Cimetidine and levamisole versus cimetidine alone for recalcitrant warts in children

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.

Use of Histamine2-Antagonists for the Treatment of Verruca Vulgaris

Objective:

To review the evidence for histamine2 (H2)-antagonists in the treatment of common warts.

Data Sources:

Relevant publications were identified through a systematic search of PubMed English-language literature using the MeSH terms and key words cimetidine, ranitidine, famotidine, nizatidine, histamine H2-antagonists, and warts. Additional articles were identified using the same key words in the Cochrane Database and International Pharmaceutical Abstracts. Systematic searches were conducted through January 2007. In addition, pertinent references from identified articles were reviewed.

Study Selection and Data Extraction:

The literature search retrieved 21 relevant citations, excluding review articles. Five open-label studies and 7 randomized controlled clinical trials were evaluated. Cimetidine was the focus of 11 studies, and ranitidine was evaluated in 1 study. No data regarding the other H2-antagonists were found. The other retrieved citations were not evaluated due to their design (case reports or case series) and/or focus on specific wart subtypes, not common warts.

Data Synthesis:

The use of H2-antagonists in the treatment of common warts is not associated with significant improvements in resolution rates. Open-label studies were promising with an estimated 48–81% response rate. However, randomized controlled trials have failed to show significant efficacy when cimetidine was compared with placebo or topical agents, and ranitidine has never been evaluated in a randomized controlled trial. Adverse effects, specifically gastrointestinal complaints, were documented. Efficacy may have been limited by inadequate dosing in some of the trials. The studies were limited by the small sample size and lack of power in a number of the trials, as well as the documented spontaneous resolution rate for warts.

Conclusions:

Several open-label trials evaluating the use of H2-antagonists for verruca vulgaris reported high response rates, but these results have not been corroborated by more rigorous clinical trials. Current data do not support the use of H2-antagonisis for the treatment of common warts.

Evolving role of immunotherapy in the treatment of refractory warts

Cutaneous and genital warts are common dermatological conditions caused by the human papilloma virus (HPV). Although it is a benign condition, it causes disfigurement, has a tendency to koebnerize, and can be transmitted to others. This makes adequate and timely treatment important. There are several conventional treatments available with variable response. Topical and systemic immunotherapy has now found a significant place in the treatment of warts because of its nondestructive action, ease of use, and promising results. Through this review, we would like to present a brief overview of the various immunotherapeutic agents used. These include more established agents such as imiquimod, Mycobacterium w vaccine, bacillus Calmette-Guérin vaccine, measles, mumps, and rubella vaccine, Candida antigen, trichophyton antigen, tuberculin, zinc, cimetidine, levamisole, HPV vaccine, and autoimplantation therapy. Other agents such as contact immunotherapy which is sparsely used now than before and newer agents such as Corynebacterium parvum, sinecatechins, echinacea, propolis, glycyrrizinic acid, and Vitamin D have also been discussed. The mechanism of action of these agents, along with their dosage, mode of administration, duration of use, expected outcomes and comparative efficacy, evidence for their use, and expected side effects, if any, are reviewed.

Immunomodulators in warts: Unexplored or ineffective?

Cutaneous warts are known to be recurrent and often resistant to therapy. Resistant warts may reflect a localized or systemic cell mediated immune (CMI) deficiency to HPV. Many modalities of treatment are in use; most of the provider-administered therapies are destructive and cause scarring, such as cryotherapy, chemical cauterisation, curettage, electrodessication and laser removal. Most patient-applied agents like podophyllotoxin have the risk of application-site reactions and recurrence. Thus immunotherapy is a promising modality which could lead to resolution of warts without any physical changes or scarring and in addition would augment the host response against the causative agent, thereby leading to complete resolution and decreased recurrences. Immunomodulators can be administered systemically, intralesionally or intradermally, and topically. A few agents have been tried and studied extensively such as cimetidine and interferons; others are new on the horizon, such as Echinacea, green tea catechins and quadrivalent HPV vaccine, and their efficacy is yet to be completely established. Though some like levamisole have shown no efficacy as monotherapy and are now used only in combination, other more recent agents require large and long term randomized placebo-controlled trials to clearly establish their efficacy or lack of it. In this review, we focus on the immunomodulators that have been used for the treatment of warts and the studies that have been conducted on them.

