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Bertolotti A, Ferdynus C, Milpied B, Dupin N, Huiart L, Derancourt C. Local Management of Anogenital Warts in Non-Immunocompromised Adults: A Network Meta-Analysis of Randomized Controlled Trials. Dermatol Ther (Heidelb) 2020; 10:249-262. [PMID: 32030564 PMCID: PMC7090115 DOI: 10.1007/s13555-020-00357-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION No hierarchy of first-line treatments for anogenital warts (AGWs) is provided in international guidelines. This study aimed to determine the efficacy of topical treatments and ablative procedures for the management of AGWs. METHODS Twelve electronic databases were systematically searched from inception to August 2018. All randomized controlled trials (RCTs) comparing immunocompetent adults with AGWs who received at least 1 provider-administered or patient-administered treatment in at least 1 parallel group were included. Risk of bias assessment followed the Cochrane Handbook. The study endpoint was complete lesion response after clearance and recurrence assessment. A network meta-analysis was performed. RESULTS A network geometry was constructed based on 49 of the 70 RCTs included in our systematic review. All but 4 RCTs had a high risk of bias. The most efficacious treatments compared to placebo were surgery (RR 10.54; CI 95% 4.53-24.52), ablative therapy + imiquimod (RR 7.52; CI 95% 4.53-24.52), and electrosurgery (RR 7.10; CI 95% 3.47-14.53). SUCRA values confirmed the superiority of surgery (90.9%), ablative therapy + imiquimod (79.8%), and electrosurgery (77.1%). The most efficacious patient-administered treatments were podophyllotoxin 0.5% solution (63.5%) and podophyllotoxin 0.5% cream (62.2%). CONCLUSIONS With low-level evidence of most included RCTs, surgery and electrosurgery were superior to other treatments after clearance and recurrence assessment. Podophyllotoxin 0.5% was the most efficacious patient-administered treatment. Combined therapies should be evaluated in future RCTs in view of their identified effectiveness. The results of future RCTs should systematically include clinical type, number and location of AGWs, and sex of the patient, to refine therapeutic indications. PROTOCOL REGISTRATION PROSPERO-CRD42015025827.
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Affiliation(s)
- Antoine Bertolotti
- Department of Infectious Disease, Saint-Pierre Hospital, Reunion Island, France.
- EA 4537, Antilles-Guyane University, Martinique, France.
- INSERM CICEC 1410, Reunion Island, France.
| | | | - Brigitte Milpied
- Department of Dermatology and Pediatric Dermatology, National Center for Rare Skin Disorders, Saint-André and Pellegrin Hospitals, Bordeaux, France
| | - Nicolas Dupin
- Department of Dermatology, Cochin Hospital, Paris Descartes University, Paris, France
| | - Laetitia Huiart
- Department of Population Health, Luxembourg Institute of Health, Luxembourg, Luxembourg
| | - Christian Derancourt
- EA 4537, Antilles-Guyane University, Martinique, France
- Department of Dermatology, Hôpital de Briançon, Briançon, France
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Bertolotti A, Milpied B, Fouéré S, Dupin N, Cabié A, Derancourt C. Local Management of Anogenital Warts in Non-immunocompromised Adults: A Systematic Review and Meta-analyses of Randomized Controlled Trials. Dermatol Ther (Heidelb) 2019; 9:761-774. [PMID: 31606873 PMCID: PMC6828858 DOI: 10.1007/s13555-019-00328-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Several therapeutic options are available to manage anogenital warts (AGWs). However, no hierarchy of treatments is provided in the latest European and American recommendations. This study aimed to determine the efficacy and safety of local treatments for the management of AGWs. METHODS A search was conducted through 12 databases from inception to August 2018. All randomized controlled trials (RCTs) in which at least one parallel treatment group composed of immunocompetent adults with AGWs received at least one provider-administered or patient-administered treatment were included. Risk of bias assessment and meta-analyses of aggregated study data were performed on the basis of the Cochrane Handbook, and quality of evidence evaluation followed the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Primary endpoints were complete clearance and recurrence at 3 months. RESULTS Seventy RCTs (9931 patients) were included. All but four RCTs had a high risk of bias. CO2 laser was slightly more efficacious than cryotherapy [risk ratio (RR) 2.05; 95% confidence interval (CI) 1.61-2.62], with fewer recurrences at 3 months (RR 0.28; 95% CI 0.09-0.89). Electrosurgery was slightly more efficacious than cryotherapy. No differences in efficacy or side effects were found between cryotherapy and imiquimod or trichloroacetic acid. Podophyllotoxin gel was slightly more efficacious than podophyllotoxin cream. 5-Fluorouracil (5-FU) was slightly more efficacious and caused less erosion than CO2 laser (RR 1.37; 95% CI 1.11-1.70). CONCLUSION The vast majority of included RCTs had a low level of evidence, thereby preventing the establishment of a hierarchy of treatments. Nevertheless, our results provide an overview of the main AGW treatments available for general practitioners and specialists. While provider-administered treatments are superior, patient-administered treatments (e.g., imiquimod, podophyllotoxin) are useful solutions for compliant patients. PROTOCOL REGISTRATION PROSPERO-CRD42015025827.
