Monochloroacetic acid and 60% salicylic acid as a treatment for simple plantar warts: effectiveness and mode of action

Factors Influencing the Formation of Salicylic Acid by Bipolar Membranes Electrodialysis

Salicylic acid is an intermediate product in the synthesis of dyes, medications and aspirin. An electrodialysis module has been constructed with commercial cationic, anionic and bipolar membranes for the conversion of sodium salicylate into salicylic acid. The effect of operating conditions such as applied electric potential, salt concentration, initial acid concentration and volumetric flow on bipolar membrane electrodialysis (BMED) yields were investigated using Taguchi analysis. The results obtained in 210 min of work show an average concentration of salicylic acid of 0.0185 M, an average electric current efficiency of 85.3%, and a specific energy consumption of 2.24 kWh/kg of salicylic acid. It was concluded that the proposed bipolar membrane electrodialysis process is an efficient alternative to produce salicylic acid (SAH) from sodium salicylate (SANa) in an environmentally friendly manner. Furthermore, the production of sodium hydroxide was obtained as a by-product of the process carried out.

Topical treatment for plantar warts: A systematic review

There are a wide variety of treatments for plantar warts, but none has been shown to be effective in all patients. We aimed to perform a systematic review of the efficacy of different topical treatments on plantar warts. Systematic electronic searches (Pubmed, Cochrane Library, Embase, and Web of Science) were conducted in April 2020. Meta-analyses, systematic reviews, and retrospective or prospective clinical trials of the effects of topical and nonsurgical treatments of plantar warts were included. Two authors performed the study selection and data extraction. Any discrepancies between the two reviewers were discussed with a third reviewer. Forty-four studies were included. The average cure rates of the most frequent treatments were variable across the studies: cryotherapy (45.61%), salicylic acid (13.6%), cantharidin-podophyllin-salicylic acid formulation (97.82%), laser (79.36%), topical antivirals (72.45%), intralesional bleomycin (83.37%), and intralesional immunotherapy (68.14%). Twenty-two studies (50%) had a level of evidence 1b and grade of recommendation A, five studies (11.4%) had a level of evidence 2b and grade of recommendation B, two studies (4.5%) had a level of evidence 3b and grade of recommendation B, and 15 studies (34,1%) with a level of evidence 4 and grade of recommendation C. First-choice treatments for common warts, such as cryotherapy and salicylic acid, have low-cure rates for plantar warts. Other treatments, such as CPA formulation, immunotherapy, and intralesional bleomycin, which have compassionate use, have higher cure rates. This review should stimulate future high-quality research to evaluate these specialized treatments.

Successful treatment of plantar warts using topical Zijinding, a traditional Chinese medicine preparation: A case series

Introduction

Plantar warts are associated with high transmissibility and morbidity. Among the available therapeutic options, none is uniformly effective or virucidal. Salicylic acid is the first‐line therapy but approximately one‐third of lesions could not resolve and become recalcitrant despite repeated treatment. Cryotherapy is widely accessible with low cost but may be complicated by pain, blister formation, hemorrhage, infection, excessive granulation tissue formation, and hyper‐/hypo‐pigmentation. Hence, alternative treatment modalities are essential.

Methods

Three patients with debilitating plantar warts refractory or intolerant to cryotherapy were treated with a course of Zijinding (a traditional Chinese medicine preparation) paste prepared with white vinegar.

Results

All three patients showed excellent clinical response with Zijinding application with evolution of lesions to scabs and subsequently healthy skin within 1.5 to 5 months of treatment. Treatment was well tolerated and had no significant side effects with excellent compliance recorded for all three patients. There was no relapse for at least 10 months after stopping the treatment.

Conclusion

Topical Zijinding could be a promising alternative modality for the treatment of plantar warts. Further clinical trials on the comparison of Zijinding and other treatment modalities of plantar warts are warranted. Further studies are required to investigate the mechanism of action of Zijinding and to isolate the active ingredient.

