Refractory warts successfully treated with a nitric-zinc complex solution

Zinc in dermatology

Zinc has numerous pharmacological uses in dermatology. Its antioxidant and immunomodulatory properties are thought to correlate with its efficacy in acne vulgaris and leishmaniasis, amongst other cutaneous conditions. We conducted a review of the literature on the use of zinc in dermatology; in particular, we investigated its role in acne vulgaris, hair loss, hidradenitis suppurativa, leishmaniasis, and warts. We searched MEDLINE selecting only articles in English and evaluating the evidence using the Oxford Center of Evidence-Based Medicine 2011 guidance. This review has found evidence to support the use of zinc in patients in infectious conditions (leishmaniasis and warts), inflammatory conditions (acne rosacea, hidradenitis suppurativa) and in hair loss disorders.Ppatients with zinc deficiency should also receive oral supplementation. Further research and large randomized controlled trials are required to investigate the role of zinc as a monotherapy.

A Multicentre, Randomised Clinical Trial to Compare a Topical Nitrizinc® Complex Solution Versus Cryotherapy for the Treatment of Anogenital Warts

INTRODUCTION

Anogenital warts (AGW) are a relevant clinical issue in the field of sexually transmitted disease, and to date no treatment provides a satisfactory clearance rate. Treatment can be both medical and surgical, and be provided by a healthcare provider or by the patient. Cryotherapy (CRYO) is among the most common treatments for AGW. Nitrizinc® Complex solution (NZCS) is a solution containing organic acids, nitric acid and zinc and copper salts that is applied topically to warts, producing mummification of the damaged tissue. It is considered to be an effective and well-tolerated treatment for genital and common warts. The aim of our study was to compare NZCS to CRYO in the treatment of AGW.

METHODS

We performed a prospective, multicentre, single-blind, randomised, superiority clinical study involving 120 patients, aged 18-55 years, diagnosed with a first episode of AGW, with each patient having from three to ten AGW. The patients were treated either with NZCS or CRYO for a maximum of four treatments. Primary endpoints were: (1) comparison of the clinical efficacy of CRYO and NZCS, based on response to treatment (clearance of AGW) within four treatment sessions; and (2) tolerability, assessed via a short questionnaire at the end of each treatment session. Secondary endpoints were: (1) number of treatments needed for clearance; and (2) recurrence at 1 and 3e months after confirmed clearance. The results were analysed on an intention-to-treat basis.

RESULTS

A complete response was achieved in 89.7% of the NZCS group and in 75.4% of the CRYO group (p = 0.0443). NZCS was found to be better tolerated. There was no difference between the NZCS and CRYO treatment arms in the number of sessions needed to clear the lesions. Recurrence occurred after 1 month in 18.4% of the NZCS group and 38.1% of the CRYO group (p = 0.0356), and after 3 months in 25 and 40.6% of these groups, respectively (p = 0.1479).

CONCLUSIONS

Nitrizinc® Complex solution can be considered to be as effective as CRYO for the treatment of small (< 5 mm) external AGW, with a better tolerability profile and lower rate of recurrence.

TRIAL REGISTRATION

ISRCTN identifier, ISRCTN36102369.

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.

Use of Topical Nitric-Zinc Complex Solution to Treat Palmoplantar and Periungual Warts in a Pediatric Population

Introduction

Nitric–zinc complex solution (NZCS) is a topically applied solution containing nitric acid, zinc, copper, and organic acids that induce a painless caustic effect on “difficult-to-treat” warts, including palmoplantar and periungual locations. The objective of the present prospective clinical study was to describe the efficacy and tolerability of NZCS in the treatment of palmoplantar and periungual warts in children.

Methods

Eligible patients were immunocompetent children and adolescents, with at least one palmoplantar or periungual wart. NZCS was topically applied every 2 weeks in clinic. Efficacy was recorded by clinical evaluation, and acceptability assessments were measured using a visual analogue scale (VAS).

