Efficacy and safety of intralesional injection of vitamin D3 versus tuberculin PPD in the treatment of plantar warts: A comparative controlled study

A Novel Triple Combination Therapy for the Treatment of Recalcitrant Plantar Warts: A Case Report

Recalcitrant plantar warts, caused by human papillomavirus, often resist conventional treatments, necessitating alternative approaches. This case report details the successful treatment of a persistent plantar wart in a 24-year-old male using a novel triple combination therapy. The patient had previously undergone multiple unsuccessful treatments, including cryotherapy, salicylic acid, and duct tape occlusion. The combination therapy consisted of cryotherapy, topical imiquimod 5% cream, and intralesional injections of purified protein derivative (PPD). The regimen was administered over six weeks, with cryotherapy and PPD injections every three weeks, and imiquimod applied every other day. Significant regression was observed by the second session, with near-complete resolution by the third. At six-month follow-up, no recurrence was noted, and the skin had healed without scarring. This case highlights the synergistic effects of combining physical destruction (cryotherapy), immune modulation (imiquimod), and local immune stimulation (PPD) to successfully treat recalcitrant plantar warts. This triple combination therapy may offer a promising option for cases unresponsive to standard treatments, providing a comprehensive approach that reduces recurrence and promotes complete resolution.

HPV Infections-Classification, Pathogenesis, and Potential New Therapies

To date, more than 400 types of human papillomavirus (HPV) have been identified. Despite the creation of effective prophylactic vaccines against the most common genital HPVs, the viruses remain among the most prevalent pathogens found in humans. According to WHO data, they are the cause of 5% of all cancers. Even more frequent are persistent and recurrent benign lesions such as genital and common warts. HPVs are resistant to many disinfectants and relatively unsusceptible to external conditions. There is still no drug available to inhibit viral replication, and treatment is based on removing lesions or stimulating the host immune system. This paper presents the systematics of HPV and the differences in HPV structure between different genetic types, lineages, and sublineages, based on the literature and GenBank data. We also present the pathogenesis of diseases caused by HPV, with a special focus on the role played by E6, E7, and other viral proteins in the development of benign and cancerous lesions. We discuss further prospects for the treatment of HPV infections, including, among others, substances that block the entry of HPV into cells, inhibitors of viral early proteins, and some substances of plant origin that inhibit viral replication, as well as new possibilities for therapeutic vaccines.

Systematic Review of Intralesional Therapies for Cutaneous Warts

Intralesional therapies are used for recalcitrant warts, but no Food and Drug Administration-approved treatment exists nor is there consensus regarding the most efficacious therapy. Therefore, this systematic review aims to summarize efficacy and adverse events reported in 62 randomized controlled trials (RCTs) of intralesional therapies for cutaneous warts. The most studied intralesional therapies included measles, mumps, rubella (MMR) vaccine (n = 24 studies), purified protein derivative (PPD) (n = 19 studies), vitamin D3 (n = 15 studies), and Candida antigen (n = 14 studies). Most studies included adult and pediatric patients or adults alone, with only 4 studies on pediatric patients alone. MMR vaccine was the most studied treatment (n = 853 patients). MMR had a complete response rate of 27-90%. The next most common treatment, PPD, had a complete response rate of 45-87%. Other treatments included Candida antigen and vitamin D3, with complete response rates of 25-84% and 40-96%, respectively. The most frequent side effects were injection-site reactions and flu-like symptoms. This systematic review represents a useful summary of intralesional therapy RCTs for clinician reference. This study also highlights the lack of large multi-institutional RCTs, despite many patients being treated for this widespread problem.

Efficacy and Safety Profile of Tuberculin Protein Purified Derivative Injection As Immunotherapy For the Treatment of Cutaneous and Anogenital Warts: A Review Article

Introduction

Various treatments available today for anogenital and cutaneous warts have limitations, including time-consuming, challenging to perform, and the risk of scarring. A new treatment using tuberculin purified protein derivative (PPD) has been developed, which is expected to generate cellular immunity against HPV.

Objective

To assess the evidence for the efficacy and safety of PPD treatment for cutaneous and anogenital warts.

Materials and methods

A literature search was performed with the keyword-based search on digital libraries, including the National Library of Medicine, Cochrane Controlled Register of Trial, and Google Scholar, using the following terms: anogenital warts, condyloma acuminata, cutaneous warts, human papillomavirus, immunotherapy, and tuberculin purified protein derivative. Original studies on treating cutaneous or anogenital warts with PPD were included. The results were 47 clinical trials and 4 case reports. Most of the research was done in countries with common Mycobacterium tuberculosis infection. The treatment showed good efficacy. Comparative studies showed that the treatment has similar efficacy with other immunotherapies. No significant side effects were reported, with evidence of the safety use on the pregnant population.