Treatment of Warts in Children: An Update

Warts are among the most common skin infections in children. Although numerous treatment options are available, none are completely effective in a single session. Treatment is particularly complicated in children, not only because certain treatments are poorly tolerated, but also because parents frequently have unrealistic expectations. In this article, we offer an update on the treatments available for warts, focusing specifically on pediatric patients. We do not discuss treatments for oral and anogenital warts.

Monochloroacetic acid application is an effective alternative to cryotherapy for common and plantar warts in primary care: a randomized controlled trial

Cryotherapy and salicylic acid (SA) often fail as treatments for skin warts. We examined the effectiveness of monochloroacetic acid (MCA) for patients with common or plantar warts. Consecutive patients aged 4 years and older with one or more newly diagnosed common or plantar warts were recruited in 53 Dutch general practices. We randomly allocated eligible patients to 13-week treatment protocols of office-applied MCA versus liquid nitrogen cryotherapy every 2 weeks for patients with common warts (n=188), and MCA versus cryotherapy combined with daily SA self-application for patients with plantar warts (n=227). The primary outcome was the proportion of patients whose warts were all cured at 13 weeks. In the common wart group, cure rates were 40/92 (43%, 95% confidence interval 34-54) for MCA and 50/93 (54%, 44-64) for cryotherapy (risk difference (RD) -10%, -25-4.0, P=0.16). In the plantar wart group, cure rates were 49/106 (46%, 37-56) for MCA and 45/115 (39%, 31-48) for cryotherapy combined with SA (RD 7.1, 5.9-20, P=0.29). For common warts, MCA is an effective alternative to cryotherapy to avoid pain during the treatment, although pain after the treatment is similar. For plantar warts, office-applied MCA may be preferred over cryotherapy combined with SA, on the basis of comparable effectiveness, less treatment pain, and less treatment burden.

Ultra-trace analysis of hormones, pharmaceutical substances, alkylphenols and phthalates in two French natural mineral waters

The aim of this work was to investigate the potential presence of a broad range of organic compounds, such as hormones, alkylphenols, bisphenol A and phthalates, as well as pharmaceutical substances in two brands of bottled natural mineral waters (Evian and Volvic, Danone). The phthalates were determined by solid-phase microextraction coupled to gas chromatography-mass spectrometry (SPME-GC-MS) and the other compounds by liquid chromatography-tandem mass spectrometry (LC-MS/MS) or gas chromatography-mass spectrometry (GC-MS) after solid-phase extraction. The potential migration of alkylphenols, bisphenol A and phthalates from polyethylene terephthalate (PET) bottles was also investigated under standardized test conditions. Evian and Volvic natural mineral waters contain none of the around 120 targeted organic compounds. Traces of 3 pharmaceuticals (ketoprofen, salicylic acid, and caffeine), 3 alkylphenols (4-nonylphenol, 4-t-octylphenol, and 4-nonylphenol diethoxylate), and some phthalates including di(2-ethylhexyl)phthalate (DEHP) were detected in the samples, but they were also present in the procedural blanks at similar levels. The additional test procedures demonstrated that the few detected compounds originated from the background laboratory contamination. Analytical procedures have been designed both in the bottling factory and in the laboratory in order to investigate the sources of DEHP and to minimize to the maximum this unavoidable laboratory contamination. It was evidenced that no migration of the targeted compounds from bottles occurred under the test conditions. The results obtained in this study underline the complexity of reaching a reliable measure to qualify the contamination of a sample at ultra-trace level, in the field of very pure matrices. The analytical procedures involving glassware, equipment, hoods, and rooms specifically dedicated to trace analysis allowed us to reach reliable procedural limits of quantification at the ng/L level, by lowering the background laboratory contamination.

