Therapeutic management of cutaneous and genital warts

[Treatment of therapy-resistant verruca plantaris with laser-assisted photodynamic therapy (PDT) with methyl aminolevulinate (MAL)]

Mosaic warts are a type of verruca vulgaris that occur almost exclusively on the soles of the feet. They are particularly known for their treatment resistance and high recurrence rate. Laser-assisted drug delivery (LADD) photodynamic therapy (PDT) with methyl aminolevulinate (MAL) offers a low pain treatment option with hardly any side effects in therapy-resistant cases of verruca plantaris. Pretreatment with an ablative fractional laser is especially important to obtain penetration of MAL through the human papillomavirus (HPV)-infected skin layer.

A Comprehensive Review of Treatment Approaches for Cutaneous and Genital Warts

Cutaneous and genital warts are common in both developed as well as developing countries. Human papillomavirus (HPV), which is a double-stranded DNA virus, is the causative agent of wart infection. Different types of HPV viruses are responsible for the different severity of diseases. Some types are associated with malignancy of the anal region and cervix. HPV is a common sexually transmitted disease in the United States. The incidence is most common in the younger age groups and the elderly population. Our main goal is to describe the different treatment modalities available for warts. Treatment modalities are divided into primary, secondary, and tertiary options. Topical medications, and physical excision of warts via cryotherapy, electrocautery, lasers, or photodynamic therapy are all common forms of treatment. Various clinical trials and randomized control trials have been seen as effective treatment against HPV infection. Higher remission rates are seen irrespective of different treatment options. Warts can be treated but the HPV virus cannot be completely removed. Older age, immunocompromised state, diabetes mellitus, and HIV are the predisposing factors for the disease. There is currently a large variety of medicines in use, all of which can differ significantly in terms of price, side-effect profiles, dosing regimens, length of therapy, and overall effectiveness. The best course of treatment has not yet been identified, and patients are often treated according to their unique needs.

Downregulation of Sonic hedgehog signaling induces G2-arrest in genital warts

BACKGROUND

Human papillomavirus (HPV) infected keratinocyte dysfunction results in the formation of genital warts, and the specific role of Sonic hedgehog (SHh) signaling in genital warts remains elusive. Thus, this study aimed to identify the correlation between wart formation and SHh signaling.

MATERIALS AND METHODS

In this study, nine male patients with genital warts were recruited, and the expression of SHh and its downstream signal molecules Patched-1 and GLI family zinc finger 1 (Ptch1 and Gli1) was detected. Moreover, G2-phase cells in the collected genital warts samples were assessed with normal foreskin samples as a comparison. HPV6/11 were detected via in situ hybridization (ISH), and SHh expression of the corresponding paraffin sections was determined via immunohistochemical staining (IHC). In addition, an in vitro down-regulated SHh model was constructed by siRNA transfection of the HaCaT cell line, and the cell cycle was detected at 36 h by flow cytometry with propidium iodide staining.

RESULTS

SHh, Ptch1, and Gli1 in warts were significantly downregulated in the condyloma acuminatum (CA) group compared to the normal foreskin group. G2-phase cells in the middle section of the spinous layer of CA wart tissues were significantly increased. Moreover, the expression of HPV-DNA was amplified and negatively correlated with SHh activity in CA wart tissues. Lastly, the downregulation of SHh-induced G2 arrest in vitro.

CONCLUSIONS

The downregulation of the SHh signaling promotes HPV replication and the formation of warts by inducing G2/M arrest in the keratinocytes of CA.

Clinical guideline for the diagnosis and treatment of cutaneous warts (2022)

AIM

Cutaneous warts caused by human papillomavirus are benign proliferative lesions that occur at any ages in human lives. Updated, comprehensive and systematic evidence-based guidelines to guide clinical practice are urgently needed.

METHODS

We collaborated with multidisciplinary experts to formulate this guideline based on evidences of already published literature, focusing on 13 clinical questions elected by a panel of experts. We adopted Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to form classification of recommendations as well as the improved Delphi method to retain respective recommendations with a consensus degree of over 80%.

RESULTS

Our guideline covered aspects of the diagnosis and treatment of cutaneous warts such as diagnostic gold standard, transmission routes, laboratory tests, treatment principle, clinical cure criterion, definitions, and treatments of common warts, flat warts, plantar warts, condyloma acuminatum, and epidermodysplasia verruciformis. Recommendations about special population such as children and pregnant women are also listed. In total, 49 recommendations have been obtained.

CONCLUSIONS

It is a comprehensive and systematic evidence-based guideline and we hope this guideline could systematically and effectively guide the clinical practice of cutaneous warts and improve the overall levels of medical services.