Verruca vulgaris of the tongue

The viral warts also known as verruca vulgaris are caused by papova group of viruses. Such warts are commonly seen on the skin but occasionally may appear in the oral cavity. There are three types of warts namely verruca plana; verruca vulgaris and filiform. The incubation period of such warts varies from 6 weeks to a year. The warts spread by autoinoculation and seldom show koebner phenomenon. The majority of mucosal warts are seen in those children who also have warts on hands. In such cases the virus may be transported to the lips and tongue during an act of chewing of warts on hands. A 42-year-old male patient reported with the chief complaint of multiple, nontender, large white finger like projections on the right lateral border of the tongue. The duration of the lesion was approximately 3 years. Patient also had two similar papillary exophytic lesion over achilles tendon of right leg. Excision of the lesion from the right lateral border of the tongue was done under local anaesthesia and sent for histopathology examination, the histopathology report was suggestive of verruca vulgaris. Post-op follow up was done for 1 year, no recurrence of the lesion reported.

Treatment of cutaneous warts: an evidence-based review

Cutaneous warts are common skin lesions caused by human papillomavirus infection. Treatment is aimed at relieving the patient's physical and psychological discomfort and at preventing the spread of infection by autoinoculation. Among the available medical and destructive therapeutic options for cutaneous warts, none is uniformly effective or virucidal. Moreover, in most cases their safety and efficacy has not been assessed in double-blind, controlled clinical trials, so that the reproducibility of many of the listed treatments is difficult to evaluate and a possible placebo effect cannot be ruled out. The aim of this article is to describe the outcome of current therapies for each clinical wart type according to evidence-based medicine studies published in the literature. For each clinical form, the existing treatments are classified as first-, second-, and third-line therapy. First-line therapy includes medical treatments (salicylic acid, silver nitrate, glutaraldehyde) that are useful to treat a single wart or a few and/or small common warts of short duration (less than 1 year). If these treatments have failed or are contraindicated, cryotherapy may be considered as second-line therapy. For recurrent or difficult-to-treat lesions, third-line therapy includes a variety of alternative therapeutic options (topical, intralesional, systemic, and physical destruction) that are generally off-label (not US FDA approved), and whose use is limited by drawbacks or adverse effects. From pooled evidence-based medicine data, it is possible to conclude that significantly higher remission rates may be expected only with cryotherapy and salicylic acid used in combination.

Comparação entre a eficácia da cimetidina e do sulfato de zinco no tratamento de verrugas múltiplas e recalcitrantes

FUNDAMENTOS: Verrugas são proliferações epiteliais na pele e mucosas causadas por diversos tipos de HPV. Elas podem involuir espontaneamente ou aumentar em número e tamanho de acordo com estado imunitário do paciente. A cimetidina e o sulfato de zinco têm importante efeito no sistema imune, sendo usados como imunomoduladores no tratamento de diversas doenças. OBJETIVO:Comparar a eficácia terapêutica de cimetidina e sulfato de zinco no tratamento de verrugas cutâneas de difícil tratamento. MÉTODOS: Estudo prospectivo duplo-cego randomizado. Dezoito pacientes com verrugas múltiplas foram divididos em dois grupos, um recebeu cimetidina 35mg/kg/dia (máximo 1.200mg/dia), e o outro, sulfato de zinco 10mg/kg/dia (máximo de 600mg/dia) por três meses. RESULTADOS: Dos 18 pacientes do estudo, nove receberam cimetidina, e nove, sulfato de zinco; apenas um do grupo do sulfato de zinco não completou o tratamento devido a náuseas e vômitos. Cura foi obtida em cinco pacientes tratados com sulfato de zinco, e apenas um não obteve alteração das lesões. Do grupo da cimetidina cinco não apresentaram modificação, e quatro apresentaram diminuição inferior a 30% das lesões iniciais. CONCLUSÕES: Sulfato de zinco na dose de 10mg/kg/dia parece ser mais efetivo que cimetidina para o tratamento de crianças e adultos com verrugas múltiplas e de difícil manejo. A pequena casuística deste trabalho não permite, entretanto, conclusão categórica.

An armamentarium of wart treatments

Patients and clinicians experience the frustration of cutaneous viral warts caused by infection with the human papilloma virus (HPV).Warts appear in various forms on different sites of the body and include common warts (verruca vulgaris), plane or flat warts, myrmecia, plantar warts, coalesced mosaic warts, filiform warts, periungual warts, anogenital warts (venereal or condyloma acuminata), oral warts and respiratory papillomas. Cervical infection with HPV is now known to cause cervical cancer if untreated. A review of the medical literature reveals a huge armamentarium of wart monotherapies and combination therapies. Official evidence-based guidelines exist for the treatment of warts, but very few of the reported treatments have been tested by rigorous blinded, randomized controlled trials.Therefore, official recommendations do not often include treatments with reportedly high success rates, but they should not be ignored when considering treatment options. It is the purpose of this review to provide a comprehensive overview of the wart treatment literature to expand awareness of the options available to practitioners faced with patients presenting with problematic warts.

