wart-associated HPV types: prevalence and relation with patient characteristics

Does HPV biotype influence the characteristics and evolution of plantar warts?

BACKGROUND

Few studies have addressed the relationship of human papillomavirus (HPV) biotypes to patient characteristics and the clinical signs, course, and response to the treatment of plantar warts.

OBJECTIVE

Analyze the HPV types associated with plantar warts and their relationship with warts characteristics, patient characteristics and response to treatment.

METHODS

A total of 372 patients sampled for hyperkeratosis of a plantar wart were included. Multiplex polymerase chain reaction (PCR) was performed to detect the HPV biotype.

RESULTS

The prevalence of HPV was 81.2%, and HPV1 was the most prevalent biotype (36.1%). HPV1 was the most prevalent biotype in patients < 70 years old (90.9% in < 10 years), and biotypes 2, 19 and 27 were the most prevalent in patients > 70 years old (p = 0.012). HPV1 was the most frequent in patients with one (39,9%) or two (47.1%) warts and HPV5 (33.3%) in patients with three warts (p < 0.001). Cure, spontaneous resolution, and recurrence were higher in HPV1 (p < 0.001). HPV14 warts healed the fastest (2 months quartile 1-3 (2.0-2.0)), and HPV5 (10.977 (6.0-20.0)) and HPV27 (7.5 (3.0-10.0)) warts (p = 0.033) took the longest to heal.

CONCLUSIONS

HPV biotype is associated with age and the number of warts and appears to influence the natural history of warts and their response to treatment.

Topical antimitotic treatments for plantar warts are more beneficial: A Bayesian network meta-analysis of randomized controlled trials

BACKGROUND

Plantar warts are common infectious cutaneous growths causing severe physiological and psychological discomforts in patients and heaving global financial burdens. However, paucity of clear-cut guidelines for plantar warts, selecting appropriate treatments for plantar warts remains challenging. The objective of the study is to evaluate the efficacy and safety of common treatments for plantar warts.

METHODS

PubMed, EMbase, and The Cochrane Library were searched from inception to March 1, 2023 for randomized controlled trials (RCTs) of plantar warts. The primary outcome (complete response) and secondary outcome (recurrence and pain) were extracted and combined using Bayesian network meta-analysis (NMA) with random-effect and fixed-effect models.

RESULTS

Totally, 33 RCTs were included in the systematic review and quantitative NMA. In NMA of complete response, topical application of 1% cantharidin, 20% podophylotoxin, 30% salicylic acid (CPS), microneedles plus bleomycin (MNB), and intralesional bleomycin injection (INB) were the only three treatments significantly superior to no treatment (NT) and CPS was of the highest possibility to be the top-ranked treatment (SUCRA = 0.9363). However, traditional warts treatments, salicylic acid (SA) and cryotherapy were not superior to NT.

CONCLUSIONS

The NMA has produced evidence for using CPS, MNB, and INB, which are all topical antimitotic treatments, to improve the management of plantar warts. The classic treatment modalities for plantar warts, including SA and cryotherapy, may play a less important role in the clinical practice of plantar warts.

Strengthening the relationship between intractable plantar keratosis and human papillomavirus

The aim of the study was to determine the presence of human papillomavirus (HPV) in patients with intractable plantar keratosis (IPK) by comparing the histopathological findings of biopsies. A prospective, observational, and concordance study was carried out. Three different specimens were taken from each IPK. A first punch was sent for histopathological examination, and a second punch and a superficial skin scraping were both sent for HPV  polymerase chain reaction (PCR) and type determination. A total of 51 patients were included. From the histopathological examination, it was determined that 35 (68.6%) samples were diagnosed as warts and 16 (31.3%) as keratosis. However, the presence of HPV was confirmed by PCR in 49 (96.1%) and in 42 (82.4%) samples obtained by punch and superficial scraping, respectively. In the 49 PCR-positive samples, the most common HPV types were HPV1, HPV2, HPV27, HPV57, and HPV65, accounting for 81.6% of the samples. In conclusion, this study demonstrates that HPV infection and IPK lesions are very closely related. Although we cannot confirm that HPV is the cause of the development of IPK, the high prevalence of HPV observed in these lesions calls for a change to the procedures for managing IPK.

Skin surface material for detecting human papillomavirus infection of skin warts

Warts, caused by human papillomavirus (HPV) infection, have various clinical presentations, making them difficult to differentiate from clavus, callus, and sometimes, squamous cell carcinoma. Although skin biopsies are the gold standard, a less-invasive method of examining these lesions is desired. Ninety patients with warts and related diseases, such as clavus and callus, were recruited to explore new differentiation methods using the surface of the warts. DNA was extracted from three types of specimens in each case: surface swab, shaved hyperkeratotic scale, and post-shaved surface swab. Total DNA was successfully extracted from these three specimens and was sufficient for subsequent HPV DNA detection. We analyzed samples for the HPV type and HPV viral load using polymerase chain reaction (PCR). Fifty-five cases were PCR-positive, and HPV1a, 2a, 4, 27, 57, and 65 were detected. The amount of HPV1a DNA produced was significantly greater than that of other HPV types. Regarding the correlation between the clinical diagnosis and HPV detection, the positive agreement rate was 90.9%, the negative agreement rate was 40.0%, and the overall agreement rate was 71.1%. Ten of the 21 cases clinically diagnosed as plantar warts were PCR-negative, especially in elderly patients. This suggests that it is difficult to distinguish plantar warts from clavus and callus in clinical practice. Although the amount of HPV DNA in the removed keratinization scale was highest for all HPV types, HPV detection by swabbing before and after shaving is also useful for follow-up as well as for differential diagnosis.

Characterization of type-specific HPV prevalence in a population of persistent cutaneous warts in Flanders, Belgium

Cutaneous warts are benign skin lesions caused by the human papillomavirus (HPV). Even though they are considered benign, they can have a considerable impact on the quality of life and cause serious illness in certain immunocompromised populations. Studies have shown that the efficacy of wart treatment is dependent on the causative HPV type. Therefore, in this article, we aim to determine the HPV genotype-specific prevalence in cutaneous warts of a Flemish population as part of the Omnivirol-Salycilic acid randomized controlled trial. Swab samples of cutaneous warts (n = 269) were collected during enrollment. The DNA extraction was performed on the automated NucliSENS® easyMAG® system (bioMérieux). The samples were analyzed with two separate in-house PCR assays capable of detecting the most prevalent cutaneous HPV types (i.e. wart-associated HPV qPCR) as well as the most relevant mucosal types (i.e. RIATOL qPCR assay). In total, the type-specific prevalence of 30 distinct HPV genotypes was determined. The beta-globin gene was used as a cellularity control and for viral load quantification. Data concerning wart persistence, previous treatment, wart type, and other relevant wart and patient characteristics was collected through a baseline questionnaire. The study population consisted mostly of persistent warts considering that 98% (n = 263) of the sampled skin lesions were older than six months and 92% (n = 247) had undergone previous treatment. The most prominent wart type was the mosaic verruca plantaris (42%, n = 113). The most prevalent HPV types were cutaneous HPV types 27 (73%, n = 195), 57 (63%, n = 169), and 2 (42%, n = 113). Only 2% (n = 6) of the lesions was HPV negative. The highest median viral loads were observed with HPV27 and 57 (i.e. 6.29E+04 and 7.47E+01 viral copies per cell respectively). The multivariate analysis found significant associations between wart persistence and certain wart types, the number of warts, and HPV genotypes. Based on these findings, persistent warts are more likely to: (1) be verruca vulgaris, verruca plantaris simple or mosaic, (2) to manifest as multiple warts, (3) and to be negative for HPV type 2 or 4. These characteristics can be useful in the clinical setting for future risk stratification when considering treatment triage and management. Trial registration: NCT05862441, 17/05/2023 (retrospectively registered).

New uses for an old remedy: Digoxin as a potential treatment for steatohepatitis and other disorders

Repurposing of the widely available and relatively cheap generic cardiac gly-coside digoxin for non-cardiac indications could have a wide-ranging impact on the global burden of several diseases. Over the past several years, there have been significant advances in the study of digoxin pharmacology and its potential non-cardiac clinical applications, including anti-inflammatory, antineoplastic, metabolic, and antimicrobial use. Digoxin holds promise in the treatment of gastrointestinal disease, including nonalcoholic steatohepatitis and alcohol-associated steatohepatitis as well as in obesity, cancer, and treatment of viral infections, among other conditions. In this review, we provide a summary of the clinical uses of digoxin to date and discuss recent research on its emerging applications.