Hepatic injury and gluconeogenesis after subcutaneous injection of monochloroacetic acid in rats

OBJECTIVE

Monochloroacetic acid (MCA) is corrosive to skin, and causes not only chemical injury but also fatal systemic poisoning. Little is known about the cause of death. We studied the acute toxicity of MCA before clinical symptoms appeared in fasting rats.

METHODS

Blood samples were analyzed 2 h after subcutaneous MCA injection (Ld(90): 162 mg/ml kg body weight). Control rats were injected with saline.

RESULTS

Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were about 1.5-fold higher than in the controls, and mitochondrial AST (mAST) was 2-fold higher. Blood urea nitrogen and creatinine were significantly increased, while serum glucose was significantly decreased in the treated group. Lactate was 6-fold higher and pyruvate was 13-fold higher than in the controls.

CONCLUSIONS

MCA caused injury to the liver and kidneys but these injuries were slight. However, the larger increase in mAST indicated that hepatocellular mitochondria were selectively targeted. Hepatocellular mitochondrial injury decreased gluconeogenesis and caused hypoglycemia and extremely high levels of lactate and pyruvate. Hypoglycemia and lactic acidosis were insidious before the critical symptoms appeared and this combination accelerated to death, affecting other organs such as the heart and brain. Nosotropic therapy of these abnormalities up to the appearance of symptoms may help to establish an early therapy for skin exposure to MCA.

Topical treatments for cutaneous warts

BACKGROUND

Viral warts are a common skin condition, which can range in severity from a minor nuisance that resolve spontaneously to a troublesome, chronic condition. Many different topical treatments are available.

OBJECTIVES

To evaluate the efficacy of local treatments for cutaneous non-genital warts in healthy, immunocompetent adults and children.

SEARCH METHODS

We updated our searches of the following databases to May 2011: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, MEDLINE (from 2005), EMBASE (from 2010), AMED (from 1985), LILACS (from 1982), and CINAHL (from 1981). We searched reference lists of articles and online trials registries for ongoing trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of topical treatments for cutaneous non-genital warts.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials and extracted data; a third author resolved any disagreements.

MAIN RESULTS

We included 85 trials involving a total of 8815 randomised participants (26 new studies were included in this update). There was a wide range of different treatments and a variety of trial designs. Many of the studies were judged to be at high risk of bias in one or more areas of trial design.Trials of salicylic acid (SA) versus placebo showed that the former significantly increased the chance of clearance of warts at all sites (RR (risk ratio) 1.56, 95% CI (confidence interval) 1.20 to 2.03). Subgroup analysis for different sites, hands (RR 2.67, 95% CI 1.43 to 5.01) and feet (RR 1.29, 95% CI 1.07 to 1.55), suggested it might be more effective for hands than feet.A meta-analysis of cryotherapy versus placebo for warts at all sites favoured neither intervention nor control (RR 1.45, 95% CI 0.65 to 3.23). Subgroup analysis for different sites, hands (RR 2.63, 95% CI 0.43 to 15.94) and feet (RR 0.90, 95% CI 0.26 to 3.07), again suggested better outcomes for hands than feet. One trial showed cryotherapy to be better than both placebo and SA, but only for hand warts.There was no significant difference in cure rates between cryotherapy at 2-, 3-, and 4-weekly intervals.Aggressive cryotherapy appeared more effective than gentle cryotherapy (RR 1.90, 95% CI 1.15 to 3.15), but with increased adverse effects.Meta-analysis did not demonstrate a significant difference in effectiveness between cryotherapy and SA at all sites (RR 1.23, 95% CI 0.88 to 1.71) or in subgroup analyses for hands and feet.Two trials with 328 participants showed that SA and cryotherapy combined appeared more effective than SA alone (RR 1.24, 95% CI 1.07 to 1.43).The benefit of intralesional bleomycin remains uncertain as the evidence was inconsistent. The most informative trial with 31 participants showed no significant difference in cure rate between bleomycin and saline injections (RR 1.28, 95% CI 0.92 to 1.78).Dinitrochlorobenzene was more than twice as effective as placebo in 2 trials with 80 participants (RR 2.12, 95% CI 1.38 to 3.26).Two trials of clear duct tape with 193 participants demonstrated no advantage over placebo (RR 1.43, 95% CI 0.51 to 4.05).We could not combine data from trials of the following treatments: intralesional 5-fluorouracil, topical zinc, silver nitrate (which demonstrated possible beneficial effects), topical 5-fluorouracil, pulsed dye laser, photodynamic therapy, 80% phenol, 5% imiquimod cream, intralesional antigen, and topical alpha-lactalbumin-oleic acid (which showed no advantage over placebo).We did not identify any RCTs that evaluated surgery (curettage, excision), formaldehyde, podophyllotoxin, cantharidin, diphencyprone, or squaric acid dibutylester.

