A comprehensive review of treatment options for recalcitrant nongenital cutaneous warts

Efficacy and Safety Profile of Tuberculin Protein Purified Derivative Injection As Immunotherapy For the Treatment of Cutaneous and Anogenital Warts: A Review Article

Introduction

Various treatments available today for anogenital and cutaneous warts have limitations, including time-consuming, challenging to perform, and the risk of scarring. A new treatment using tuberculin purified protein derivative (PPD) has been developed, which is expected to generate cellular immunity against HPV.

Objective

To assess the evidence for the efficacy and safety of PPD treatment for cutaneous and anogenital warts.

Materials and methods

A literature search was performed with the keyword-based search on digital libraries, including the National Library of Medicine, Cochrane Controlled Register of Trial, and Google Scholar, using the following terms: anogenital warts, condyloma acuminata, cutaneous warts, human papillomavirus, immunotherapy, and tuberculin purified protein derivative. Original studies on treating cutaneous or anogenital warts with PPD were included. The results were 47 clinical trials and 4 case reports. Most of the research was done in countries with common Mycobacterium tuberculosis infection. The treatment showed good efficacy. Comparative studies showed that the treatment has similar efficacy with other immunotherapies. No significant side effects were reported, with evidence of the safety use on the pregnant population.

Conclusion

Based on good efficacy and safety, PPD can be considered an alternative therapy, especially in countries where tuberculosis is frequent.

Application of cantharidin, retinoic acid cream and salicylic acidy in multiple palmoplantar warts

OBJECTIVE

Multiple palmoplantar warts, caused by human papillomavirus (HPV) infection, were investigated for clinical efficacy using cantharidin, retinoic acid cream, and salicylic acid cream.

METHODS

A total of 110 patients with multiple palmoplantar warts were enrolled. The experimental group (54 cases) received a 1:1:1 combination (CRS) of 0.25% cantharidin, 0.1% retinoic acid cream, and 5% salicylic acid, applied with pressurized encapsulation for 8 h every night, three times per week. The control group (56 cases) underwent conventional liquid nitrogen freezing. Monthly follow-ups assessed cure rate, effective rate, dermatological life quality index (DLQI), visual analog scale (VAS), and cost, with evaluations conducted after 3 months.

RESULTS

The treatment group exhibited a cure rate of 85.19% and a total effective rate of 96.30%, surpassing the control group with rates of 39.29% and 51.79%, respectively (p < 0.05). The treatment group's DLQI score (1.84 ± 1.06) was significantly lower than the control group's score (6.04 ± 1.78) (p = 0.0005). Additionally, the treatment group's VAS score (1.84 ± 1.06) was notably lower than the control group's score (8.56 ± 1.07) (p < 0.0001). The treatment group's total cost (43.20 ± 2.85) was markedly lower than the control group's cost (206.38 ± 90.81), with a statistically significant difference (p < 0.0001).

CONCLUSION

The combination of cantharidin, retinoic acid cream, and salicylic acid with local encapsulation is a safe, effective, economical, and convenient treatment method for multiple palmoplantar warts, exhibiting few side effects and showing promise.

Clinical observation and study of local hyperthermia for treating plantar warts: A pilot study with 38 patients

Warts are benign lesions caused by infection of the keratinocytes by the human papillomavirus (HPV). There is still no consensus on the standard treatment for plantar warts, and the various treatments (both destructive and non-destructive) have variable efficacy with a long list of shortcomings, such as higher recurrence, pain, and scarring. Local hyperthermia was considered a safe, effective, and promising therapy in the treatment of plantar warts. After getting approval from the hospital's ethics committee, the present study was designed to assess the clinical efficacy of local hyperthermia in the treatment of plantar warts. A total of 38 patients were enrolled in the study, and all patients received a standard regimen in a 5-week schedule, with local 45°C treatment for 30 mins on days 1, 2, 3, 14, 15, 22, 29, and 36. Of the 38 patients, complete resolution of the warts was observed in 13 (34.2%), 8 (21.1%) achieved partial remission, and 17 (44.7%) revealed poor response to the treatment. Patients were followed up for at least 3 months, and there was no recurrence of lesions in the 13 clinically cured patients at the last follow-up. The findings in the current study demonstrate that local hyperthermia is a safe, effective, and promising therapy for the treatment of plantar warts.

Recalcitrant Cutaneous Warts in a Family with Inherited ICOS Deficiency

Recalcitrant warts, caused by human papillomaviruses (HPVs), can be a cutaneous manifestation of inborn error of immunity. This study investigated the clinical manifestations, immunodeficiency, single-gene susceptibility, and HPV repertoire in a consanguineous family with severe sinopulmonary infections and recalcitrant warts. Clinical and immunologic evaluations, including FACS and lymphocyte transformation test, provided evidence for immunodeficiency. Combined whole-exome sequencing and genome-wide homozygosity mapping were utilized to disclose candidate sequence variants. Whole-transcriptome sequencing was used to concomitantly investigate the HPV genotypes and the consequences of detected sequence variants in the host. The proband, a male aged 41 years, was found to be homozygous for the c.6delG, p.Lys2Asnfs∗17 variant in ICOS, encoding the inducible T-cell costimulator. This variant was located inside the 5 megabase of runs of homozygosity on 2q33.2. RNA sequencing confirmed the deleteriousness of the ICOS variant in three skin biopsies revealing significant downregulation of ICOS and its ligand, ICOSLG. Reads unaligned to the human genome were applied to 926 different viruses, and α-HPV57, β-HPV107, β-HPV14, and β-HPV17 were detected. Collectively, we describe a previously unrecognized inborn error of T-cell immunity to HPVs, indicating that autosomal recessive ICOS deficiency can underlie recalcitrant warts, emphasizing the immunologic underpinnings of recalcitrant warts at the nexus of human and viral genomic variation.