Exploring the Molecular Pathogenesis, Pathogen Association, and Therapeutic Strategies against HPV Infection

The human papillomavirus (HPV), commonly documented as the cause of warts, has gained much interest recently due to its possible links to several types of cancer. HPV infection is discussed in this review from multiple angles, including its virology, epidemiology, etiology, immunology, clinical symptoms, and treatment. Recent breakthroughs in molecular biology have led to the development of new methods for detecting and treating HPV in tissue. There is no cure for HPV, and although vaccines are available to prevent infection with the most common HPV viruses, their utilization is limited. Destruction and excision are the primary treatment modalities. This review sheds light on the epidemiology, molecular pathogenesis, the association of several other pathogens with HPV, the latest treatment strategies available to treat the same, and an overview of the progress made and the obstacles still to be overcome in the fight against HPV infection.

Long-pulsed neodymium-doped yttrium-aluminum-garnet laser versus cryotherapy for the treatment of cutaneous warts: A randomized controlled trial

BACKGROUND

Observational studies have shown promising therapeutic effects of long-pulsed neodymium-doped yttrium-aluminum-garnet (LP-Nd:YAG) laser on warts.

OBJECTIVE

To evaluate whether LP-Nd:YAG laser was superior to cryotherapy for cutaneous warts.

METHODS

In this study, 150 adult patients with warts were randomized equally to receive laser or cryotherapy every 3 to 4 weeks, for a maximum of 4 sessions. The primary outcomes were the cure rates at 16 weeks and 6 months; secondary outcomes included time to clearance of warts and treatment-related adverse effects.

RESULTS

There was no difference in the cure rate for laser versus cryotherapy at 16 weeks (54.1% vs 46.7%, respectively) and 6 months (59.5% vs 57.3%, respectively). However, time to clearance of warts, up to 16 weeks and 6 months, tended to be shorter for laser versus cryotherapy (P = .04 and .08, respectively). Post hoc analyses showed a significantly higher cure rate for laser versus cryotherapy in 3 subgroups of human papillomavirus 2/27/57-induced recalcitrant warts but not in their counterpart subgroups. Laser had more mild adverse effects.

LIMITATIONS

Single center.

CONCLUSIONS

The overall therapeutic effects of LP-Nd:YAG laser were similar to cryotherapy, but laser may be more effective to relatively recalcitrant warts and may be associated with shorter time to clearance of warts.

Oral isotretinoin versus acitretin in male patients with multiple recalcitrant common warts: A randomized, double-blinded placebo-control study

BACKGROUND

Management of multiple recalcitrant common warts represents a therapeutic challenge. Both oral isotretinoin and acitretin have shown a promising efficacy in the treatment of various types of warts. However, a comparative study of the two medicines in wart treatment has not yet been conducted.

OBJECTIVE

The aim of this study was to assess the efficacy and adverse effects of oral isotretinoin versus acitretin in the treatment of multiple recalcitrant common warts.

METHODS

This study was conducted on 75 adult male patients with recalcitrant multiple common warts. The patients were randomly assigned to three groups: group 1 (30 patients) received oral isotretinoin, group 2 (30 patients) received acitretin, and group 3 received oral placebo (15 patients). The treatment was given daily until complete clearance or for a maximum of 3 months.

RESULTS

Complete clearance of the treated lesions was observed in 18 patients (60%) of the isotretinoin group, in 22 patients (73.3%) of the acitretin group, and in 0 patients (0%) of the placebo group. A statistically significant difference was observed in the therapeutic response between the treatment groups, and the placebo group was observed. Adverse effects of the used drugs were mild and transient.

CONCLUSION

Oral isotretinoin and acitretin are promising effective modalities with minimal side effects for the treatment male patients with multiple recalcitrant common warts with a relative superiority of acitretin.

An Improved Protocol for Comprehensive Etiological Characterization of Skin Warts and Determining Causative Human Papillomavirus Types in 128 Histologically Confirmed Common Warts

Human papillomaviruses (HPVs) are etiologically associated with various benign and malignant neoplasms of cutaneous and mucosal epithelia. We describe an improved diagnostic protocol for comprehensive characterization of causative HPV types in common warts, in which broad-spectrum PCRs followed by Sanger sequencing, two previously described and seven newly developed type-specific quantitative real-time PCRs (qPCRs) coupled with the human beta-globin qPCR were used for: (i) diagnosis of HPV infection in warts; (ii) estimation of cellular viral loads of all HPV types detected; and (iii) determination of their etiological role in 128 histologically confirmed fresh-frozen common wart tissue samples. A total of 12 different causative HPV types were determined in 122/126 (96.8%) HPV-positive warts, with HPV27 being most prevalent (27.0%), followed by HPV57 (26.2%), HPV4 (15.1%), HPV2 (13.5%), and HPV65 (7.9%). The cellular viral loads of HPV4 and HPV65 were estimated for the first time in common warts and were significantly higher than the viral loads of HPV2, HPV27, and HPV57. In addition, we showed for the first time that HPV65 is etiologically associated with the development of common warts in significantly older patients than HPV27 and HPV57, whereas HPV4-induced warts were significantly smaller than warts caused by HPV2, HPV27, HPV57, and HPV65.

Cost-utility study of home-based cryotherapy device for wart treatment: a randomized, controlled, and investigator-blinded trial

BACKGROUND

Cryotherapy is typically performed by physicians. No cost-utility studies of home-based cryotherapy have been reported.

OBJECTIVES

To study the cost utility of home-based cryotherapy devices and in-hospital liquid nitrogen therapy for cutaneous warts.

MATERIALS AND METHODS

This randomized, controlled, investigator-blinded trial was carried out on patients with cutaneous warts. Participants were randomly assigned to two groups: home-based cryotherapy and in-hospital liquid nitrogen therapy. Clinical examinations were conducted at baseline and monthly until cure, and outcomes (cure rate, side effects, total costs, and quality of life) were compared. A cost-utility analysis was performed.

RESULTS

Nineteen of 22 patients completed the treatment and were analyzed. The efficacy of home-based cryotherapy and in-hospital therapy was 72.8% and 64.3%, respectively. Side effects (pain, redness, and burning) were observed. The mean numbers of medical visits were 2.83 for home-based therapy and 3.30 for in-hospital therapy. The total costs for home-based therapy and the in-hospital therapy were US $76.03 and $100.45, respectively. The home-based therapy had 0.2297 quality-adjusted life years, slightly higher than the corresponding value of 0.2254 for in-hospital therapy.

CONCLUSIONS

Home-based cryotherapy devices are a cost-saving strategy with similar efficacy to in-hospital liquid nitrogen therapy.

Verrucae pedis in children with juvenile idiopathic arthritis and other paediatric rheumatic diseases: a cross-sectional study

BACKGROUND

Verrucae pedis (verrucae / VPs) are a common viral infection of the skin seen in children. There are limited studies of the prevalence, duration and impact of verrucae pedis in children who are immunosuppressed. The studies available suggest that, in these children, the warts are more widespread and are more long-standing. The primary aim of this study was to determine the prevalence of verrucae pedis in children attending rheumatology clinics who may have some degree of immunosuppression due to their prescribed medication and compare this to the reported prevalence in the healthy population.

METHOD

Children attending out-patient rheumatology appointments were recruited. The young people were aged between four and 17 years old. A visual inspection of both feet was used to identify potential verrucae. Diagnosis of a verruca pedis was confirmed on observation of the typical clinical features. The location, duration of presence, previous treatments, presence of verrucae in other family members and psychological impact was recorded.

RESULTS

A total of 71 children were included. Of the group, 55 children had no verrucae present, 16 children had one or more verrucae. The prevalence of verrucae was 22.5%. Medication impacting on the immune system was prescribed in 80% of the group. There appeared to be no greater chance of having verrucae if taking immunosuppressive medication than compared to having no medication (OR = 1.1, 95%CI 0.26 to 4.48, p = 0.46). Children with verrucae tended to be between 9 and 12 years old. In total, 37.5% of the young people with verrucae had lesions reportedly present for 24 months or more. Two-thirds of the participants were not concerned about verrucae being present and most participants with a verruca were not aware of what a verruca was, but despite this the majority of participants (81%) had sought treatment for the verrucae.