Conclusion

Based on good efficacy and safety, PPD can be considered an alternative therapy, especially in countries where tuberculosis is frequent.

Efficacy of Cryotherapy Combined With Intralesional Purified Protein Derivative (PPD) Versus Intralesional PPD Monotherapy in the Treatment of Multiple Common Warts

INTRODUCTION

Intralesional antigen immunotherapy represents a promising therapeutic approach for the treatment of different types of warts, particularly if multiple and/or recalcitrant.

AIM

to investigate the efficacy and safety of combined cryotherapy with intralesional purified protein derivative (PPD) immunotherapy in the treatment of multiple common warts.

METHODS

Fifty patients were randomly divided into two groups (25 patients each): Group A: receiving intralesional PPD immunotherapy for the largest wart, while group B: receiving cryotherapy for all warts plus intralesional PPD for the largest wart. Treatments were performed every 2 weeks for a maximum of four sessions. Photographs were taken at baseline and at each visit and clinical response was evaluated by the reduction in number and size of warts. Adverse effects were recorded.

RESULTS

There was a significant reduction in size and number of warts in both groups (P < .001), with no significant difference between the two groups. Complete clearance of the lesions was observed in 48% of patients in group A and 44% in group B (P = .39). Higher rates of near complete/complete response were achieved after fewer sessions (2, 3 sessions) in group B (P = .002). Blistering was common after cryotherapy. Higher rate of hypopigmentation was noticed after combined treatment than after PPD monotherapy (56%, 8% respectively; P < .001), which resolved gradually.

CONCLUSION

Both intralesional PPD alone and combined cryotherapy with PPD are safe and effective in clearing of common warts. Cryotherapy may be a successful adjunct to intralesional PPD immunotherapy that helps in reducing the number of treatment sessions.The study protocol was registered at ClinicalTrials.gov with ID: NCT04288817.

Intralesional combined furosemide and digoxin in cutaneous warts treatment: A randomized controlled clinical trial

Although being a benign lesion, Warts can affect the quality of life by causing discomfort, disfigurement, and social embarrassment besides the tendency to spread. Cutaneous wart treatment faces many challenges as the development of an antiviral drug that can eradicate the human papilloma virus (HPV) is difficult. This clinical study aimed to assess the efficacy and safety of intralesional combined furosemide and digoxin in the treatment of multiple cutaneous warts. This double blinded randomized clinical trial included 80 adult patients with multiple cutaneous warts (≥2 warts) who were randomized into two groups, Group I (40 patients) treated with intralesional combined furosemide and digoxin and Group II (40 patients) who were treated with intralesional normal saline solution as a control group, weekly till improvement or for maximum five sessions. Clinical and dermoscopic evaluation at baseline, every session, and monthly for 6 months after the last session to detect any recurrence was performed. Complete wart clearance was observed in 92.5% of patients in the intralesional combined furosemide and digoxin group (Group I) compared with 10.0% in saline group (Group II), with highly statistically significant difference (P-value = 0.000). Pain during injection in 95.0% and 45.0% of patients in Group I and Group II respectively, treatment group was superior compared to control group. Intralesional injection of combined furosemide and digoxin can be a safe and effective treatment option in multiple cutaneous warts with minimal side effects in this study.

Interleukin-18 serum level before and after intralesional immunotherapy with tuberculin purified protein derivative in patients with cutaneous and genital warts

BACKGROUND

Several studies demonstrated the efficacy of intralesional purified protein derivative (PPD) immunotherapy in warts eradication. Nevertheless, the precise induced immune mechanisms are undetermined. Injected PPD is hypothesized to induce a delayed hypersensitivity reaction associated with cytokines release. Interleukin (IL)-18 has a major role in defense against viral infection via inducing interferon-γ release from T-helper 1 and natural killer (NK) cells. Moreover, IL-18 triggers Fas ligand expression on cytotoxic T cells and NK cells enhancing their cytotoxicity against virally infected cells.

AIM

The aim of this study was to assess the role of IL-18 in the response to intralesional PPD injection in patients with warts.

METHODS

The study included 25 patients with warts and 25 HCs. Patients underwent PPD skin test, and only patients with positive tests were included and received intralesional PPD injections starting 72 h after the test then every 2 weeks until wart clearance or a maximum of 3 sessions. Serum IL-18 level was measured via enzyme-linked immune-sorbent assay in patients (pre-treatment and 2 weeks after the last injection) and HCs.

RESULTS

After 3 sessions of injection, six (24%) patients were designated responders, nine (36%) patients showed partial response, and 10 (40%) patients were designated non-responders. Serum IL-18 level, post-treatment, was significantly higher than pre-treatment level (p = 0.025) and level in HCs (p = 0.036). Furthermore, the post-treatment level was significantly higher in responders than non-responders (p = 0.025).