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Affiliation(s)
- Antoine Bertolotti
- EA 4537, Antilles University, Martinique, France.
- Infectious Diseases, Centre Hospitalier Universitaire de la Réunion, Saint-Pierre, La Réunion, France.
| | - Brigitte Milpied
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Saint-André and Pellegrin Hospitals, Bordeaux, France
| | - Sébastien Fouéré
- Department of Dermatology, Saint-Louis Hospital, Paris Diderot University, Paris, France
| | - Nicolas Dupin
- Department of Infectious Diseases, CHU Martinique, Fort-de-France, Martinique, France
| | - André Cabié
- EA 4537, Antilles University, Martinique, France
- Department of Dermatology, Cochin Hospital, Paris Descartes University, Paris, France
| | - Christian Derancourt
- EA 4537, Antilles University, Martinique, France
- Department of Dermatology, Briançon Hospital, Briançon, France
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Barton S, Wakefield V, O'Mahony C, Edwards S. Effectiveness of topical and ablative therapies in treatment of anogenital warts: a systematic review and network meta-analysis. BMJ Open 2019; 9:e027765. [PMID: 31676644 PMCID: PMC6830637 DOI: 10.1136/bmjopen-2018-027765] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To generate estimates of comparative clinical effectiveness for interventions used in the treatment of anogenital warts (AGWs) through the systematic review, appraisal and synthesis of data from randomised controlled trials (RCTs). DESIGN Systematic review and network meta-analysis of RCTs. Search strategies were developed for MEDLINE, Embase, the Cochrane Library and the Web of Science. For electronic databases, searches were run from inception to March 2018. The systematic review was carried out following the general principles recommended in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. PARTICIPANTS People aged ≥16 years with clinically diagnosed AGWs (irrespective of biopsy confirmation). INTERVENTIONS Topical and ablative treatments recommended by the British Association for Sexual Health and HIV for the treatment of AGWs, either as monotherapy or in combination versus each other. OUTCOME MEASURES Complete clearance of AGWs at the end of treatment and at other scheduled visits, and rate of recurrence. RESULTS Thirty-seven RCTs met inclusion criteria. Twenty studies were assessed as being at unclear risk of bias, with the remaining studies categorised as high risk of bias. Network meta-analysis indicates that, of the treatment options compared, carbon dioxide laser therapy is the most effective treatment for achieving complete clearance of AGWs at the end of treatment. Of patient-applied topical treatments, podophyllotoxin 0.5% solution was found to be the most effective at achieving complete clearance, and was associated with a statistically significant difference compared with imiquimod 5% cream and polyphenon E 10% ointment (p<0.05). Few data were available on recurrence of AGWs after complete clearance. Of the interventions evaluated, surgical excision was the most effective at minimising risk of recurrence. CONCLUSION Of the studies assessed, as a collective, the quality of the evidence is low. Few studies are available that evaluate treatment options versus each other. TRIAL REGISTRATION NUMBER CRD42013005457.