AUTHORS' CONCLUSIONS

Data from two new trials comparing SA and cryotherapy have allowed a better appraisal of their effectiveness. The evidence remains more consistent for SA, but only shows a modest therapeutic effect. Overall, trials comparing cryotherapy with placebo showed no significant difference in effectiveness, but the same was also true for trials comparing cryotherapy with SA. Only one trial showed cryotherapy to be better than both SA and placebo, and this was only for hand warts. Adverse effects, such as pain, blistering, and scarring, were not consistently reported but are probably more common with cryotherapy.None of the other reviewed treatments appeared safer or more effective than SA and cryotherapy. Two trials of clear duct tape demonstrated no advantage over placebo. Dinitrochlorobenzene (and possibly other similar contact sensitisers) may be useful for the treatment of refractory warts.

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.

Current choices in the treatment of cutaneous warts: a survey among Dutch GP

BACKGROUND

GPs apply several treatments for patients with cutaneous warts. Available evidence recommends salicylic acid application.

OBJECTIVE

We investigated whether current choices of GPs in the treatment of warts are in agreement with available evidence.

METHODS

A nationwide random sample of 700 Dutch GPs received a postal questionnaire on their choices in the treatment of warts. In addition, factors that influence these choices, their view on the effectiveness of treatments and their view on the natural history of warts were assessed.

RESULTS

The questionnaire was returned by 280 GPs (40%). Cryotherapy was first choice treatment in 73% of GPs for hand warts, 49% of GPs for plantar warts and 72% of GPs for warts on other locations. Salicylic acid application or the combination of cryotherapy and salicylic acid were used less frequently, followed by an expectant awaiting policy and (electro) surgery. Most important factors influencing their treatment choice were GPs' routine and GPs' views on effectiveness.

CONCLUSIONS

In contrast to available evidence, most GPs apply cryotherapy as first choice treatment of cutaneous warts. Pragmatic high-quality trials on the effectiveness of wart treatments conducted in primary care might solve this discrepancy between evidence and practice.

Treatment of palmoplantar warts with a diphencyprone and salicylic acid ointment

We report on 50 consecutive suitable patients with one or more palmoplantar warts who were treated with a patient-applied ointment comprising 0.1% diphencyprone and 15% salicylic acid in white soft paraffin. All patients sensitized to diphencyprone were followed up clinically and assessed by patient questionnaire. The intention to treat success rate in this series was 88%. The time to wart clearance ranged from less than 4 weeks to 4 months. In our patient group, 90% rated their treatment as 'excellent' or 'good', whereas 10% stated that the reaction induced by diphencyprone was 'too severe'. Our results are compared with those previously published using diphencyprone in the treatment of palmoplantar warts.

Topical treatments for cutaneous warts

BACKGROUND

Viral warts are common and usually harmless but very troublesome. A very wide range of local treatments are used.

OBJECTIVES

To assess the effects of different local treatments for cutaneous, non-genital warts in healthy people.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (March 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to March 2005), EMBASE (1980 to March 2005) and a number of other biomedical databases. The references of all trials and selected review articles were also searched. In addition, we contacted pharmaceutical companies involved in local treatments for warts and experts in the field

SELECTION CRITERIA

Randomised controlled trials of local treatments for cutaneous non-genital viral warts in immunocompetent (healthy) people.