CONCLUSION

Children with Juvenile Idiopathic Arthritis and other rheumatic conditions have no greater prevalence of verrucae compared to the general population. The verrucae present were of a similar clinical type and did not seem to be more widespread or have atypical features, which has been reported in other immunocompromised populations. The percentage of lesions remaining beyond 24 months was found to be slightly greater than has been reported in other healthy populations. The children in this study seemed to be less emotionally concerned about their verrucae, despite this most families had sought treatment for the verrucae.

Efficacy of the Treatment of Plantar Warts Using 1064 nm Laser and Cooling

Cutaneous plantar warts may be treated using several optional methods, with the use of laser surgery having increased in the last few years. This work examined the efficacy of laser treatment combined with simple cooling to reduce pain. The cure rate was approximately 84%. There were no significant differences in the efficacy of treatment for different viral genotypes. The laser parameters were 500 msec pulses, 30 W of power, and a fluence of 212 J/cm² delivered in up to four sessions. Successful treatment was achieved after an average of 3.6 sessions.

Dermoscopy Features of Cutaneous Warts

Background

Cutaneous warts are benign epithelial skin lesions, caused by human papilloma virus (HPV). These warts can affect any part of the body, and the clinical presentation of cutaneous warts is highly variable, making it difficult to diagnose. Dermoscopy is a relatively new, non-invasive, diagnostic tool, which can assist in the identification of different types of skin lesions.

Purpose

The purpose of this research article is to determine the effectiveness of dermoscopy in discerning the most common characteristics of cutaneous warts, in order to provide sufficient information on characteristic features of cutaneous warts, which may aid in differentiating cutaneous warts from other similar skin lesions.

Patients and Methods

A total of 104 patients diagnosed with warts were included in our study. Each individual case had one of the four different types of warts: common warts (26 cases), palmer warts (27 cases), plantar warts (25 cases), flat warts (26 cases).

Results

In this study, we found that a percentage of cutaneous warts appear clinically nonclassical, overlapping with other lesions. A 42% (11 cases) of common warts were clinically nonclassical, and all of these cases presented with papillomatous growth. Other presentations were dotted, linear vessels, hairpin-like vessels and bleeding spots. All palmar wart cases were classical, while 8% (2 cases) of plantar warts were clinically nonclassical. The dermoscopic presentations were papillomatous growth, bleeding spots, dotted and linear vessels, structureless yellowish-gray appearance. Flat wart consisted of 11.5% (3 cases) with nonclassical clinical presentation. The dermoscopic presentation includes dotted and linear vessels, bleeding spots. Red, whitish (pale) and red-gray backgrounds.

Conclusion

Dermoscopy can improve the accuracy of diagnosing different types of clinically nonclassical cutaneous warts, as well as help in distinguishing them from other similar skin lesions.

A non-invasive method for diagnosing plantar warts caused by human papillomavirus (HPV)

The methods that are used for the diagnostic confirmation of human papillomavirus (HPV) include excisional biopsy and histopathological studies or polymerase chain reaction (PCR). They are invasive, laborious, and subject to ethical restrictions due to the benign nature of these warts. This study aims to analyse the accuracy of noninvasive swab samples to diagnose plantar warts. Fifty plantar warts were included in the study. Skin swabs and hyperkeratosis skin scales were collected from each wart. Multiplex PCR was performed to detect and type the HPVs. The prevalence of HPV in this study was 90% when the sample was obtained using the wart scraping method and 94% when it was obtained using swabs and the new method. In 45 of the 45 positive samples (sensitivity: 100%), the result between the wart scab and wart swab were almost identical. The genotyping result was identical in all 46 patients who had a positive result using both methods. The swab method appears to be a simple and accurate technique to diagnose plantar warts due to HPV. It is a noninvasive technique that could be performed even by inexperienced professionals and in patients with pain or a fear of needles.

Human Papillomavirus Vaccine Efficacy and Effectiveness against Cancer

Human papillomavirus (HPV) is the most common sexually transmitted infection, with 15 HPV types related to cervical, anal, oropharyngeal, penile, vulvar, and vaginal cancers. However, cervical cancer remains one of the most common cancers in women, especially in developing countries. Three HPV vaccines have been licensed: bivalent (Cervarix, GSK, Rixensart, Belgium), quadrivalent (Merck, Sharp & Dome (Merck & Co, Whitehouse Station, NJ, USA)), and nonavalent (Merck, Sharp & Dome (Merck & Co, Whitehouse Station, NJ, USA)). The current HPV vaccine recommendations apply to 9 years old and above through the age of 26 years and adults aged 27–45 years who might be at risk of new HPV infection and benefit from vaccination. The primary target population for HPV vaccination recommended by the WHO is girls aged 9–14 years, prior to their becoming sexually active, to undergo a two-dose schedule and girls ≥ 15 years of age, to undergo a three-dose schedule. Safety data for HPV vaccines have indicated that they are safe. The most common adverse side-effect was local symptoms. HPV vaccines are highly immunogenic. The efficacy and effectiveness of vaccines has been remarkably high among young women who were HPV seronegative before vaccination. Vaccine efficacy was lower among women regardless of HPV DNA when vaccinated and among adult women. Comparisons of the efficacy of bivalent, quadrivalent, and nonavalent vaccines against HPV 16/18 showed that they are similar. However, the nonavalent vaccine can provide additional protection against HPV 31/33/45/52/58. In a real-world setting, the notable decrease of HPV 6/11/16/18 among vaccinated women compared with unvaccinated women shows the vaccine to be highly effective. Moreover, the direct effect of the nonavalent vaccine with the cross-protection of bivalent and quadrivalent vaccines results in the reduction of HPV 6/11/16/18/31/33/45/52/58. HPV vaccination has been shown to provide herd protection as well. Two-dose HPV vaccine schedules showed no difference in seroconversion from three-dose schedules. However, the use of a single-dose HPV vaccination schedule remains controversial. For males, the quadrivalent HPV vaccine possibly reduces the incidence of external genital lesions and persistent infection with HPV 6/11/16/18. Evidence regarding the efficacy and risk of HPV vaccination and HIV infection remains limited. HPV vaccination has been shown to be highly effective against oral HPV type 16/18 infection, with a significant percentage of participants developing IgG antibodies in the oral fluid post vaccination. However, the vaccines’ effectiveness in reducing the incidence of and mortality rates from HPV-related head and neck cancers should be observed in the long term. In anal infections and anal intraepithelial neoplasia, the vaccines demonstrate high efficacy. While HPV vaccines are very effective, screening for related cancers, as per guidelines, is still recommended.

The status of treatment for plantar warts in 2021: No definitive advancements in decades for a common dermatology disease

Plantar warts are among the most common skin conditions and are classically resistant to treatment. To perform an evidence-based evaluation of the efficacy and safety of available treatment options for plantar warts, we conducted a systematic review of PubMed and Cochrane databases to identify large interventional and observational studies involving more than 100 patients who were treated for plantar warts from inception to October 2020. We identified only nine contributions meeting our inclusion criteria (N ≥ 100), representing 1,657 adult and pediatric patients with plantar warts. Treatments included in this review were topical keratolytic agents, cryotherapy, laser therapies, and intralesional and systemic treatments. Our evidence-based review of the larger studies suggests keratolytic agents and destructive treatments, in particular salicylic acid and cryotherapy, remain the primary treatments for plantar warts. Treatment with pulsed dye laser had the lowest rate of recurrence. Newer treatments and intralesional treatments were not represented owing to lack of large studies involving these modalities.

HPV type-specific distribution among family members and linen in households of cutaneous wart patients

Background

Common and plantar warts are caused by human papillomaviruses (HPV). Mode of transmission of wart HPVs within families is largely unknown.

Objective

To demonstrate similarity of HPV type(s) among wart cases, family members and household linen.