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Affiliation(s)
| | | | - Colm O'Mahony
- Nuffield Health, Chester, UK
- Liverpool Medical Institution, Liverpool, UK
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Abstract
Introduction: Genital warts are a frequent form of sexually transmitted disease. Cryotherapy represents the first line of therapy. Healing occurs in 94%, and recurrence in 10% . Side effects are common during the treatment. Aim: The aim of this study is to determine the successfulness of cryotherapy of genital warts, frequency of recurrence, and side effects. Patients and methods: In a retrospective study, data from 50 women with genital warts who were treated in the Gynecological Centre “Dr Mahira Jahić” in Tuzla in a period from 2012–2018 were analyzed. Every woman was treated with cryotherapy. Treatments were repeated every 7 days, maximal number of treatments being 7. In processing of data, X2statistical method was used. Results: 50% (N-25) of genital warts eliminated after 3 treatments with cryotherapy . Genital warts are eliminated in 78% (N-39) of women, while this treatment was unsuccessful in 18% (N-9). Recurrence after 3 months in 4% (N-2). Most common side effect was exudation in 78% (N-39), swelling in 72% (N-36) and pain in 66% (N-33). PAP smears in women with genital warts in 64% (N-34) of cases were inflammatory benign changes, while in 36% (N-18) mild abnormal changes in cells ASCUS and LSIL were found. LSIL lesions of cervix are more common (p<0,01) in women with genital warts of vulva. Conclusion: Cryotherapy is a method with a high success rate in healing of genital warts, and it decreases the concentration of HPV virus and removes the trigger that allows the development of cancer.
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Affiliation(s)
- Mahira Jahic
- Gynecology centre ,,Dr Mahira Jahić" Tuzla, Bosnia and Herzegovina.,Faculty of Medicine, University of Tuzla, Tuzla, Bosnia and Herzegovina
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Thurgar E, Barton S, Karner C, Edwards SJ. Clinical effectiveness and cost-effectiveness of interventions for the treatment of anogenital warts: systematic review and economic evaluation. Health Technol Assess 2017; 20:v-vi, 1-486. [PMID: 27034016 DOI: 10.3310/hta20240] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Typically occurring on the external genitalia, anogenital warts (AGWs) are benign epithelial skin lesions caused by human papillomavirus infection. AGWs are usually painless but can be unsightly and physically uncomfortable, and affected people might experience psychological distress. The evidence base on the clinical effectiveness and cost-effectiveness of treatments for AGWs is limited. OBJECTIVES To systematically review the evidence on the clinical effectiveness of medical and surgical treatments for AGWs and to develop an economic model to estimate the cost-effectiveness of the treatments. DATA SOURCES Electronic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library databases and Web of Science) were searched from inception (or January 2000 for Web of Science) to September 2014. Bibliographies of relevant systematic reviews were hand-searched to identify potentially relevant studies. The World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov were searched for ongoing and planned studies. REVIEW METHODS A systematic review of the clinical effectiveness literature was carried out according to standard methods and a mixed-treatment comparison (MTC) undertaken. The model implemented for each outcome was that with the lowest deviance information criterion. A de novo economic model was developed to assess cost-effectiveness from the perspective of the UK NHS. The model structure was informed through a systematic review of the economic literature and in consultation with clinical experts. Effectiveness data were obtained from the MTC. Costs were obtained from the literature and standard UK sources. RESULTS Of 4232 titles and abstracts screened for inclusion in the review of clinical effectiveness, 60 randomised controlled trials (RCTs) evaluating 19 interventions were included. Analysis by MTC indicated that ablative techniques were typically more effective than topical interventions at completely clearing AGWs at the end of treatment. Podophyllotoxin 0.5% solution (Condyline(®), Takeda Pharmaceutical Company Ltd; Warticon(®) solution, Stiefel Laboratories Ltd) was found to be the most effective topical treatment evaluated. Networks for other outcomes included fewer treatments, which restrict conclusions on the comparative effectiveness of interventions. In total, 84 treatment strategies were assessed using the economic model. Podophyllotoxin 0.5% solution first line followed by carbon dioxide (CO2) laser therapy second line if AGWs did not clear was most likely to be considered a cost-effective use of resources at a willingness to pay of £20,000-30,000 per additional quality-adjusted life-year gained. The result was robust to most sensitivity analyses conducted. LIMITATIONS Limited reporting in identified studies of