DATA COLLECTION AND ANALYSIS

Data was extracted and two authors independently selected the trials and assessed methodological quality.

MAIN RESULTS

Sixty trials were identified that fulfilled the criteria for inclusion. The evidence provided by these studies was generally weak due to poor methodology and reporting. In 21 trials with placebo groups that used participants as the unit of analysis, the average cure rate of placebo preparations was 27% (range 0 to 73%) after an average period of 15 weeks (range 4 to 24 weeks). The best available evidence was for simple topical treatments containing salicylic acid, which were clearly better than placebo. Data pooled from five placebo-controlled trials showed a cure rate of 117/160 (73%) compared with 78/162 (48%) in controls, which translates to a risk ratio of 1.60 (95% confidence interval 1.16 to 2.23), using a random effects model. Evidence for the absolute efficacy of cryotherapy was surprisingly lacking. Two trials comparing cryotherapy with salicylic acid and one comparing duct tape with cryotherapy showed no significant difference in efficacy. Evidence for the efficacy of the remaining treatments reviewed was limited.

AUTHORS' CONCLUSIONS

There is a considerable lack of evidence on which to base the rational use of topical treatments for common warts. The reviewed trials are highly variable in method and quality. Cure rates with placebo preparations are variable but nevertheless considerable. There is certainly evidence that simple topical treatments containing salicylic acid have a therapeutic effect. There is less evidence for the efficacy of cryotherapy, but reasonable evidence that it is only of equivalent efficacy to simpler and safer treatments. The benefits and risks of topical dinitrochlorobenzene and 5-fluorouracil, intralesional bleomycin and interferons, photodynamic therapy and other miscellaneous treatments remain to be determined.

Management of cutaneous warts: an evidence-based approach

Cutaneous warts are benign epidermal proliferations caused by human papillomavirus infection. Treatment aims to cure the patient's physical and psychological discomfort, and to prevent the spread of infection by contact with other body areas or with other individuals. Among the available medical and destructive therapeutic options for cutaneous warts, none is uniformly effective or virucidal. Moreover, in most cases the safety and efficacy of these treatment options has not been assessed in randomized controlled trials, so that the reproducibility of many of the listed treatments is difficult to evaluate and a possible placebo effect cannot be ruled out. This article provides indications for the management of patients with cutaneous warts through an evidence-based approach, considering a first-, second-, and third-line therapy for each clinical form. The first line includes medical treatments useful to cure single, or few, and/or small common warts of short duration (<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, a third-line of therapy includes a variety of alternative therapeutic options that are in clinical use but are not necessarily approved by the US FDA, and their use may be further limited by adverse effects.

Local treatments for cutaneous warts

BACKGROUND

Viral warts caused by the human papilloma virus represent one of the most common diseases of the skin. Any area of skin can be affected although the hands and feet are by far the commonest sites. A very wide range of local treatments are available.

OBJECTIVES

To assess the effects of different local treatments for cutaneous, non-genital warts in healthy people.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (January 2003), the Skin Group trials register (January 2003), MEDLINE (1966 to January 2003), EMBASE (1980 to January 2003) and a number of other key biomedical and health economics databases. In addition the cited references of all trials identified and key review articles were searched. Pharmaceutical companies involved in local treatments for warts and experts in the field were contacted. The most recent searches were carried

SELECTION CRITERIA

Randomised controlled trials of local treatments for cutaneous non-genital viral warts in immunocompetent human hosts were included.

DATA COLLECTION AND ANALYSIS

Study selection and assessment of methodological quality were carried out by two independent reviewers.