Intralesional Purified Protein Derivative Versus Zinc Sulfate 2% in the Treatment of pediatric warts: Clinical and Dermoscopic Evaluation

BACKGROUND

Warts are common in children and can be difficult to treat. Many treatments for warts are destructive and painful in contrast to intralesional immunotherapy using different types of antigens.

AIM

to evaluate the efficacy, safety, and tolerability of intralesional purified protein derivative (PPD) versus intralesional zinc sulfate 2% in the treatment of pediatric warts.

METHODS

This randomized clinical trial included 120 children with multiple warts divided into two equal groups. Group Ⅰ received intralesional 10 IU (0.1 ml) of PPD, group Ⅱ received intralesional zinc sulfate 2% in the largest wart every 2 weeks till improvement or for a maximum five treatment sessions. The follow up period was 6 months after the last treatment session.

RESULTS

the overall response was equal in both groups (81.7%), but the response of the injected wart was higher in the zinc sulfate group (93.4%) versus PPD group (83.3%) with no significant difference. The highest cure rates were after the 5^th session in the PPD group and the 1^st session in the zinc sulfate group with slightly lower numbers of sessions needed for cure in the zinc sulfate group (3 sessions) versus the PPD group (4 sessions). The zinc sulfate group showed statistically significant higher rates of complications (pain, inflammation, necrosis, and scar) than PPD group. The zinc sulfate group showed non-significant higher rates of recurrence during the follow up period.

CONCLUSION

Both intralesional PPD and zinc sulfate 2% are effective in pediatric warts with higher safety profile of PPD.

Pulsed dye laser versus Nd:YAG laser in the treatment of recalcitrant plantar warts: an intraindividual comparative study

Plantar warts are common cutaneous lesions caused by the human papillomavirus. Treatment of recalcitrant plantar warts stays a continuous challenge, and they are more refractory to treatment than common warts. To compare the efficacy of Long-Pulsed neodymium: yttrium-aluminum-garnet (Nd:YAG) laser versus pulsed dye laser (PDL) on the therapy of multiple recalcitrant plantar warts. Thirty patients with recalcitrant plantar warts were included in the current study. Half the number of warts were treated by PDL in each patient, while the other half were treated by Nd:YAG. Laser sessions were applied every 2 weeks for a maximum of six sessions. Patients were followed up both clinically and using dermoscopy. There was a complete clearance of warts in 20 patients (66.7%) with Nd:YAG laser and 19 patients (63.3%) with PDL with no statistically significant difference between both types of lasers. Pain during laser sessions was higher with Nd:YAG laser PDL and it was statistically significant (p = .0001). Both Nd:YAG laser and PDL showed efficacy and safety for the treatment of recalcitrant plantar warts. The use of dermoscopy adds great value in evaluating treatment response and in decreasing the incidence of recurrence.

A Perspective on Imiquimod Microneedles for Treating Warts

Warts are a common skin problem and are caused by infection with a virus. Warts are currently mainly treated by therapies involving ablating tissue or interrupting cellular division. However, all these existing treatments are either invasive or cause skin pain and tissue destruction. Imiquimod is a synthetic compound that belongs to the imidazoquinolinone family. It has been successfully used as a topical drug to treat external anogenital warts. However, topical imiquimod cream for warts is restricted by low skin permeability, and several side effects such as itching, pain, and erosions occur most frequently following topical treatment. Microneedle technology, a minimally invasive drug delivery system, has the potential to overcome the barrier of the stratum corneum. This technique would also offer a painless treatment choice and provide personalized therapies. In the study, we loaded imiquimod within dissolving microneedles using the molding method. Gelatin was used as a structural material for microneedle formation without adding a crosslinker. To our knowledge, this is the first study of using dissolving microneedles and exploring their utilization with imiquimod for the treatment of warts. First, we added fluorescent dye and trypan blue into the microneedles to evaluate the status of drugs in the microneedles and the degradation property of microneedles made of gelatin, respectively. Here we also prove the strength of the imiquimod microneedles and study their capability to penetrate the skin. The results show no apparent differences in mechanical failure after an additional imiquimod-loaded. Besides, we provide evidence that imiquimod microneedles induce secreted embryonic alkaline phosphatase (SEAP) in the RAW 264.7 macrophages. Gelatin does not affect the imiquimod in microneedles; a similar immune response was affected by the imiquimod alone or imiquimod complexed with gelatin. Our research demonstrates a proof of concept of using imiquimod microneedles for future warts treatment.

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

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