baseline characteristics for the enrolled population generates uncertainty around the comparability of the study populations and therefore the generalisability of the results to clinical practice. Subgroup analyses were planned based on type, number and size of AGWs, all of which are factors thought to influence treatment effect. Lack of data on clinical effectiveness based on these characteristics precluded analysis of the differential effects of treatments in the subgroups of interest. Despite identification of 60 studies, most comparisons in the MTC are informed by only one RCT. Additionally, lack of head-to-head RCTs comparing key treatments, together with minimal reporting of results in some studies, precluded comprehensive analysis of all treatments for AGWs. CONCLUSIONS The results generated by the MTC are in agreement with consensus opinion that ablative techniques are clinically more effective at completely clearing AGWs after treatment. However, the evidence base informing the MTC is limited. A head-to-head RCT that evaluates the comparative effectiveness of interventions used in clinical practice would help to discern the potential advantages and disadvantages of the individual treatments. The results of the economic analysis suggest that podophyllotoxin 0.5% solution is likely to represent a cost-effective first-line treatment option. More expensive effective treatments, such as CO2 laser therapy or surgery, may represent cost-effective second-line treatment options. No treatment and podophyllin are unlikely to be considered cost-effective treatment options. There is uncertainty around the cost-effectiveness of treatment with imiquimod, trichloroacetic acid and cryotherapy. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005457. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Camargo CLDA, Belda Junior W, Fagundes LJ, Romiti R. A prospective, open, comparative study of 5% potassium hydroxide solution versus cryotherapy in the treatment of genital warts in men. An Bras Dermatol 2014; 89:236-40. [PMID: 24770498 PMCID: PMC4008052 DOI: 10.1590/abd1806-4841.20141702] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 04/05/2013] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Genital warts are caused by human papillomavirus infection and represent one of
the most common sexually transmitted diseases. Many infections are transient but
the virus may recur, persist, or become latent. To date, there is no effective
antiviral treatment to eliminate HPV infection and most therapies are aimed at the
destruction of visible lesions. Potassium hydroxide is a strong alkali that has
been shown to be safe and effective for the treatment of genital warts and
molluscum contagiosum. Cryotherapy is considered one of the most established
treatments for genital warts. No comparative trials have been reported to date on
the use of potassium hydroxide for genital warts. OBJECTIVE A prospective, open-label, randomized clinical trial was conducted to compare
topical potassium hydroxide versus cryotherapy in the treatment of genital warts
affecting immunocompetent, sexually active men. METHODS Over a period of 10 months, 48 patients were enrolled. They were randomly divided
into two groups and selected on an alternative basis for either potassium
hydroxide therapy or cryotherapy. While response to therapy did not differ
substantially between both treatment modalities, side effects such as local pain
and post-treatment hypopigmentation were considerably more prevalent in the groups
treated using cryotherapy. RESULT In our study, potassium hydroxide therapy proved to be at least as effective as
cryotherapy and offered the benefit of a better safety profile. CONCLUSION Topical 5% potassium hydroxide presents an effective, safe, and low-cost treatment
modality for genital warts in men and should be included in the spectrum of
therapies for genital warts.
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Yanofsky VR, Patel RV, Goldenberg G. Genital warts: a comprehensive review. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2012; 5:25-36. [PMID: 22768354 PMCID: PMC3390234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
External genital warts, also known as condylomata acuminata, are extremely common, with between 500,000 to one million new cases diagnosed each year in the United States alone. To date, more than 120 distinct subtypes of human papillomavirus have been identified. Human papillomavirus types 6 and 11 rarely give rise to cervical cancers, but are responsible for 90 percent of the cases of genital warts. The current treatment options are largely centered upon removal of the warts rather than elimination of the underlying viral infection. A wide range of therapies are presently in use, which are highly variable and can differ dramatically with respect to cost, side-effect profiles, dosing schedules, duration of treatment, and overall effectiveness. As of yet, no definitive therapy has emerged as the ideal standard of care in the treatment of genital warts, and therapy selection generally occurs in a patient-specific manner.