CONCLUSION

IL-18 is probably implicated in the immune mechanisms induced by PPD injection that cause eradication of warts.

Effect of 5-Aminolevulinic Acid Photodynamic Therapy with Transfer Factor Capsules in the Treatment of Multiple Plantar Warts

BACKGROUND

Plantar warts are a common cutaneous disease of the sole of the foot caused by human papillomavirus. Photodynamic therapy has gained increasing attention in the treatment of plantar warts.

OBJECTIVE

To investigate the effect of photodynamic therapy combined with transfer factor capsules in the treatment of multiple plantar warts.

METHODS

Sixty-one patients with multiple plantar warts who visited our outpatient department from September 2017 to August 2019 were randomly divided into two groups. Twenty-three patients received photodynamic therapy (treatment group) and thirty-eight received cryotherapy (control group). Both groups also received immune modulator transfer factor capsules. Skin lesion score, numeric rating scale- (NRS-) 10 score, recurrence rate, adverse reactions, and Dermatology Life Quality Index (DLQI) were analyzed in both groups.

RESULTS

The mean skin lesion score improved from 13.39 ± 3.88 before treatment to 1.48 ± 2.50 after the last treatment in the treatment group and from 12.47 ± 2.99 before treatment to 4.47 ± 3.67 after the last treatment in the control group. The success rate after 3 months of treatment was 86.96% in the treatment group and 39.47% in the control group. After 3 months of follow-up, the recurrence rate was significantly lower in the treatment group (20%) than in the control group (53.33%). The mean DLQI score at three months after treatment was significantly lower in the treatment group (3.61 ± 1.16) than in the control group (6.31 ± 2.59).

CONCLUSION

Photodynamic therapy combined with immunomodulators significantly increased the cure rate and reduced the recurrence rate of multiple plantar warts compared with traditional cryotherapy combined with immunomodulators.

Intralesional immunotherapy for multiple recalcitrant plantar warts: Candida antigen is superior to intralesional purified protein derivative

BACKGROUND

Treatment of recalcitrant plantar warts represent a highly challenging issue for both patients and physicians. Candida antigen and purified protein derivative (PPD) have shown promising efficacy in the treatment of warts, however no previous studies have compared both antigens for recalcitrant plantar warts.

AIM

To assess the efficacy and safety of intralesional Candida antigen versus intralesional PPD in the management of recalcitrant plantar warts.

PATIENTS AND METHODS

The study included 120 adult patients with multiple recalcitrant plantar warts. They were randomly assigned to one of three groups; Candida antigen, PPD, or normal saline. Injections into the largest wart were repeated every two weeks until clearance or for a maximum of 5 sessions.

RESULTS

Complete wart clearance was reported in 33 patients (82.5%) of the Candida antigen group, in 22 patients (55.6%) of the PPD group, and in one patient (5%) of the control saline group. A statistically significant difference was found between the studied groups in favor of Candida antigen. Adverse effects were mild and insignificant in the 3 groups.

CONCLUSIONS

Intralesional antigen immunotherapy by Candida antigen or PPD is a promising, safe, and cost-effective therapeutic option for multiple recalcitrant plantar warts, with statistically significant superiority of Candida antigen. This article is protected by copyright. All rights reserved.

Intralesional Purified Protein Derivative Versus Zinc Sulfate 2% in the Treatment of pediatric warts: Clinical and Dermoscopic Evaluation

BACKGROUND

Warts are common in children and can be difficult to treat. Many treatments for warts are destructive and painful in contrast to intralesional immunotherapy using different types of antigens.

AIM

to evaluate the efficacy, safety, and tolerability of intralesional purified protein derivative (PPD) versus intralesional zinc sulfate 2% in the treatment of pediatric warts.

METHODS

This randomized clinical trial included 120 children with multiple warts divided into two equal groups. Group Ⅰ received intralesional 10 IU (0.1 ml) of PPD, group Ⅱ received intralesional zinc sulfate 2% in the largest wart every 2 weeks till improvement or for a maximum five treatment sessions. The follow up period was 6 months after the last treatment session.

RESULTS

the overall response was equal in both groups (81.7%), but the response of the injected wart was higher in the zinc sulfate group (93.4%) versus PPD group (83.3%) with no significant difference. The highest cure rates were after the 5^th session in the PPD group and the 1^st session in the zinc sulfate group with slightly lower numbers of sessions needed for cure in the zinc sulfate group (3 sessions) versus the PPD group (4 sessions). The zinc sulfate group showed statistically significant higher rates of complications (pain, inflammation, necrosis, and scar) than PPD group. The zinc sulfate group showed non-significant higher rates of recurrence during the follow up period.

CONCLUSION

Both intralesional PPD and zinc sulfate 2% are effective in pediatric warts with higher safety profile of PPD.