A randomized, double-blind, placebo-controlled trial of systemically administered interferon-alpha, -beta, or -gamma in combination with cryotherapy for the treatment of condyloma acuminatum

Adjuvant treatment of anogenital warts with systemic interferon: a systematic review and meta-analysis

BACKGROUND

Interferons are natural messenger proteins that are used to treat various disease entities. Due to their immunomodulating, antiviral and antiproliferative effects, the systemic administration of interferons after ablative treatment for anogenital warts (AGWs) has been advocated to increase clearance and decrease recurrence rates. However, studies investigating the efficacy of adjuvant systemic interferon have yielded inconsistent results. The objective of this systematic review and meta-analysis was to comprehensively assess and evaluate the available evidence from randomised controlled trials.

METHODS

A literature search was conducted in Cochrane Central Register of Controlled Trials, Embase and MEDLINE. Available data were classified according to the interferon type and dosage. Pooled effect estimates were calculated for predefined outcomes. The Cochrane Collaboration's risk of bias tool was used to assess the included trials and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate our confidence in the effect estimates.

RESULTS

Twelve trials were identified that met the inclusion criteria and assessed immunocompetent patients with external AGW. Compared with placebo, adjuvant alpha-, beta- and gamma-interferon were generally not significantly superior in terms of complete clearance over the short, intermediate or long term, nor with regard to intermediate- or long-term recurrence. However, the low-dose subgroup of adjuvant alpha-interferon was significantly superior compared with placebo regarding intermediate-term complete clearance and recurrence. Further data were available for the comparison of different dosages of alpha- and beta-interferon and for comparisons of the three interferon types. No significant differences were seen in these comparisons regarding efficacy. Data on quality of life were not available.

CONCLUSIONS

The GRADE quality of the evidence ranged from 'very low' to 'high'. The significantly higher efficacy of low-dose alpha-interferon compared with placebo was based on a single trial, and our confidence in the effect estimates rated as 'low'. Overall, we found no reliable evidence favouring the systemic use of interferon after ablative treatment of AGW.

Clinical practice trends in cryosurgery: a retrospective study of cutaneous lesions

Introduction

Cryosurgery is an alternative treatment for many benign, premalignant, and malignant lesions of the skin.

Aim

To review the indications of cryosurgery for cutaneous lesions.

Material and methods

The retrospective study was based on the assessment of medical records of 1031 dermatology patients who had cryosurgery.

Results

One thousand two hundred and forty-four sessions of cryosurgery were applied to the total of 1031 patients. Of the 1031 patients, the most frequent indication for cryosurgery was common warts which were present in 535 (61.59%) patients, followed by anogenital warts in 119 (11.54%) patients, callosity in 81 (7.85%) patients, actinic keratosis in 77 (7.46%) patients, molluscum contagiosum in 35 (3.39%) patients, and other benign or malignant skin lesions.

Conclusions

Cryosurgery is still a valuable treatment of choice in various benign, premalignant, and malignant skin diseases but seems to be underused for indications other than viral warts.

Cidofovir: clinical experience and future perspectives on an acyclic nucleoside phosphonate analog of cytosine in the treatment of refractory and premalignant HPV-associated anal lesions

BACKGROUND

Cidofovir, a nucleotide analog with antiviral activity against a broad range of DNA viruses including human papilloma viruses (HPV), is available off label to clinicians.

OBJECTIVE

To provide a better knowledge of pharmacology and effects when topically applied.

METHODS

After reviewing the chemistry, physiology, and animal studies, an overview of clinical studies is provided.

RESULTS/CONCLUSIONS

Cidofovir, as a result of its antiviral and antiproliferative activity and its ability to induce apoptosis, can offer a solution for the treatment of severe recurrent HPV-induced lesions. It can also be used to attempt to treat dysplastic lesions and as an adjuvant treatment. The long-lasting antiviral activity allows infrequent dosing. As a rule, cidofovir applied on the skin is well tolerated, even in long-term treatment. The dose-limiting nephrotoxicity of the drug is not a concern in patients with a glomerular filtration rate within the normal range. Cidofovir has clearly influenced the landscape of refractory and dysplastic anogenital condylomata acuminata and its use has increased over the last decade. However, further controlled clinical trials are needed to assess the role of cidofovir and its derivatives.