From the Cochrane Library: Topical Treatments for Cutaneous Warts

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Correlation of the ALA-PDT Treatment Efficacy and the HPV Genotype Profile of Genital Warts after Cryotherapy Failure and Podophyllotoxin Therapy in Male Patients

Background: Genital warts are the manifestation of the human papillomavirus (HPV) infection, which may last for weeks or months before the clinical presentation. The primary aim of the study was the correlation of the DNA HPV genotypes eradication with the treatment response in male patients with persistent genital warts. Methods: Twenty-one male patients (age range: 22–58) after failure of cryotherapy and podophyllotoxin treatment were enrolled in the study. Genetic tests (Real Time - PCR method) analyzed the presence of DNA-HPV before and 6 months after four sessions (4 weeks apart) of photodynamic therapy with 5-aminolaevulinic acid (ALA-PDT). The treatment efficacy was evaluated before each PDT session and at the end of the study. Results: The single HPV DNA type was present in 15/21 of the patients (13/15 HPV6). The high-risk HPV types were found in 8/21 subjects, of which 6/8 had several types. Six months after four sessions of PDT, complete response was found in 16/21 (76.19%; p = 0.0007) of patients, and DNA HPV clearance was found in 66.67% (p = 0.03). The eradication rate differed among patients with primary low-risk and high-risk HPV types—76.92% (10/13; p = 0.0003) and 50% (4/8; p = 0.05) respectively. Conclusion: ALA-PDT is an effective treatment even after the failure of previous modalities. The persistence of clinical lesions and high oncological risk HPV types should be an indication for treatment prolongation.

Comparison of the Efficacy and Safety of Two Cryotherapy Protocols in the Treatment of Common Viral Warts: A Prospective Observational Study

Background

Cryotherapy (freezing by liquid nitrogen) is an effective and widely used method for treatment of common warts. Patients often need multiple sessions at variable intervals. Protocols used by different dermatologists vary in terms of freezing time, the number of cycles, and the intervals between sessions.

Aim

To compare the efficacy (cure rates) and safety (complications, early and late) of two cryotherapy treatment protocols for common viral warts.

Method

A prospective observational study was conducted; it involved 80 patients with common warts on the hands and feet who were treated with cryotherapy done by two dermatologists who use different protocols; group 1 (45 patients) were treated by a single cycle of 10 seconds of freezing at 2 weekly intervals, and group 2 (35 patients) received a single cycle of 20 seconds of freezing at 4-weeks intervals. The two protocols were compared in terms of cure rate and complications 1-2 months after the final treatment. Recurrence rate and late complications were assessed at 9-12 months after the final treatment.

Results

Group 1 patients achieved higher cure rate than group 2, 77.8% and 54.3%, respectively (P=0.001). Early (blistering) and late complications (dyspigmentation and scarring) were comparable in both groups. Pain score associated with protocol 1 (5.2/10) was less than protocol 2 (6.4/10) (P=0.004). Recurrence rate (17%) was comparable in both groups. Association between cure rate and duration of warts (P=0.022) and also association between cure rate and the mean number of warts (P=0.001) were demonstrated.

Conclusions

Cryotherapy is an effective and safe treatment for common viral warts of hands and feet. The impact of shorter intervals on cure rate was more significant than increasing freezing time with longer intervals between freezing sessions. The study was approved by the local IRB committee (285-2018).

Pre-treatment vitamin B12, folate, ferritin, and vitamin D serum levels in patients with warts: a retrospective study

Aim

To compare the serum levels of 25-hydroxyvitamin D, ferritin, folate, vitamin B12, zinc, and thyroid stimulating hormone between patients with warts and healthy individuals.

Methods

This retrospective study enrolled 40 patients with warts and 40 healthy individuals treated at the Ufuk University Hospital, Ankara, between July and December 2017. Serum levels of 25-hydroxyvitamin D, ferritin, folate, vitamin B12, zinc, and thyroid stimulating hormone status were evaluated retrospectively.

Results

Participants with and without warts had similar mean serum 25-hydroxyvitamin D, ferritin, folate, zinc, and thyroid stimulating hormone levels. However, patients with warts had significantly lower mean serum vitamin B12 level (P = 0.010). Patients with warts non-significantly more frequently had decreased serum levels of 25-hydroxyvitamin D, ferritin, and folate (P = 0.330, P = 0.200, P = 0.070, respectively).

Conclusion

Patients with warts may require evaluation of serum levels of vitamin B12, folate, ferritin, and vitamin D.