Methods

In a cross‐sectional study, swabs taken from 123 warts and foreheads of 62 index patients and 157 family members and from 58 kitchen towels and 59 bathroom mats were tested for DNA of 23 cutaneous wart‐associated HPV types. Generalized estimating equations (GEE) were used to estimate the chance of detecting the same HPV type as was found in the index patients on the family contacts and on the kitchen towels and bathroom mats.

Results

HPV1, HPV2, HPV27 and HPV57 were the most prevalent types in the warts of the index patients. Altogether, 60 (42.3%) of the 142 family members without warts had HPV DNA on their foreheads. When HPV1 and HPV2 were found in the warts, these types were also frequently (>50%) found on the foreheads of index patients and their family members, as well as on the kitchen towels and the bathroom mats. HPV27 and HPV57 were less frequently found (<25%) on foreheads and linen. No associations were found for age, sex and site of HPV DNA presence.

Conclusion

Dissemination of skin wart‐causing HPV types, from wart cases to household contacts and linen, such as kitchen towels and bathroom mats, is more likely for HPV1 and HPV2 than for HPV27 and HPV57. The role of towels and bathroom mats in HPV transmission deserves further investigation.

Linked Commentary A. Kreuter and U. Wieland. J Eur Acad Dermatol Venereol 2022; 36: 11–12. https://doi.org/10.1111/jdv.17820.

A Combination of Herbal Medicine and Moxibustion Treatment is Effective for a Recalcitrant Cutaneous Warts in a Pediatric Patient: A Case Report

Although warts are a common skin condition/disease that recurs in childhood, treatment completion is difficult owing to the pain associated with conventional therapies. In this case, Korean herbal medicine, Guijakjihwang-Tang, and indirect moxibustion was used to treat a recalcitrant cutaneous wart without pain and recurrence. A 7-year-old boy presented with recurrent cutaneous warts on his right hand and received cryotherapy 3 times in the previous year. The wart recurred during the course of cryotherapy treatment, and the patient did not want to suffer any more pain from the previous treatment. Therefore, parents sought an efficient and painless therapy. The patient was treated for 2 months using Guijakjihwang-Tang combined with indirect moxibustion. The prominent lesion separated in the 2nd month of treatment and completely recovered without adverse events in the 3rd month. There was no recurrence over 12 months of follow-up. This report provides meaningful insights into the use of Korean medicine as a safe, painless and efficient treatment for warts in pediatric patients.

Human Papilloma Virus Vaccination

Human papilloma virus (HPV) is the most common sexually transmitted infection worldwide causing a variety of benign and malignant conditions. A significant portion of the global population is infected with HPV, with the virus attributed to causing up to 5% of cancers worldwide. Bivalent, quadrivalent, and nine-valent vaccinations exist to aid in the prevention of these diseases and have been proven to be effective at preventing both benign and malignant disease. While vaccination is readily accessible in more developed countries, barriers exist to worldwide distribution and acceptance of vaccination. Vaccination and screening of HPV infection when used in combination are proven and predicted to decrease HPV related pathology. Improvements in vaccination formulations, for treatment as well as prevention, are actively being sought from a variety of mechanisms. Despite these advancements, and the data supporting their efficacy, there has been substantial delay in obtaining adequate vaccination coverage. In reviewing these challenges and looking forward to new vaccine development—especially within the current pandemic—it is clear from the challenges of HPV we require methods to more effectively encourage vaccination, ways to dispel vaccination myths as they occur, and implement better processes for vaccine distribution globally.

Development and validation of a wart-associated human papilloma virus genotyping assay for detection of HPV in cutaneous warts

Cutaneous warts are infectious disorders caused by human papillomavirus (HPV). A recent study revealed that the HPV genotype influences the natural course and response to treatment for plantar warts, suggesting that HPV genotyping could potentially be used to optimize wart treatment schemes. For this purpose, a wart-associated HPV genotyping assay was developed. The assay was subjected to an intensive validation process including, i.a., empiric determination of the annealing temperature, primer-probe optimization, evaluation of the analytical specificity and sensitivity, viral load quantification, and qualitative as well as quantitative analysis of intra-run repeatability and inter-run reproducibility. The newly developed assay was employed in a small-scale HPV genotyping study of wart biopsies (n = 50). The assay exhibited an analytical type-specific sensitivity and specificity of 100% (95% confidence interval [CI]: 83.9%-100%). The limit of quantification of the tested sequences corresponded to less than 17 viral copies/µl, while the limit of detection was less than 5 copies/µl. Very good to excellent agreements were gained between intra- and inter-run measurements (κ = 0.85-1.00) and coefficients of variation of the quantitative agreements were less then 3%. 22.5% (95% CI: 11%-39%) of the analyzed biopsies were negative for the tested HPV types, while 35% (95% CI: 21%-52%) contained multiple infections. The wart-associated HPV quantitative polymerase chain reaction assay was proven to be highly sensitive and specific. Multiple HPV infections were detected in 35% of lesions, contradicting the current literature claiming that in immunocompetent patients only 4%-16% of warts exhibit multiple HPV infections. This assay is qualified to be implemented in development of future genotype specific wart treatment strategies.

Human Papillomavirus-type distribution in anogenital lesions of prepubertal children

BACKGROUND

In contrast to adults, only limited data are available on the human papillomavirus (HPV)-type spectrum in anogenital warts (AGW) of children.

OBJECTIVE

This study aimed to evaluate the HPV-type spectrum in AGW of prepubertal children.

MATERIALS & METHODS

In a retrospective German multicentre study, HPV genotyping was performed in AGW biopsies of 55 1- to 12-year-old children using HPV group-specific PCRs followed by hybridization with type-specific probes or sequence analysis.

RESULTS

Human papillomavirus-DNA was found in 53 of the 55 AGW. In 58.5% (31/53) of the HPV-positive AGW, mucosal HPV types were detected. HPV6 (27/53, 50.9%) was the predominant type. 43.4% (23/53) of the lesions were induced by cutaneous HPV types (HPV2, HPV27, HPV57). Mucosal HPV types were significantly more common in children under 5 years of age than in children 5 years of age and older (22/25, 88.0% [95% CI: 70.0-95.8] vs. 9/28, 32.1% [95% CI: 17.9-50.7], P < 0.001). In contrast, cutaneous HPV types were significantly more prevalent in the 5- to 12-year age group (4/25, 16.0% [95% CI 6.4-34.7] vs. 19/28, 67.9% [95% CI 49.3-82.1], P < 0.001).

CONCLUSION

Anogenital warts in 5- to 12-year-old children are frequently associated with cutaneous HPV types, possibly due to horizontal transmission. HPV typing, in addition to comprehensive clinical and psychosocial evaluation, can potentially help in the assessment of these cases.

Efficacy of retinoids alone or in combination with other remedies in the management of warts: A systematic review and network meta-analysis

The use of combined systemic retinoids and intralesional immunotherapy in the management of warts is still debatable without straightforward evidence. Through network meta-analysis, the current study evaluated the efficacy and safety of systemic retinoids alone or combined with other remedies in the treatment of warts. We searched six literature databases for clinical trials that compared systemic retinoids to local treatments or placebo in wart management. Outcomes were calculated as odds ratios (OR) with 95% confidence-interval. We used the R software to perform conventional and network meta-analyses (with a frequentist approach). Network meta-analysis of eight trials showed that oral acitretin plus intralesional Candida Ag (OR = 367.71), INF-α plus oral isotretinoin (OR = 223.77), oral acitretin (OR = 117), Candida Ag (OR = 91.93), oral isotretinoin (OR = 62.26) and topical isotretinoin (OR = 17.69) had higher complete recovery rates than placebo. Regarding the P-score, oral acitretin plus intralesional Candida Ag had the highest efficacy in achieving complete response (P-score = 0.88), followed by INF-α plus oral isotretinoin (P-score = 0.79), then oral acitretin (P-score = 0.60). Variable baseline characteristics and lack of data on some outcomes. The current study shows the efficacy for systemic retinoids in the treatment of warts, especially reluctant or recurrent types. Moreover, combinations of systemic retinoids with intralesional immunotherapy yield higher rates of complete clearance with lower recurrence.