Therapy for genital human papillomavirus-related disease

Genital human papillomavirus (HPV) infection is very common, and often sub-clinical and usually resolves without any treatment. Genital warts are caused by HPV 6/11 infection and are one of the commonest clinically recognised disease manifestations of genital HPV. Subjects with genital warts usually perceive them as cosmetically disfiguring, often leading to adverse psychological symptoms, and most subjects with genital warts will present requesting treatment. A wide variety of treatments are available including both provider- and patient-applied therapies. Various individual subject and disease factors mediate appropriate therapy choice. Some of the treatments that are used for genital warts can also be used for some cases of intraepithelial neoplasia caused by high-oncogenic risk HPVs occurring at vulval, anal or penile sites. Specific treatment considerations apply to genital warts in pregnancy and laryngeal papillomatosis and these are also discussed.

External genital warts: diagnosis, treatment, and prevention

External genital warts (EGWs) are visible warts that occur in the perigenital and perianal regions. They are due primarily to non-oncogenic human papillomavirus (HPV) types, usually types 6 and 11. Physical examination assisted by bright light and magnification is the recommended approach for primary diagnosis. Biopsy is indicated when EGWs are fixed to underlying structures or discolored or when standard therapies are not effective. Recurrences are common, and there is no single treatment that is superior to others. Among women with atypical squamous cells, molecular HPV testing may be useful in determining who should be referred for colposcopy. Condoms may provide some protection against HPV-related diseases and thus are recommended in new sexual relationships and when partnerships are not mutually monogamous. Because the efficacy of cesarean section in preventing vertical transmission of HPV infection from women with EGWs to their progeny has not been proved, it is not recommended.

Resolution of recurrent perianal condylomata acuminata by topical cidofovir in patients with HIV infection

Anogenital condylomata acuminata are the most frequent clinical manifestation of genital human papillomavirus (HPV) infection. Association between human immunodeficiency virus (HIV) and HPV infections is frequent (range: 26-60% in males). Topical cidofovir (a nucleotide analogue antiviral drug active against a broad range of DNA viruses) is a potential treatment for anogenital warts in immunocompromised patients. We treated three HIV-infected patients with HPV perianal condylomas with topical 1% cidofovir in flexible collodion once a day for 2 weeks. The treatment resulted in complete clearance of the HPV lesions. The patients experienced mild transient erythema without any other side-effects. None of the patients relapsed during the 10-14-month follow-up period.

The treatment of human papillomavirus lesions of the lower genital tract

Anogenital warts are caused by human papillomavirus types 6 and 11 infection, and are the most common clinical manifestation of lower genital tract human papillomavirus infection. They are the most frequently recognized sexually transmitted disease in the developed world, occurring at an incidence rate of 0.5-1.2% in young men and women aged 18-25 years. Many therapies for genital warts have been described, none being ideal in that all therapeutic modalities fail to clear the warts in a proportion of patients, and the recurrence of warts after successful treatment is seen with all treatments. The current knowledge base of the therapy of genital warts is flawed by a lack of good natural history data either with treatment or without treatment over longer periods of time, in that most trials report comparisons of monotherapies over a short time and there is a lack of structured trials addressing consecutive therapies over longer durations, as occurs in real-life clinical situations.

Cryosurgery of benign skin lesions

Cryosurgery is a widely used treatment modality in dermatology. Its place in cutaneous malignant and premalignant disease is well established; however, it also has great utility with benign lesions. Vascular, infectious, fibrotic diseases, solar damage, acne, as well as some cosmetic defects are amenable to freezing. The mechanism of treatment involves inducing tissue damage, vascular stasis and occlusion, as well as inflammation, to destroy unwanted tissue. After destruction of epidermal lesions, healing involves rapid re-epithelialization over a relatively cold-insensitive dermal network. Side effects are common but shortlived and are rarely severe. The equipment required is relatively economical and readily available. The technique is straightforward and reproducible, making cryosurgery an attractive option for many commonly encountered benign skin conditions. This review outlines treatment with the timed spot freeze technique of some commonly encountered benign lesions.