MAIN RESULTS

Fifty two trials were identified which fulfilled the criteria for inclusion in the review. The evidence provided by these studies was generally weak because of poor methodology and reporting. In 17 trials with placebo groups that used participants as the unit of analysis the average cure rate of placebo preparations was 30% (range 0 to 73%) after an average period of 10 weeks (range 4 to 24 weeks). The best available evidence was for simple topical treatments containing salicylic acid, which are clearly better than placebo. Data pooled from six placebo-controlled trials show a cure rate of 144/191 (75%) compared with 89/185 (48%) in controls, odds ratio 3.91 (95% confidence interval 2.40 to 6.36), random effects model. Most of the bigger trials of cryotherapy studied different regimens rather than comparing cryotherapy with other treatments or placebo. Pooled data from two small trials that included cryotherapy and placebo or no treatment, showed no significant difference in cure rates. In two trials comparing cryotherapy with salicylic acid and one comparing duct tape with cryotherapy no significant difference in efficacy was demonstrated. There was no consistent evidence for the effectiveness of intralesional bleomycin. Four studies, using warts rather than individuals as the unit of analysis, had widely varying results which could not be meaningfully pooled. There was some evidence for the efficacy of dinitrochlorobenzene, a potent contact sensitizer. Pooled data from two small studies comparing dinitrochlorobenzene with placebo showed cure rates of 32/40 (80%) and 15/40 (38%) respectively, odds ratio 6.67 (95% confidence interval 2.44 to 18.23), random effects model. Only limited evidence was found for the efficacy of topical 5-fluorouracil, intralesional interferons and photodynamic therapy.Bleomycin, dinitrochlorobenzene, 5-fluorouracil, interferons and photodynamic therapy are potentially hazardous or toxic treatments.

REVIEWER'S CONCLUSIONS

There is a considerable lack of evidence on which to base the rational use of the local treatments for common warts. The reviewed trials are highly variable in method and quality. Cure rates with placebo preparations are variable but nevertheless considerable. There is certainly evidence that simple topical treatments containing salicylic acid have a therapeutic effect. There is less evidence for the efficacy of cryotherapy and some evidence that it is only of equivalent efficacy to simpler, safer treatments. Dinitrochlorobenzene appears to be effective but there were no statistically significant differences when compared with the safer, simpler and cheaper topical treatments containing salicylic acid. The benefits and risks of 5-fluorouracil, bleomycin, interferons and photodynamic therapy remain to be determined.

Local treatments for cutaneous warts: systematic review

OBJECTIVE

To assess the evidence for the efficacy of local treatments for cutaneous warts.

METHODS

Systematic review of randomised controlled trials.

MAIN OUTCOMES MEASURES

Total clearance of warts and adverse effects such as irritation, pain, and blistering.

STUDY SELECTION

Randomised controlled trials of any local treatment for uncomplicated cutaneous warts. All published and unpublished material was considered, with no restriction on date or language.

RESULTS

50 included trials provided generally weak evidence because of poor methods and reporting. The best evidence was for topical treatments containing salicylic acid. Data pooled from six placebo controlled trials showed a cure rate of 75% (144 of 191) in cases compared with 48% (89 of 185) in controls (odds ratio 3.91, 95% confidence interval 2.40 to 6.36). Some evidence for the efficacy of contact immunotherapy was provided by two small trials comparing dinitrochlorobenzene with placebo. Evidence for the efficacy of cryotherapy was limited. No consistent evidence was found for the efficacy of intralesional bleomycin, and only limited evidence was found for the efficacy of topical fluorouracil, intralesional interferons, photodynamic therapy, and pulsed dye laser.

CONCLUSIONS

Reviewed trials of local treatments for cutaneous warts were highly variable in methods and quality, and there was a paucity of evidence from randomised, placebo controlled trials on which to base the rational use of the treatments. There is good evidence that topical treatments containing salicylic acid have a therapeutic effect and some evidence for the efficacy of dinitrochlorobenzene. Less evidence was found for the efficacy of all the other treatments reviewed, including cryotherapy.