Epidemiology and Burden of Human Papillomavirus and Related Diseases, Molecular Pathogenesis, and Vaccine Evaluation

Diagnosed in more than 90% of cervical cancers, the fourth deadliest cancer in women, human papillomavirus (HPV) is currently the most common pathogen responsible for female cancers. Moreover, HPV infection is associated with many other diseases, including cutaneous and anogenital warts, and genital and upper aerodigestive tract cancers. The incidence and prevalence of these pathologies vary considerably depending on factors including HPV genotype, regional conditions, the study population, and the anatomical site sampled. Recently, features of the cervicovaginal microbiota are found to be associated with the incidence of HPV-related diseases, presenting a novel approach to identify high-risk women through both blood and cervical samples. Overall, the HPV repartition data show that HPV infection and related diseases are more prevalent in developing countries. Moreover, the available (2-, 4-, and 9-valent) vaccines based on virus-like particles, despite their proven effectiveness and safety, present some limitations in terms of system development cost, transport cold chain, and oncogenic HPV variants. In addition, vaccination programs face some challenges, leading to a considerable burden of HPV infection and related diseases. Therefore, even though the new (9-valent) vaccine seems promising, next-generation vaccines as well as awareness programs associated with HPV vaccination and budget reinforcements for immunization are needed.

Global gene methylation profiling of common warts caused by human papillomaviruses infection

Infection with the human papillomaviruses (HPV) often involves the epigenetic modification of the host genome. Despite its prevalence among the population, host genome methylation in HPV-induced warts is not clearly understood. In this study, genome-wide methylation profiling was carried out on paired healthy skin and wart samples in order to investigate the effects that benign HPV infection has on gene methylation status. To overcome this gap in knowledge, paired wart (n = 12) and normal skin (n = 12) samples were obtained from Arab males in order to perform DNA extraction and subsequent genome-wide methylation profiling on the Infinium Methylation EPIC Bead Chip microarray. Analysis of differential methylation revealed a clear pattern of discrimination between the wart and normal skin samples. In warts, the most differentially methylated (DM) genes included long non-coding RNAs (AC005884, AL049646.2, AC126121.2, AP001790.1, and AC107959.3), microRNAs (MIR374B, MIR596, MIR1255B1, MIR26B, and MIR196A2),snoRNAs (SNORD114-22, SNORD70, and SNORD114-31), pseudogenes (AC069366.1, RNU4ATAC11P, AC120057.1, NANOGP3, AC106038.2, TPT1P2, SDC4P, PKMP3, and VN2R3P), and protein-coding genes (AREG, GJB2, C12orf71, AC020909.2, S100A8, ZBED2, FABP7, and CYSLTR1). In addition, pathway analysis revealed that, among the most differentially methylated genes, STAT5A, RARA, MEF2D, MAP3K8, and THRA were the common regulators. It can be observed that HPV-induced warts involve a clear and unique epigenetic alteration to the host genome.

The Bacillus Calmette-Guérin (BCG) Vaccine: Is it a better choice for the treatment of viral warts?

Objectives

This study aimed to compare the effectiveness of the bacillus Calmette-Guérin (BCG) vaccine with topical salicylic acid (SA) in the treatment of viral warts.

Methods

This non-randomised controlled trial was conducted at the Al-Sader Teaching Hospital, Basrah, Iraq, from January 2016 to April 2017. A total of 201 patients with viral warts were injected with an intradermal purified protein derivative. Subsequently, those with negative tuberculin test results received an intradermal BCG vaccination, while those with positive results underwent conventional treatment with topical SA. Patients were assessed for any signs of improvement at one, two and three months.

Results

Overall, 190 patients completed the trial; of these, 133 (70%) received the BCG vaccine and 57 (30%) were treated with topical SA. Complete response to treatment was observed in 9.8% and 5.3% of patients in the BCG and SA groups, respectively (P <0.001). Cure rates were significantly higher for patients with genital (22.2% versus 7.7%; P = 0.002) and common warts (8.5% versus 0%; P = 0.001) treated with the BCG vaccine; however, the reverse was true for flat warts (12.9% versus 25%; P = 0.041). A binary logistic regression analysis indicated that BCG therapy was the only significant independent predictor of positive treatment response (odds ratio: 7.56, 95% confidence interval: 3.72-15.36; P <0.001).

Conclusion

The BCG vaccine was more effective than topical SA for treating viral warts, with the best response noted in the treatment of genital warts, followed by flat warts. However, plantar warts demonstrated least response to this treatment.

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.

Genotyping of 30 kinds of cutaneous human papillomaviruses by a multiplex microfluidic loop-mediated isothermal amplification and visual detection method

Background

Human papillomaviruses (HPVs), a group of non-enveloped small viruses with double-stranded circular DNA which lead to multiple skin diseases such as benign warts, are commonly seen in clinics. The current HPV detection systems aim mainly at mucosal HPVs, however, an efficient clinical approach for cutaneous HPVs detection is lacking.

Objectives

To establish a rapid detection system for cutaneous HPVs using a colorimetric loop-mediated isothermal amplification (LAMP) with hydroxynaphthol blue (HNB) dye in combination with microfluidic technology.

Methods

L1 DNA sequences of the 30 cutaneous HPVs were chemically synthesized, and LAMP primers against L1 DNA were designed with use of an online LAMP designing tool. Isothermal amplification was performed with use of a water bath and the amplification results were inspected with the naked eye. Using PCR sequencing as a control method, the specificity and sensitivity of the new detection system were obtained by detecting clinical samples.

Results

The lower detection limit of the LAMP assay was 10⁷ viral DNA copies/μl when tested on synthesized L1 DNA sequences, which was better than the conventional PCR. Compared to PCR sequencing, the sensitivity of HPV27, HPV2, HPV1, HPV57, HPV3, HPV4, HPV7 and HPV75 genotypes detections were 100%, whereas the specificity was 34.55, 45.12, 95.83, 98.59 and 97.62% respectively, when tested on clinical samples.

Conclusions

The new cutaneous type HPV detection system is characterized by both a good sensitivity and specificity compared to conventional methods.

Comparison of 40% trichloroacetic acid and cryotherapy for the treatment of plantar warts: A single-blind, randomized clinical trial

Plantar warts can cause pain near the toes and the sole of the foot and may result in referral for treatment. This study was aimed at comparing 40% trichloroacetic acid (TCA) and cryotherapy (Cryo) for the treatment of plantar warts. This single-blind, randomized clinical trial was performed on 60 subjects presenting with plantar wart in Sabzevar, Iran in 2018. The first intervention group was treated with 40% TCA in four sessions within 4 weeks. The second intervention group was treated with Cryo using liquid nitrogen in four sessions within 8 weeks. The mean (SD) age of subjects was 20.16 ± 5.96 years and 68.33% (n = 41) were male. Although the resolution rate of warts in the TCA 40% group was greater than the Cryo group, there was no statistical association found between the two groups by adjusting age, sex, and basal time (P = .648). Findings suggest that although 40% TCA was almost as effective as Cryo in the treatment of plantar warts, considering the lower adverse effects of TCA 40% group as compared to the Cryo group, it could be a proper alternative.

A comprehensive review of treatment options for recalcitrant nongenital cutaneous warts

Introduction: The treatment of recalcitrant nongenital cutaneous warts has always been challenging for dermatologists as they often recur and relapse. Multiple treatment options have been investigated to improve the outcome. This review provides an overview of the current treatment modalities and summarizes the efficacy and side effects of each treatment option for recalcitrant nongenital cutaneous warts.Methods: A PubMed search was performed through July 2019 to include all English language reports investigating the treatment for recalcitrant nongenital cutaneous warts, regardless of design.Results: A total of 144 studies were included in this review. The treatment options for recalcitrant nongenital cutaneous warts can be divided into three groups: destructive treatment, immunotherapy, and cytotoxic agents. Although both destructive therapies and cytotoxic agents demonstrated high complete response rates, immunotherapy, which is a minimally invasive method, was superior in terms of the clearance of distant warts. Intralesional mumps-measles-rubella injections and purified protein derivatives currently demonstrate high efficacy with well-established clinical evidence.Conclusions: Many upcoming treatment modalities, especially immunotherapy, are promising. However, more comparative studies are required to verify the efficacy and safety profile.

Determination of Causative Human Papillomavirus Type in Tissue Specimens of Common Warts Based on Estimated Viral Loads

Background: Assessment of human papillomavirus (HPV) type-specific viral load (VL) is a valid tool for determining the etiology of HPV-related skin tumors, especially when more than one HPV type is detected within one lesion.