Nonavalent human papillomavirus vaccination as alternative treatment for genital warts

Genital warts caused by the human papillomavirus (HPV) are the most common sexually transmitted disease and have a negative impact on quality of life. Of the more than 200 different types of HPV, low-risk types 6 and 11 are mainly responsible for the development of condyloma acuminata. Despite a large arsenal of local therapies such as numerous topical agents, CO₂ laser ablation, and surgical removal, genital warts tend to be recalcitrant. HPV vaccination is mainly used as a preventive strategy to prevent genital warts, cervical cancer, and other anogenital cancers. However, in a few cases, HPV vaccination has been shown to be a good treatment alternative for patients with recalcitrant skin warts. Here we report five cases of recalcitrant genital warts that responded well to treatment with the nonavalent HPV vaccine. HPV vaccines could be beneficial as a noninvasive treatment alternative for recalcitrant genital warts.

HPV infection in urology practice

Human papillomavirus (HPV) is the most common pathogen of sexually transmitted disease worldwide. While HPV is responsible for low-grade benign lesions in the anogenital area such as condyloma acuminatum, it is also strongly associated with cervical, anal, vulvar/vaginal, and penile carcinomas. In addition to being an oncogenic virus, HPV causes a substantial socioeconomic burden due to the recurrence of benign lesions, the lack of a definitive treatment option that provides a complete cure, and the high cost of treatment. The global incidence of HPV infection is rising, especially among young and sexually active individuals; as a result, in recent years these infections have also become increasingly conspicuous in urology practice, both as incidental findings and primary complaints. The aim of this review is to evaluate the pathogenesis, diagnosis, and treatment modalities of HPV infections in light of the current literature from the urologist's perspective.

Can quadrivalent human papillomavirus prophylactic vaccine be an effective alternative for the therapeutic management of genital warts? an exploratory study

OBJECTIVE

To evaluate the treatment effect of genital warts, we investigated the quadrivalent HPV vaccine injection compared with surgical excision.

MATERIALS AND METHODS

This prospective study included 26 patients (M:F = 24:2) who received HPV vaccine or surgical excision. After explanation of surgical excision or HPV vaccine, 16 patients underwent surgical excision and the others received HPV vaccine injections. Based on gross findings of genital warts, treatment outcomes were classified as complete response (no wart), partial response, and failed treatment.

RESULTS

Among enrolled patients, 42% (11 / 26) patients had recurrent genital warts. In vaccination group, complete response rates of genital wart were 60% following 3 times HPV vaccine. Partial response patients wanted to excise the genital lesions before the 3 times injection, because they worried about sexual transmission of disease to their sexual partners. One patient underwent surgical excision after 3 times injection. Excision sites included suprapubic lesions, but other sites including mid-urethra and glans showed complete response after injection. At a mean follow-up period of 8.42 ± 3.27 months, 10 patients (100%) who received HPV vaccine did not show recurrence.

CONCLUSION

The response rates after HPV vaccine injection were 90% (complete and partial). Our results suggested that HPV vaccines could be effective in management of genital warts.

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/

Viral metagenomics updated the prevalence of human papillomavirus types in anogenital warts

To investigate the composition of human papillomavirus (HPV) types in anogenital warts (AGWs), viral nucleic acid in 110 AGWs, pooled into 11 specimen pools, were subjected to viral metagenomic analysis. After finding HPV7 in AGWs, conventional PCR screening was performed for HPV7 in other 190 individual AGW specimens. Viral metagenomic results indicated that 29 different types of HPV were recovered, with HPV11 and HPV6 showing the highest proportion of sequence reads. HPV7 was detected in 7 of 11 pools, 5 of which contained abundant HPV7 sequence reads. 24 complete genomes of HPV were acquired in viral metagenomic analysis, including 5 HPV7 genomes, based on which phylogenetic analysis and pairwise sequence comparison were conducted. PCR screening for HPV7 in other 190 individual AGW specimens revealed 25 positive cases (13.16%), of which the amplified fragments were sequenced and confirmed to be HPV7 sequences. Although HPV7 was generally found in hand warts and recently also in warts in toe webs, our data suggested that the role of HPV7 in AGW should be considered in the future clinical test and vaccine development for AGWs.

Genital warts treatment: Beyond imiquimod

Genital warts are one of the most common sexually transmitted diseases worldwide. The disease is a result of infection with low-risk types of human papillomaviruses, mostly type 6 and 11. Current therapies for genital warts are mainly ablative, or alternatively topical application of imiquimod cream and sinecatechin (polyphenon E) ointment to the warts. However, low patient compliance and high recurrence rate are significant problems for the treatment of genital warts by imiquimod and ablative therapies. We summarise recent literature in this area and propose combining imiquimod with other therapies to increase the efficacy of imiquimod.