Results

Pediatric patients (N = 12) were equally distributed by gender, and the mean age was 9.60 ± 3.34 years. The youngest patient was 4 years old. A total of 31 warts were identified: 24 periungual warts (77.4%), 2 palmar warts (6.45%), and 5 plantar warts (16.12%). We observed complete resolution in 83.9% of the warts treated with NZCS, achieving total cure considered as therapy success in 87.5% of periungual warts and 71% of palmoplantar warts, with a mean of 6.0 treatment sessions. The esthetic results evaluated by the investigator were considered excellent in 83.3% of cases and good in 16.7%. In 100% of the completely resolved cases, no scars, erythema, hyperpigmentation, hypopigmentation, or hypertrophy in the area surrounding the treated warts were observed by the investigator. The esthetic results evaluated by the patients or parents/guardians were excellent. Pain and burning sensation were minimal and well tolerated. No clinically relevant adverse events were reported.

Conclusion

NZCS was an effective treatment of warts in this pediatric population. The painlessness, simplicity, and twice-monthly dosing regimen of this treatment represents an advantage over standard approaches.

Funding

ISDIN.

Trial Registration

Retrospectively registered 6 September 2019, ISRCTN90862249.

Efficacy Assessment of a Topically Applied Nitric-Zinc Complex Solution for the Treatment of External Ano-genital Warts in 100 Patients

INTRODUCTION

External ano-genital warts (AGWs) due to human papilloma virus infection are the most common sexually transmitted ano-genital lesions of viral origin worldwide. Treatments include topical chemicals/drugs, excisional surgery, cryosurgery, electrosurgery and laser surgery. Nitric-zinc complex (NZC) is a new topically applied solution containing nitric acid, zinc, copper and organic acids that induces a caustic effect on condyloma. The objective of this study was to investigate the efficacy and tolerability of NZC in the treatment of AGWs.

METHODS

Patients attending for AGWs between September 2016 and February 2018 were retrospectively studied. They received at least one NZC application for a maximum of four treatments (V0, V1, V2, V3) with average intervals of 25 days between sessions. Recurrences were evaluated at 3 and 6 months after clearance.

RESULTS

One hundred patients (70 males, 30 females) with a mean age of 36.39 years were studied. The total number of AGWs diagnosed at the baseline visit (V0) in all patients was 418 with a mean of 4.18 AGWs per patient. A wart cure rate of 92% was observed in ≤ 4 treatment sessions (383 lesions cured at visit 4, V4, out of 418 lesions at baseline), with a cure rate of 49% with only one NZC application. Complete clearance was observed in 25, 52, 72 and 84% of patients at V1, V2, V3 and V4, respectively. Relapses were observed in 29% of patients at 3 months and in 5% at 6 months. Of note, patients with ≤ 5 AGWs at V0 showed better clearance results than patients with > 5 lesions (p < 0.05). The treatment was well tolerated by most patients.

CONCLUSION

NZC has been demonstrated to be effective for AGWs after 1-4 treatment sessions, obtaining a good response from the first application. The better response in patients with fewer warts suggests that the earlier diagnosis is made and treatment started, the better the expected results.

FUNDING

ISDIN.

The SILVER study. Efficacy of topical nitric-zinc complex solution in the treatment of resistant warts: A postmarketing evaluation

The treatment of cutaneous viral warts caused by human papillomavirus (HPV) infection is often subject to local recurrence and a long clinical and treatment course. Our aim was to analyze real-life data on the treatment of difficult-to-treat warts from a multicenter postmarketing surveillance assessment on the efficacy, tolerability, and safety of a commercially available nitric-zinc complex solution (NZCS). Dermatologists from 14 Italian centers completed a questionnaire about their clinical experience on treatment of "difficult-to-treat" warts, which included warts in the plantar, periungual, anogenital and aesthetically sensitive areas. The questionnaire was designed to obtain detailed information on wart treatment and compare NZCS efficacy with previous treatments. Of 106 questionnaires returned, 83 reported NZCS use; 67 had previous treatments (23 cryotherapy, 2 electrocoagulation, 12 other topical application, and 30 combined treatment, such as laser, cryotherapy, and/or electrocoagulation). NZCS had superior efficacy to that of previous treatments (p < .0001), resulting in 84.1% with a full or partial clearance (vs. 44.8% for previous treatments), and had better local tolerability (p < .0001). NZCS showed better efficacy and tolerability than other previous wart treatments.