Methods: The causative HPV type was determined in 185 fresh-frozen tissue specimens of histologically confirmed common warts (CWs) collected from 121 immunocompetent patients. All tissues were tested using the type-specific quantitative real-time polymerase chain reactions (PCR) for the most common wart-associated Alpha-PV (HPV2/27/57) and Mu-PV types (HPV1/63/204). The presence of 23 additional low-risk HPVs was evaluated using a conventional wide-spectrum PCR.

Results: HPV DNA was detected in 176/185 (95.1%) CWs and multiple HPV types in 71/185 (38.4%) lesions. Using the VL approach and a robust cutoff of one viral copy/cell established in this study, HPV2/27/57 were determined as causative agents in 41/53 (77.3%) and 53/71 (74.7%) CWs with single and multiple HPVs, respectively.

Conclusions: CWs are mostly etiologically associated with HPV2/27/57 and only rarely with HPV1. In the majority of CWs containing multiple HPVs, a single HPV type was present in high concentration, indicating etiological association. No significant differences in VLs of lesion-causing HPV types in CWs containing single or multiple HPVs were found.

Prevalence of HPV Genotypes in Adult Male Patients with Cutaneous Warts: A Cross-Sectional Study

AIM

This study was aimed at determining the distribution of type-specific human papillomavirus (HPV) in men with cutaneous warts and correlating this with the clinical and morphological presentation of warts.

METHODS

Cutaneous wart samples were obtained from 167 adult men presenting to a dermatology clinic. The tissues were fixed and screened for HPV DNA using real-time PCR. The HPV genotype was determined by PCR-based sequencing.

RESULTS

Nine different HPV genotypes were detected, comprising 6 from the α genus (HPV2, 6, 27b, 57b, 57c, and 94), 2 from the γ genus (HPV4 and 65), and HPV1a from the mu genus. Single HPV infection was encountered in 93.4% of the patients, whereas multiple infections were encountered in only 6.6%. The prevalence of HPV27b was highest among four body sites, followed by HPV57c, 1a, and 2. HPV1a was the most common genotype encountered in multiple infections, followed by HPV27b. Patient age, the number of warts, the duration of the presence of warts, and contact with people who have warts were not predictors of wart location. However, a high number of patients with palmar or common body warts had wart sizes of <1 cm.

CONCLUSIONS

This study shows that genus α HPV types are detected in about 82% of patients with cutaneous warts.

Genome-Wide Tiling Array Analysis of HPV-Induced Warts Reveals Aberrant Methylation of Protein-Coding and Non-Coding Regions

The human papillomaviruses (HPV) are a group of double-stranded DNA viruses that exhibit an exclusive tropism for squamous epithelia. HPV can either be low- or high-risk depending on its ability to cause benign lesions or cancer, respectively. Unsurprisingly, the majority of epigenetic research has focused on the high-risk HPV types, neglecting the low-risk types in the process. Therefore, the main objective of this study is to better understand the epigenetics of wart formation by investigating the differences in methylation between HPV-induced cutaneous warts and normal skin. A number of clear and very significant differences in methylation patterns were found between cutaneous warts and normal skin. Around 55% of the top-ranking 100 differentially methylated genes in warts were protein coding, including the EXOC4, KCNU, RTN1, LGI1, IRF2, and NRG1 genes. Additionally, non-coding RNA genes, such as the AZIN1-AS1, LINC02008, and MGC27382 genes, constituted 11% of the top-ranking 100 differentially methylated genes. Warts exhibited a unique pattern of methylation that is a possible explanation for their transient nature. Since the genetics of cutaneous wart formation are not completely known, the findings of the present study could contribute to a better understanding of how HPV infection modulates host methylation to give rise to warts in the skin.

Gene Expression Profiling of MicroRNAs in HPV-Induced Warts and Normal Skin

: Infection with the human papillomavirus (HPV) is a common occurrence among the global population, with millions of new cases emerging on an annual basis. Dysregulated microRNA (miRNA) expression is increasingly being identified to play a role in a number of different diseases, especially in the context of high-risk HPV infection. The present study investigated the miRNA expression profiles of warts induced by low-risk HPV. In warts, miR-27b, miR-24-1, miR-3654, miR-647, and miR-1914 were downregulated while miR-612 was upregulated compared to normal skin. Using miRTargetLink Human, experimentally supported evidence was obtained showing that miR-27b targeted the vascular endothelial growth factor C (VEGFC) and CAMP-responsive element binding protein 1 (CREB1) genes. The VEGFC and CREB1 genes have been reported to be involved in tumorigenesis and wart formation, respectively. Similarly, the oxidized low-density lipoprotein receptor 1 (OLR1) gene, which plays an important role in the humoral immunity of the skin, and the plexin D1 (PLXND1) gene, which is highly expressed in tumor vasculature, were both found to be common targets of miR-27b, miR-1914, and miR-612.

Real-life treatment of cutaneous warts with cantharidin podophyllin salicylic acid solution

Patients often request treatment of their burdensome cutaneous warts. However, a safe and effective treatment for cutaneous warts is lacking. This study evaluates treatment outcome, side effects, and patient satisfaction after topical application of cantharidin 1% podophyllin 2% salicylic acid 30% (CPS1) solution in a large series of children and adults with cutaneous warts. Fifty‐two children and 83 adults with warts, treated with CPS1 solution between October 2012 and October 2014, were included. Complete clearance of warts occurred in 86.5% of children and 62.7% of adults treated with CPS1 solution (p < .01). Resolution of warts was partial in 3.9 and 24.1% and absent in 9.6 and 13.2% of children and adults respectively. Side effects were present in 41.2% of children and 46.3% of adults (p = .7). Most common side effects were blistering, pain, and burning sensation. No serious adverse events occurred. On a 10‐point scale, median patient satisfaction score was 9.0 (interquartile range 7.8–10.0) and 8.0 (interquartile range 5.1–9.7) for children and adults respectively (p < .01). CPS1 solution is a safe and promising treatment modality with a high clearance and high patient satisfaction rate for the management of cutaneous warts, particularly in children.

The Relationship between the Soluble Receptor for Advanced Glycation End Products and Oxidative Stress in Patients with Palmoplantar Warts

Background and objectives: Warts are the most common lesions caused by human papillomavirus (HPV). Recent research suggests that oxidative stress and inflammation are involved in the pathogenesis of HPV-related lesions. It has been shown that the soluble receptor for advanced glycation end products (sRAGE) may act as a protective factor against the deleterious effects of inflammation and oxidative stress, two interconnected processes. However, in HPV infection, the role of sRAGE, constitutively expressed in the skin, has not been investigated in previous studies. Materials and Methods: In order to analyze the role of sRAGE in warts, we investigated the link between sRAGE and the inflammatory response on one hand, and the relationship between sRAGE and the total oxidant/antioxidant status (TOS/TAS) on the other hand, in both patients with palmoplantar warts (n = 24) and healthy subjects as controls (n = 28). Results: Compared to the control group, our results showed that patients with warts had lower levels of sRAGE (1036.50 ± 207.60 pg/mL vs. 1215.32 ± 266.12 pg/mL, p < 0.05), higher serum levels of TOS (3.17 ± 0.27 vs. 2.93 ± 0.22 µmol H2O2 Eq/L, p < 0.01), lower serum levels of TAS (1.85 ± 0.12 vs. 2.03 ± 0.14 µmol Trolox Eq/L, p < 0.01) and minor variations of the inflammation parameters (high sensitivity-CRP, interleukin-6, fibrinogen, and erythrocyte sedimentation rate). Moreover, in patients with warts, sRAGE positively correlated with TAS (r = 0.43, p < 0.05), negatively correlated with TOS (r = −0.90, p < 0.01), and there was no significant correlation with inflammation parameters. There were no significant differences regarding the studied parameters between groups when we stratified the patients according to the number of the lesions and disease duration. Conclusions: Our results suggest that sRAGE acts as a negative regulator of oxidative stress and could represent a mediator involved in the development of warts. However, we consider that the level of sRAGE cannot be used as a biomarker for the severity of warts. To the best of our knowledge, this is the first study to demonstrate that sRAGE could be involved in HPV pathogenesis and represent a marker of oxidative stress in patients with warts.