Oral cimetidine adjuvant therapy for recalcitrant, diffuse conjunctival papillomatosis

PURPOSE

To describe a case of recurrent, advanced conjunctival papillomatosis, treated by oral cimetidine (CIM) combined with secondary surgical intervention and an application of intraoperative mitomycin C.

METHODS

Case report and literature review.

RESULTS

A 9-year-old boy suffered from recurrent, progressive, diffuse multifocal conjunctival papillomatosis over the left upper and lower palpebral and the fornical conjunctiva. He underwent 3 separate surgeries; however, they did not prevent tumor recurrence. The recurrent lesions were more severe and extensive than before the surgeries. To avoid postoperative symblepharon, ankyloblepharon, dry eye, and possible corneal neovascularization after extensive lesion excision, oral CIM at a dosage of 200 mg 4 times daily was administered for 4 months before surgery. A debulking excision of the residual tumor with an intraoperative application of mitomycin C was performed as a secondary therapy after the main mass decreased in size. Postoperative oral CIM was continued for 6 months. The papillomatosis cleared without recurrence or symblepharon, ankyloblepharon, conjunctival scarring, or corneal neovascularization after 4 years of follow-up examinations.

CONCLUSION

Oral CIM can be used as an initial, nonsurgical strategy for treating cases of massive, recalcitrant conjunctival papillomatosis. If there is tumor shrinkage, surgical debulking with applications of mitomycin C may be sufficient to eliminate any residual tumor tissue without inducing conjunctival scarring or corneal neovascularization.

How and when to treat molluscum contagiosum and warts in children

Warts and molluscum contagiosum are common skin diseases in children and are usually self-limiting. The decision of whether to treat children with molluscum or warts should be individualized to the patient and his or her family. Considerations include how symptomatic the lesions are, the extent and duration of disease, the ability of the child and the parents to tolerate and comply with treatment recommendations, and any underlying medical conditions (Table, see page 219). Recurrences of molluscum contagiosum and especially warts are common, and realistic expectations regarding the potential for treatment failure and recurrence should be discussed with the child and his or her family prior to initiating any therapy. As pediatric practitioners, we all remain acutely aware of our patients' physical and psychological development and the potential for any intervention to influence this development. Although various treatment modalities now exist for the treatment of these viral diseases, any intervention should be balanced against these considerations.

Human papillomavirus infections in children

PURPOSE OF REVIEW

The human papillomavirus is a ubiquitous 55-nm DNA virus that causes a variety of clinical disease states in children, commonly referred to as warts. The natural history of warts is spontaneous regression through the development of a complex blend of cell-mediated and humoral immunity. Although spontaneous immunity can develop, as many as one third of children will have persistent human papillomavirus infection beyond 2 years. Therapeutic modalities are manifold, primarily because no therapy is universally effective. The purpose of this review is to update the reader with the latest information on the human papillomavirus and its therapeutics in children.

RECENT FINDINGS

Recently, encouraging research has been conducted in human papillomavirus, including destructive and immunologic therapies. Vaccines tailored to genital human papillomavirus strains are just coming into clinical use.

SUMMARY

Manipulation of the immune system through medications or vaccination will likely help contain human papillomavirus in the future and prevent secondary human papillomavirus oncogenesis of the skin and cervix.

Levamisole in dermatology : a review

Levamisole, an anthelmintic agent with a wide range of immunomodulatory actions, has been used successfully as monotherapy and an adjunct to treatment in a variety of diseases. Since 1990, combination therapy of levamisole and fluorouracil has played an important role in the treatment of resected Dukes stage C adenocarcinoma of the colon. Because of its immunomodulating effects levamisole has been used in a wide range of diseases with and without success. In dermatologic disease levamisole has been successfully used in the treatment of parasitic, viral and bacterial infections including leprosy, collagen vascular diseases, inflammatory skin diseases and children with impaired immune a variety of reasons. It has also been used in combination with other drugs for treating a number of dermatologic disorders, e.g. in combination with cimetidine for treating recalcitrant warts, with prednisolone for treating lichen planus, erythema multiforme and aphthous ulcers of the mouth. Adverse affects of levamisole are mild and infrequent and include rash, nausea, abdominal cramps, taste alteration, alopecia, arthralgia, and a flu-like syndrome. It can rarely cause agranulocytosis. More studies need to be undertaken to study the full potential of levamisole in dermatologic diseases.