Topical photodynamic therapy with 5-aminolaevulinic acid for condylomata acuminata on the distal urethra

Photodynamic therapy in the treatment of condyloma acuminata: A systematic review of clinical trials

INTRODUCTION

Condylomata acuminata (CA) is a sexually transmitted infection with a high prevalence associated with psychosexual morbidity in both men and women of various age. Up to now, treatment modalities yield low clearance and recurrence rate (RR) and are also deemed low quality evidence-wise. Photodynamic therapy (PDT) is a novel and promising therapy to effectively cure and prevent CA recurrence.

METHOD

This systematic review was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) and registered to the International Prospective Register of Systematic Review (PROSPERO) (CRD42022332760).

RESULTS

Ten studies were included in this systematic review. A significant value of complete response (CR) ranging from 63-100% in patients with genital warts after receiving several sessions of PDT. A relatively low recurrence rate was seen in all 10 studies, with an RR of less than 17%. Quality assessment of included studies reported mostly high-quality research.

CONCLUSIONS

PDT therapy resulted in a higher CR with significantly lower RR compared to other therapies. Thus, PDT can be an alternative treatment of CA with low RR and minimal side effects. Additional research, especially randomized clinical trials in various countries, is needed to further substantiate this treatment and formulate definitive protocols.

Update on the Medical and Surgical Management of Urethral Condyloma

INTRODUCTION

Condyloma acuminata (CA) of the urethra presents a management challenge due to high recurrence rates, difficulty in accessing urethral lesions, risk of stricture formation, and potential for sexual dysfunction. While standard treatment modalities are acceptable for some external genital condyloma, they are not always feasible or appropriate for urethral lesions.

OBJECTIVES

We sought to review the literature on epidemiology, presentation, diagnosis and treatment of urothelial CA with a focus on surgical treatment options.

METHODS

We performed a comprehensive literature search of PubMed to identify all studies pertaining to urethral CA through November 2020.

RESULTS

Urethral CA is a relatively rare, but challenging disease to manage with a considerable amount of treatment side effects and downstream morbidity associated. In our comprehensive review we have found a wide selection of treatment modalities ranging from minimally invasive strategies to surgical reconstructive techniques. Proper follow-up to monitor for disease recurrence at the 3-4 month mark is appropriate and will determine subsequent treatment strategies as needed. Future studies and treatment directions include novel drug delivery models to optimize minimally invasive topical drug efficacy.

CONCLUSION

Treatment of urethral CA should be approached in a step-wise fashion. Medical therapy would be an appropriate option for asymptomatic or minimally symptomatic patients with small lesions who desire to avoid any interventions. If patient is symptomatic, has extensive disease burden or has failed medical therapy intervention should be considered with options including PDT, laser ablation or surgical excision with or without urethral reconstruction. Appropriate selection depends on patient characteristics and preferences along with prior treatment history. Kim CJ, Campbell SP, Allkanjari A, et al. Update on the Medical and Surgical Management of Urethral Condyloma. Sex Med Rev 2021;xxx:xxx-xxx.

The place of 5-aminolaevulinic acid-photodynamic therapy in the treatment landscape of urethral warts: A systematic review

BACKGROUND

Human papilloma virus (HPV) infection is the most common sexually transmitted disease worldwide and the main cause of genital warts. Clear recommendations for the management of urethral warts, which are often hard to detect and difficult to treat, are still lacking.

OBJECTIVE

To summarize all available data describing treatment modalities of urethral warts, compare their efficacy and side effects, and provide physicians a treatment strategy outline.

MATERIAL AND METHODS

Till June 2020, we conducted a systematic review of articles studying the different treatment modalities of urethral condylomas. A chi-square test was used to compare the recurrence rates between treatment modalities, the complete clearance rates at first follow-up and the rates of adverse events.

RESULTS

A total of 26 articles with 1730 patients were included in our review. 61 % of patients were deemed completely cured on the first follow-up while 21 % recurred. 5-aminolevulinic acid (ALA) mediated photodynamic therapy (PDT) was the most common treatment and yielded the lowest recurrence rate (7.5 %) followed by laser therapy (24 %) and topical therapy (31 %) (p < 0.01). ALA-PDT resulted in a higher rate of clearance on follow up (96 %) compared to laser therapy (69 %) and topical therapy (14 %) (p < 0.01). Adverse events were more frequent in the ALA-PDT group (69 %) compared to laser therapy (28 %) and topical treatment (30 %) (p < 0.01).