Genome-Wide CpG Island Methylation Profiles of Cutaneous Skin with and without HPV Infection

HPV infection is one of the most commonly transmitted diseases among the global population. While it can be asymptomatic, non-genital HPV infection often gives rise to cutaneous warts, which are benign growths arising from the epidermal layer of the skin. This study aimed to produce a global analysis of the ways in which cutaneous wart formation affected the CpG island methylome. The Infinium MethylationEPIC BeadChip microarray was utilized in order to quantitatively interrogate CpG island methylation in genomic DNA extracted from 24 paired wart and normal skin samples. Differential methylation analysis was carried out by means of assigning a combined rank score using RnBeads. The 1000 top-ranking CpG islands were then subject to Locus Overlap Analysis (LOLA) for enrichment of genomic ranges, while signaling pathway analysis was carried out on the top 100 differentially methylated CpG islands. Differential methylation analysis illustrated that the most differentially methylated CpG islands in warts lay within the ITGB5, DTNB, RBFOX3, SLC6A9, and C2orf27A genes. In addition, the most enriched genomic region sets in warts were Sheffield's tissue-clustered DNase hypersensitive sites, ENCODE's segmentation and transcription factor binding sites, codex sites, and the epigenome sites from cistrome. Lastly, signaling pathway analysis showed that the GRB2, GNB1, NTRK1, AXIN1, and SKI genes were the most common regulators of the genes associated with the top 100 most differentially methylated CpG islands in warts. Our study shows that HPV-induced cutaneous warts have a clear CpG island methylation profile that sets them apart from normal skin. Such a finding could account for the temporary nature of warts and the capacity for individuals to undergo clinical remission.

Human Papillomavirus Infection of the Skin

CONTEXT

- Human papillomavirus is implicated in the pathogenesis of benign and malignant neoplasms of the skin.

OBJECTIVE

- To review the role of human papillomavirus in the development of malignancies and their precursor lesions in skin.

DATA SOURCES

- The study comprised a review of the literature.

CONCLUSIONS

- The use of low-grade squamous intraepithelial lesion and high-grade squamous intraepithelial lesion terminology brings order and simplicity to these lesions, correlates with the current understanding of the biology of human papillomavirus infections, and helps to promote accurate diagnosis of and appropriate treatment for these lesions.

Novel Approaches for Vaccination Against HPV-Induced Cancers

To date, more than 5 % of all cancers are as a result of human papillomavirus (HPV) infection, and this incidence is increasing. Early recognition of disease is associated with good survival, but late presentation results in devastating consequences. Prevention is better than cure, and there are now successful prophylactic vaccination programmes in place. We discuss these and the prospect of therapeutic vaccinations in the near future to address a growing need for improved therapeutic options.

The human papillomavirus vaccine as a treatment for human papillomavirus-related dysplastic and neoplastic conditions: A literature review

BACKGROUND

Human papillomavirus (HPV) infections are associated with common dermatologic and nondermatologic diseases. Although HPV vaccines are well established as preventive measures for genital warts and cervical neoplasia, their use as therapeutic agents deserves greater attention.

OBJECTIVE

To evaluate the use of HPV vaccine(s) as a treatment modality for cutaneous and/or mucosal disease.

METHODS

A primary literature search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted in January 2019 by using the PubMed and Cochrane databases.

RESULTS

A total of 63 articles with 4439 patients were included. The majority of patients with cutaneous warts, recurrent respiratory papillomatosis, and squamous and basal cell carcinomas were successfully treated with HPV vaccination. Preliminary data on patients with pre-existing anogenital warts, cervical intraepithelial neoplasia, anal intraepithelial neoplasia, and vulvar intraepithelial neoplasia is promising.

LIMITATIONS

This review was limited by the lack of controls, patients' previous HPV vaccination status, and publication bias.

CONCLUSION

The commercially available three-dose, quadrivalent HPV vaccine is a potential therapeutic option for the treatment of cutaneous warts, recurrent respiratory papillomatosis, and squamous and basal cell carcinomas. Noncommercially available HPV vaccines demonstrate therapeutic response for treating anogenital warts, cervical intraepithelial neoplasia, anal intraepithelial neoplasia, and vulvar intraepithelial neoplasia. The vaccine's efficacy as an adjunct therapy for HPV-associated cutaneous and/or mucosal disease warrants further exploration.

Mucosal and Cutaneous Human Papillomavirus Infections and Cancer Biology

Papillomaviridae is a family of small non-enveloped icosahedral viruses with double-stranded circular DNA. More than 200 different human papillomaviruses (HPVs) have been listed so far. Based on epidemiological data, a subgroup of alphapapillomaviruses (alpha HPVs) was referred to as high-risk (HR) HPV types. HR HPVs are the etiological agents of anogenital cancer and a subset of head and neck cancers. The cutaneous HPV types, mainly from beta and gamma genera, are widely present on the surface of the skin in the general population. However, there is growing evidence of an etiological role of betapapillomaviruses (beta HPVs) in non-melanoma skin cancer (NMSC), together with ultraviolet (UV) radiation. Studies performed on mucosal HR HPV types, such as 16 and 18, showed that both oncoproteins E6 and E7 play a key role in cervical cancer by altering pathways involved in the host immune response to establish a persistent infection and by promoting cellular transformation. Continuous expression of E6 and E7 of mucosal HR HPV types is essential to initiate and to maintain the cellular transformation process, whereas expression of E6 and E7 of cutaneous HPV types is not required for the maintenance of the skin cancer phenotype. Beta HPV types appear to play a role in the initiation of skin carcinogenesis, by exacerbating the accumulation of UV radiation-induced DNA breaks and somatic mutations (the hit-and-run mechanism), and they would therefore act as facilitators rather than direct actors in NMSC. In this review, the natural history of HPV infection and the transforming properties of various HPV genera will be described, with a particular focus on describing the state of knowledge about the role of cutaneous HPV types in NMSC.

Safety and Plasma Concentrations of a Cyclin-dependent Kinase 9 (CDK9) Inhibitor, FIT039, Administered by a Single Adhesive Skin Patch Applied on Normal Skin and Cutaneous Warts

Background

Cutaneous warts are caused by human papilloma virus (HPV) infection. FIT039, a specific inhibitor of CDK9, suppresses the proliferation of DNA viruses in vitro.

Purpose

We evaluated the safety, plasma concentrations, and efficacy of FIT039 delivered by single application of an adhesive skin patch on normal back skin and cutaneous warts.

Patients and Methods

In this placebo-controlled, dose-escalation, open-label, two-cohort phase I/II clinical trial, after a single administration of a 1% FIT039 patch, 3% FIT039 patch, or placebo on back skin, patients with cutaneous warts were treated with cryotherapy followed by a 1% FIT039 patch for 24 h in the first cohort. In the second cohort, cutaneous warts were treated with cryotherapy followed by a 3% FIT039 patch for 24 h. Adverse events and adverse drug reactions, the concentrations of FIT039, and surface area of cutaneous warts were evaluated.

Results

Neither irritant reactions nor symptoms related to FIT039 occurred when the FIT039 patches were applied to patients’ backs or on warts in ten patients. The concentrations of FIT039 were under 0.1 ng/ml at every time point. The median wart surface area at 1 week after application of the 1% FIT039 patch was similar to baseline, while that of the 3% FIT039 patch was smaller than baseline.

Conclusion

The FIT039 patch showed no topical or systemic adverse reactions when applied on normal skin or cutaneous warts. The safety and good adherence of the FIT039 patch are encouraging and support further studies to evaluate the efficacy of FIT039 in patients with cutaneous warts.

Electronic supplementary material

The online version of this article (10.1007/s40261-018-0712-7) contains supplementary material, which is available to authorized users.