Cutaneous warts: diagnosis and treatment

Cutaneous warts are a common malady that affects all ages, but are most prevalent in children and young adults. Warts result from infection with human papillomavirus and can lead to a condition that may be painful, disfiguring, and recurrent, despite treatment. A multitude of therapeutic modalities exist, though no single agent is invariably effective. Successful treatment must take into consideration the patient's level of motivation, expense, and physician experience.

Squaric acid immunotherapy for warts in children

BACKGROUND

Warts are a common pediatric skin infection caused by human papillomavirus (HPV). Spontaneous clearance of warts involves anti-HPV immunity, which may be enhanced by contact sensitizers. Squaric acid dibutylester (SADBE) is a nonmutagenic sensitizing agent useful for immunotherapy of alopecia areata.

OBJECTIVE

We hypothesized that SADBE home application might be effective therapy for warts.

METHODS

An open-label, retrospective study of 61 children with warts was performed. Sensitization with 2% SADBE on the forearm was followed with home application of 0.2% SADBE to warts 3 to 7 nights per week for at least 3 months.

RESULTS

Complete clearing occurred in 34 patients (58%), with a mean duration of therapy of 7 weeks. Partial clearing occurred in 11 (18%), and no response in 14 (24%). Clearance correlated with plantar distribution, wart duration under 2 years (P <.05), and first-line therapy with SADBE. Mild side effects occurred in one third of patients, were limited most commonly to mild erythema at the site of sensitization, and necessitated discontinuation of therapy in only 2 patients.

CONCLUSION

SADBE topical immunotherapy is a safe, effective option for home therapy of warts in children.

Interaction of salicylic acid with verrucae assessed by FT-Raman spectroscopy

FT-Raman spectroscopy has been used to investigate treated verrucae (warts from the sole of the foot) with a local application of a salicylic acid paint. Differences in the molecular structure of the stratum corneum across the verruca sample were observed, and by comparison with normal and hyperkeratotic skin it was concluded that the tissue around the edges of the verrucae was typically hyperkeratotic skin. In the centre of the verruca, the molecular structure of the skin was altered showing evidence of the interaction with salicylic acid. Salicylic acid was not observed in its characteristic dimerised acid structure, but spectroscopic evidence suggested that fission of the intermolecular H-bonding essentially cleaved the dimer. Observed changes in the v(CCO) stretching mode of the carboxyl and hydroxyl groups indicate the inter H-bonds have broken. These spectral changes are believed to be more consistent with salicylic acid bonding within the human papillomavirus-containing verruca tissue rather than simple acid dissociation upon dissolution in water within the tissue. No evidence for the presence of the other paint components, lactic acid and flexible collodion, was found in the verrucae spectra. This Raman approach may help to elucidate the molecular basis for therapeutic agents interacting with diseased skin.

Treatment of xanthelasma palpebrarum with bichloracetic acid

BACKGROUND

Although many treatment modalities have been described for xanthelasma palpebrarum, no single technique has emerged as dominant.

OBJECTIVES

Our purpose was to review the various therapeutic modalities for xanthelasma and to assess the efficacy of topical bichloracetic acid.

METHODS

Thirteen patients with 25 xanthelasma were treated with topical 100% bichloracetic acid. Efficacy was assessed over a follow-up period of 7 months to 10.5 years (average, 64 months).

RESULTS

Eighty-five percent of patients experienced initial complete clearing, and 72% of their lesions have not required retreatment over an average period of 68 months. Recurrences responded well to repeat treatment. Eighty-three percent of recurrent or poorly responsive lesions were associated with high cholesterol. The most resistant patient had four-lid involvement. Excellent cosmetic results and high patient satisfaction were seen.

CONCLUSIONS

Topical bichloracetic acid is a viable alternative to other modalities in the management of xanthelasma. Advantages include simplicity, cost-effectiveness, speed, safety, and efficacy.