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Affiliation(s)
- Valerie R. Yanofsky
- Department of Dermatology, Mount Sinai School of Medicine, New York, New York
| | - Rita V. Patel
- Albert Einstein College of Medicine, Bronx, New York
| | - Gary Goldenberg
- Department of Dermatology, Mount Sinai School of Medicine, New York, New York
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Sensenig R, Kalghatgi S, Cerchar E, Fridman G, Shereshevsky A, Torabi B, Arjunan KP, Podolsky E, Fridman A, Friedman G, Azizkhan-Clifford J, Brooks AD. Non-thermal plasma induces apoptosis in melanoma cells via production of intracellular reactive oxygen species. Ann Biomed Eng 2011; 39:674-87. [PMID: 21046465 PMCID: PMC3268344 DOI: 10.1007/s10439-010-0197-x] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2010] [Accepted: 10/19/2010] [Indexed: 11/28/2022]
Abstract
Non-thermal atmospheric pressure dielectric barrier discharge (DBD) plasma may provide a novel approach to treat malignancies via induction of apoptosis. The purpose of this study was to evaluate the potential of DBD plasma to induce apoptosis in melanoma cells. Melanoma cells were exposed to plasma at doses that did not induce necrosis, and cell viability and apoptotic activity were evaluated by Trypan blue exclusion test, Annexin-V/PI staining, caspase-3 cleavage, and TUNEL® analysis. Trypan blue staining revealed that non-thermal plasma treatment significantly decreased the viability of cells in a dose-dependent manner 3 and 24 h after plasma treatment. Annexin-V/PI staining revealed a significant increase in apoptosis in plasma-treated cells at 24, 48, and 72 h post-treatment (p < 0.001). Caspase-3 cleavage was observed 48 h post-plasma treatment at a dose of 15 J/cm(2). TUNEL® analysis of plasma-treated cells demonstrated an increase in apoptosis at 48 and 72 h post-treatment (p < 0.001) at a dose of 15 J/cm(2). Pre-treatment with N-acetyl-L: -cysteine (NAC), an intracellular reactive oxygen species (ROS) scavenger, significantly decreased apoptosis in plasma-treated cells at 5 and 15 J/cm(2). Plasma treatment induces apoptosis in melanoma cells through a pathway that appears to be dependent on production of intracellular ROS. DBD plasma production of intracellular ROS leads to dose-dependent DNA damage in melanoma cells, detected by γ-H2AX, which was completely abrogated by pre-treating cells with ROS scavenger, NAC. Plasma-induced DNA damage in turn may lead to the observed plasma-induced apoptosis. Since plasma is non-thermal, it may be used to selectively treat malignancies.
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Affiliation(s)
- Rachel Sensenig
- Department of Surgery, College of Medicine, Drexel University, Philadelphia, PA 19102, USA
| | - Sameer Kalghatgi
- Electrical and Computer Engineering, Drexel University, Philadelphia, PA 19104, USA
- Department of Biomedical Engineering, Centre for Advanced Biotechnology, Boston University, ERB 301, 44 Cummington St, Boston, MA 02215, USA
| | - Ekaterina Cerchar
- Department of Surgery, College of Medicine, Drexel University, Philadelphia, PA 19102, USA
| | - Gregory Fridman
- School of Biomedical Engineering, Drexel University, Philadelphia, PA 19104, USA
| | - Alexey Shereshevsky
- Department of Surgery, College of Medicine, Drexel University, Philadelphia, PA 19102, USA
| | - Behzad Torabi
- Molecular Biology and Biochem, College of Medicine, Drexel University, Philadelphia, PA 19102, USA
| | | | - Erica Podolsky
- Department of Surgery, College of Medicine, Drexel University, Philadelphia, PA 19102, USA
| | - Alexander Fridman
- Department of Mechanical Engineering and Mechanics, Drexel University, Philadelphia, PA 19104, USA
| | - Gary Friedman
- Electrical and Computer Engineering, Drexel University, Philadelphia, PA 19104, USA
| | - Jane Azizkhan-Clifford
- Molecular Biology and Biochem, College of Medicine, Drexel University, Philadelphia, PA 19102, USA
| | - Ari D. Brooks
- Department of Surgery, College of Medicine, Drexel University, Philadelphia, PA 19102, USA
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9
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W Buck H. Warts (genital). BMJ CLINICAL EVIDENCE 2010; 2010:1602. [PMID: 21418685 PMCID: PMC3217761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION External genital warts (EGWs) are sexually transmitted benign epidermal growths caused by the human papillomavirus (HPV), on the anogenital areas of both females and males. About 50% to 60% of sexually active women aged 18 to 49 years have been exposed to HPV infection, but only 10% to 15% will have genital warts. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for external genital warts? What are the effects of interventions to prevent transmission of external genital warts? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 55 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: bi- and trichloroacetic acid; condoms; cryotherapy; electrosurgery; imiquimod; intralesional, topical, or systemic interferons; laser surgery; podophyllin; podophyllotoxin; surgical excision; and vaccines.