The interaction of high and low-risk human papillomavirus genotypes increases the risk of developing genital warts: A population-based cohort study

Cervical cancer is among the most common type of cancers in women and is associated with human papillomavirus (HPV) infection. Genital warts are also reported to be linked with HPV infection types 11 and 6. In turn, clinical characteristics and morphological features of warts may be useful in the prediction of prognosis and in making treatment decisions. Thus, we have investigated the association of high and low-risk HPVs genotype with genital wart risk, as well as pathological and cytological information in cases recruited from a population-based cohort study of 1380 patients. Patients infected with HPV genotype 6 or 11 had an increased risk of having warts, with OR of 2.34 (95% CI: 0.955-5.737, P = 0.06). Also, this association was enhanced in the presence of high plus low-risk HPV for having genital wart (OR: 2.814; 95%: 1.208-6.55, P = 0.017) and cases having high-risk HPV (OR: 2.329; 95% CI: 1.029-5.269, P = 0.042). Moreover, we observed patients with genital warts having CIN2/3, indicating the importance of informing the physician to the patient to prevent more severe lesions. Our data demonstrated that patients with both low/high-risk HPV types had an increased risk of developing genital warts and persistent infection with HPV was a necessary precursor for the increase in cervical lesions.

Stereophotogrammetric three-dimensional photography is an accurate and precise planimetric method for the clinical visualization and quantification of human papilloma virus-induced skin lesions

Background

The quantification of human papilloma virus (HPV)‐induced skin lesions is essential for the clinical assessment of the course of disease and the response to treatment. However, clinical assessments that measure dimensions of lesions using a caliper do not provide complete insight into three‐dimensional (3D) lesions, and its inter‐rater variability is often poor.

Objective

The aim of this study was to validate a stereophotogrammetric 3D camera system for the quantification of HPV‐induced lesions.

Methods

The camera system was validated for accuracy, precision and interoperator and inter‐rater variability. Subsequently, 3D photographs were quantified and compared to caliper measurements for clinical validation by Bland–Altman modelling, based on data from 80 patients with cutaneous warts (CW), 24 with anogenital warts (AGW) patients and 12 with high‐grade squamous intraepithelial lesions of the vulva (vulvar HSIL) with a total lesion count of 220 CW, 74 AGW and 31 vulvar HSIL.

Results

Technical validation showed excellent accuracy [coefficients of variation (CV) ≤ 0.68%] and reproducibility (CVs ≤ 2%), a good to excellent agreement between operators (CVs ≤ 8.7%) and a good to excellent agreement between different raters for all three lesion types (ICCs ≥ 0.86). When comparing 3D with caliper measurements, excellent biases were found for diameter of AGW (long diameter 5%), good biases were found for diameter of AGW (short diameter 10%) and height of CW (8%), and acceptable biases were found for the diameter of CW (11%) and vulvar HSIL (short diameter 14%, long diameter 16%). An unfavourable difference between these methods (bias 25%) was found for the assessment of height of AGWs.

Conclusion

Stereophotogrammetric 3D imaging is an accurate and reliable method for the clinical visualization and quantification of HPV‐induced skin lesions.

Linked Commentary: M. Skerlev et al. J Eur Acad Dermatol Venereol 2019; 33: 1445–1446. https://doi.org/10.1111/jdv.15791.

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/

Prevalence and factors associated with warts in primary school children in Tema District, Sohag Governorate, Egypt

BACKGROUND

Warts are one of the most common, persistent, and frustrating cutaneous problems encountered in dermatology clinical practice especially in younger generations.

OBJECTIVE

To determine the prevalence of warts in primary school children in Tema District, Sohag, Egypt, and to determine possible factors associated with transmission.

PARTICIPANTS AND METHODS

A school-based cross-sectional (prevalence) study was carried out during the academic year 2015-2016 in six primary schools in Tema District, Sohag Governorate, Egypt. A total of 1045 students were examined. Data was collected using a self-administered semi-structured questionnaire which was taken home by the student to be completed by his/her caregiver.

RESULTS

Among 1045 examined school students, 108 students were diagnosed as having warts with a prevalence rate of 10.3%. Common wart was the most common type among students (49.0%) followed by plantar and plane warts (24.1%, each) while genital wart was the least one (2.8%). There was no significant sex or age difference. The prevalence of warts was significantly higher among students from public schools, rural areas, and big families; students with lower paternal education level; and students who were sharing shoes, walking barefoot, having contact with house pets, or exposed to water channels.

CONCLUSION

Warts, especially the common variant, are highly prevalent in primary school children. The significant factors associated with the development of warts in these children were big family size and sharing shoes. Other significant associated factors included living in rural areas, attending public schools, illiterate parents, fathers with manual work, and swimming in water canals.

Metagenomic Discovery of 83 New Human Papillomavirus Types in Patients with Immunodeficiency

Although some members of the viral family Papillomaviridae cause benign skin warts (papillomas), many human papillomavirus (HPV) infections are not associated with visible symptoms. For example, most healthy adults chronically shed Gammapapillomavirus (Gamma) virions from apparently healthy skin surfaces. To further explore the diversity of papillomaviruses, we performed viromic surveys on immunodeficient individuals suffering from florid skin warts. Our results nearly double the number of known Gamma HPV types and suggest that WHIM syndrome patients are uniquely susceptible to Gamma HPV-associated skin warts. Preliminary results suggest that treatment with the drug plerixafor may promote resolution of the unusual Gamma HPV skin warts observed in WHIM patients.

Several immunodeficiencies are associated with high susceptibility to persistent and progressive human papillomavirus (HPV) infection leading to a wide range of cutaneous and mucosal lesions. However, the HPV types most commonly associated with such clinical manifestations in these patients have not been systematically defined. Here, we used virion enrichment, rolling circle amplification, and deep sequencing to identify circular DNA viruses present in skin swabs and/or wart biopsy samples from 48 patients with rare genetic immunodeficiencies, including patients with warts, hypogammaglobulinemia, infections, myelokathexis (WHIM) syndrome, or epidermodysplasia verruciformis (EV). Their profiles were compared with the profiles of swabs from 14 healthy adults and warts from 6 immunologically normal children. Individual patients were typically infected with multiple HPV types; up to 26 different types were isolated from a single patient (multiple anatomical sites, one time point). Among these, we identified the complete genomes of 83 previously unknown HPV types and 35 incomplete genomes representing possible additional new types. HPV types in the genus Gammapapillomavirus were common in WHIM patients, whereas EV patients mainly shed HPVs from the genus Betapapillomavirus. Preliminary evidence based on three WHIM patients treated with plerixafor, a leukocyte mobilizing agent, suggest that longer-term therapy may correlate with decreased HPV diversity and increased predominance of HPV types associated with childhood skin warts.

IMPORTANCE Although some members of the viral family Papillomaviridae cause benign skin warts (papillomas), many human papillomavirus (HPV) infections are not associated with visible symptoms. For example, most healthy adults chronically shed Gammapapillomavirus (Gamma) virions from apparently healthy skin surfaces. To further explore the diversity of papillomaviruses, we performed viromic surveys on immunodeficient individuals suffering from florid skin warts. Our results nearly double the number of known Gamma HPV types and suggest that WHIM syndrome patients are uniquely susceptible to Gamma HPV-associated skin warts. Preliminary results suggest that treatment with the drug plerixafor may promote resolution of the unusual Gamma HPV skin warts observed in WHIM patients.

Epidemiology and Clinical Profile of Cutaneous Warts in Chinese College Students: A Cross-Sectional and Follow-Up Study

In this study, the hands and feet of 15,384 undergraduate and postgraduate students in 3 colleges in Beijing were examined for the presence of cutaneous warts at college-entry, and those diagnosed with warts were followed up 2-3 years later. We identified totally 215 (1.4%; 95% CI, 1.2-1.6%) students with warts. The prevalence was significantly higher in male than in female students (2.0% vs. 0.9%, P < 0.0001). Of the 215 patients, 66.9% and 62.1% had only one wart and 98.3% and 93.2% had warts <1 cm in diameter, on the hands and feet, respectively. Of the 130 patients with a follow-up visit, 78 did not receive any treatment (44 recovered within 2 years). Patients aged 21-25 compared to those aged ≤20 were more likely to be free of warts (hazard ratio = 1.76; 95% CI, 1.07-2.89), while lower father's education (hazard ratio = 0.19; 95% CI, 0.04-0.98) and poor sleep quality (hazard ratio = 0.41; 95% CI, 0.18-0.92) decreased the likelihood of resolution. The prevalence of warts is 1.4% in college students. The majority of patients have warts <1 cm and approximately 2/3 patients has one wart. Slightly over half of patients recover spontaneously within 2 years. Patients' age, sleep quality, and paternal education may affect the resolution.