CONCLUSION

ALA-PDT appears to be the most effective treatment of urethral condylomas in term of clearance and recurrence rate, but with a higher risk of adverse events. Management should be tailored to the type of lesion found at presentation.

Treatment of intraurethral condylomata acuminata with surgery and cidofovir instillations in two immunocompromised patients and review of the literature

Condylomata acuminata (CA) or anogenital warts are benign proliferative lesions caused by low-risk human papillomaviruses (HPV). Treating CA can be very frustrating for patients and clinicians due to the high recurrence rates. Immunosuppression is associated with larger size of CA that are more frequently resistant to treatment. Surgical approaches tend to be poorly effective in the long-term because of high recurrence rates related to the persistence of HPV-infected cells. In our search to find an agent to treat intraurethral CA with minor or no side effects, we evaluated intraurethral cidofovir in two male patients, who were under immunosuppressing therapy due to organ transplantation and suffered from extensive urethral HPV lesions. Both patients underwent biopsy of the lesions and initial transurethral resection. In our first case, intraurethral cidofovir instillations were started after 2 months due to recurrence after surgical treatment. In our second case, intraurethral cidofovir was administered after surgery because of incomplete resection of extensive lesions. Because of persistent or rapidly recurrent lesions despite intraurethral cidofovir instillations, the first patient needed two additional surgical interventions while the second patient underwent one additional surgical intervention. After surgical intervention, both patients received again adjuvant cidofovir instillations without side effects. Over a period of 56 weeks, both patients received each a total of 28 instillations with cidofovir. Following 3.5 years (patient 1) of the last cidofovir instillation, no recurrences were observed in our first patient. Following 6 months of the last cidofovir instillation (patient 2), two very small recurrent lesions in the most distal part of the urethra were observed in our second patient for which he will receive a cycle of 6 cidofovir instillations in the near future. Intraurethral cidofovir is a safe, easy-to-use, well-tolerated and an effective adjuvant to surgery for extensive intraurethral CA in immunocompromised patients.

Topical photodynamic therapy with 5-aminolevulinic acid in Chinese patients with Rosacea

Background: Rosacea is difficult to cure and frequently recurs. Topical photodynamic therapy (PDT) has been tentatively used, with only preliminary results reported. Objective: To evaluate the efficacy and safety of topical PDT in Chinese patients with rosacea. Methods & Materials: Seventeen participants with rosacea were treated three times using 5-aminolevulinic acid (ALA)-PDT at intervals of 7-10 days. Papule and pustule numbers, erythema severity, telangiectasia severity, physician's global assessment (PGA) score (1 [best]-6), and patient satisfaction score (0-3 [highest]) were assessed. Rosacea improvement and the total effective rate were calculated. Stratum corneum hydration and sebum levels, and the melanin index (MI) and erythema index (EI) were measured non-invasively. Results: After three treatments with ALA-PDT, the total effective rate (≥50% improvement) was 64.71%, mean PGA score was 2.88 ± 0.93, and mean patient satisfaction score was 1.71 ± 0.69. The EI significantly decreased 1 month after the final treatment (from 468 ± 80.61 to 439 ± 77.78 for the forehead and from 507.65 ± 92.51 to 483.27 ± 78.32 for the nasal ala). Four participants received three additional treatments. They achieved 50-74% improvement after three treatments and ≥75% improvement after six treatments. Conclusion: ALA-PDT is safe and effective for treating rosacea.

Clinical analysis of five methods used to treat condylomata acuminata

OBJECTIVE

Treatments for condylomata acuminata (CA) include pharmacotherapy and surgical therapies, but each treatment has its limitations. The aim of this study was to investigate the virus clearance rate, wart cure rate and safety of 5 methods on CA.

METHODS

361 patients diagnosed with CA were divided into groups A (<0.5 cm), B (0.5-2.0 cm) and C (>2.0-4.0 cm) according to the maximum diameter of their lesion. Five treatments were compared in each group, and the clinical outcomes were evaluated during follow-ups.

RESULTS

A 5-aminolevulinic acid-mediated photodynamic therapy (ALA-PDT) is preferred if the maximum lesion diameter is <0.5 cm and an ALA-PDT plus cryotherapy treatment is preferred for lesions 0.5-2.0 cm. For lesions >2.0- 4.0 cm, an ALA-PDT retreatment (after cryotherapy or CO2 laser treatment) should be the first choice.

CONCLUSIONS

The treatments for CA should be chosen according to the maximum diameter of each patient's lesion.