A randomized phase II study comparing four different interferon therapies in patients with recalcitrant condylomata acuminata

BACKGROUND

Interferon (IFN) alpha and IFN gamma have synergistic in vitro and in vivo effects and have each been used in the treatment of anogenital condylomata acuminata.

STUDY GOALS

To compare the efficacy and safety of regional 3 x 10(6) U IFN alpha (Group A), 3 x 10(6) U IFN gamma (Group B), 1.5 x 10(6) U IFN alpha plus 1.5 x 10(6) U IFN gamma (Group C), and 3 x 10(6) U IFN alpha plus 1.5 x 10(6) U IFN gamma (Group D) in the treatment of recalcitrant anogenital condylomata acuminata.

STUDY DESIGN

Six-week courses of regional IFNs were administered in a randomized, double-blind, multicenter study. Response was assessed as change in the total area affected by condylomata.

RESULTS

The treatments of Groups A, B, and C were similarly effective (complete response in 13.6%, 18.5%, and 16.0%, respectively). Group D had the lowest rate of complete response (3.8%), but this combination was the most effective when partial and complete responses were combined (73.0%).

CONCLUSION

Regional IFN is a moderately effective and safe treatment in patients with recalcitrant anogenital condylomata acuminata. Combinations of IFNs alpha and gamma were not superior to IFN monotherapy.

Antiviral treatment of diseases in pediatric dermatology

Pediatric dermatologic disease that have specific therapies and/or specific prophylactic measures are reviewed. Herpes simplex virus and varicella-zoster virus infections, human papillomavirus infections, and molluscum contagiosum infections are discussed with special emphasis on recent advances of therapy and prophylaxis.

A randomized, double-blind trial of parenteral low dose versus high dose interferon-beta in combination with cryotherapy for treatment of condyloma acuminatum

Forty-nine subjects were enrolled in a study comparing two dosages of parenterally administered interferon (IFN)-beta in combination with cryotherapy for the treatment of anogenital warts. Subjects were randomized to receive subcutaneous injections of either 2 x 10(6) or 4 x 10(6) IU/m2 of IFN-beta (Biogen) three times a week for a total of 6 weeks. Cryotherapy was administered concomitantly by aerosolization of liquid nitrogen at 10-day intervals. Systemic side- effects were modest in intensity and included fever, chills, myalgia, and headaches (flu-like symptoms). During the first 2 weeks of therapy, they were more common in the high dose group than in the low dose group (P = 0.02). Using survival analysis, there was no significant difference between the two groups in rates of resolution of warts present at baseline (P = 0.62). However, the rate of new lesion formation during the study was significantly lower in the high dose group (P = 0.04).

What is new in clinical research of viral diseases of the skin

Viral diseases of the skin have become a much more serious problem with the increasing number of patients immunosuppressed by either AIDS or cancer chemotherapy. The emphasis in research on the diagnosis and treatment of these diseases is similar to that on the bacterial diseases several decades ago.

Therapeutic efficacy and complications of excisional biopsy of condyloma acuminatum

BACKGROUND AND OBJECTIVES

Among the various treatment modalities for condyloma acuminatum, excisional cold-blade surgery appears excellent but it has been little studied and little used, particularly for lesions not located in the perianal area.

GOALS

To examine the efficacy and complications of scissors excision of single anogenital warts.

STUDY DESIGN

Retrospective analysis of single warts completely excised with scissors for the purpose of biopsy before patient entry in a randomized, placebo-controlled study of the efficacy and safety of various parenteral interferons in combination with cryotherapy.

RESULTS

Of 152 patients entered in the main study, 85 patients were available for analysis. At 4 and 16 weeks after excision, 16 of 85 (19%) and 14 of 68 (21%) of the excised lesions recurred. After at 6 least months of follow-up, 2 of 11 (18%) of the excision sites demonstrated some evidence of pigmentation changes.

CONCLUSIONS

Scissors excision of single anogenital warts has a high rate of success and acceptable long-term side-effects.