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Affiliation(s)
- Henry W Buck
- University of Kansas, Lawrence & Kansas City, USA
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10
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W Buck H. Warts (genital). BMJ CLINICAL EVIDENCE 2007; 2007:1602. [PMID: 19454104 PMCID: PMC2943795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION External genital warts (EGWs) are sexually transmitted benign epidermal growths caused by the human papillomavirus (HPV), on the anogenital areas of both females and males. About 50-60% of sexually active women aged 18-49 have been exposed to HPV infection, but only 10-15% will have genital warts. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for external genital warts? What are the effects of interventions to prevent transmission of external genital warts? We searched: Medline, Embase, The Cochrane Library and other important databases up to February 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 47 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: bi- and trichloroacetic acid; condoms; cryotherapy; electrosurgery; imiquimod; intralesional, topical, or systemic interferons; laser surgery; podophyllin; podophyllotoxin; surgical excision; and vaccines.
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Affiliation(s)
- Henry W Buck
- University of Kansas, Lawrence & Kansas City, USA
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Chang GJ, Welton ML. Human papillomavirus, condylomata acuminata, and anal neoplasia. Clin Colon Rectal Surg 2004; 17:221-30. [PMID: 20011263 PMCID: PMC2780052 DOI: 10.1055/s-2004-836942] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Genital human papillomavirus (HPV) infection is an increasingly common sexually transmitted disease. This virus causes condylomata acuminata and is associated with anal neoplasia. Management options are discussed.
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Affiliation(s)
- George J Chang
- Department of Surgical Oncology, UT MD Anderson Cancer Center, Houston, TX 77230-1402, USA.
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von Krogh G, Lacey CJ, Gross G, Barrasso R, Schneider A. European course on HPV associated pathology: guidelines for primary care physicians for the diagnosis and management of anogenital warts. Sex Transm Infect 2000; 76:162-8. [PMID: 10961190 PMCID: PMC1744154 DOI: 10.1136/sti.76.3.162] [Citation(s) in RCA: 158] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The European Course on HPV Associated Pathology (ECHPV) was founded in 1990 by a group of clinicians, pathologists, and virologists to teach important principles for the practice and management of human papillomavirus (HPV) disease to gynaecologists, dermatologists, and other medical disciplines. These guidelines are intended to assist the practice of primary care physicians for diagnosis and treatment of anogenital warts.
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Affiliation(s)
- G von Krogh
- Department of Dermatovenereology, Karolinska Hospital, Stockholm, Sweden
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13
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Affiliation(s)
- A Scoular
- Department of Genitourinary Medicine, Middlesex Hospital, London, UK
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14
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Handley JM, Horner T, Maw RD, Lawther H, Dinsmore WW. Subcutaneous interferon alpha 2a combined with cryotherapy vs cryotherapy alone in the treatment of primary anogenital warts: a randomised observer blind placebo controlled study. Genitourin Med 1991; 67:297-302. [PMID: 1916791 PMCID: PMC1194704 DOI: 10.1136/sti.67.4.297] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To compare patient tolerance and treatment efficacy of subcutaneous interferon (IFN) alpha 2a plus cryotherapy versus cryotherapy alone in treatment of primary anogenital (AG) warts. DESIGN Randomised placebo controlled observer blind study. Statistical analysis was by chi square and Mann Whitney U tests. PATIENTS 60 patients with newly diagnosed AG warts. INTERVENTION 29 and 31 patients were treated with subcutaneous IFN alpha 2a plus cryotherapy or placebo injections plus cryotherapy, respectively. MAIN OUTCOME MEASURES Clinical presence or absence of AG warts. Patients wart-free at 8 weeks were asked to re-attend at 12 weeks; those with persistent warts at 8 weeks were withdrawn from the study. RESULTS At 8 weeks 60.7% (17/28 patients) of the IFN group and 67.9% (19/28 patients) of the placebo group were clinically wart-free (not significant); corresponding figures at 12 week review were 29.6% (8/27 patients) and 40% (10/25 patients) respectively (not significant). There was no difference in treatment response between males and females. Recurrence of warts at three month review, in patients cleared of warts at 8 weeks, was seen in 50% (8/16) and 37.5% (6/16) of patients in the IFN and placebo groups respectively (not significant). Multiple warts and the presence of perianal/anal canal warts, either alone or concurrent with warts on the genitalia, at first clinic attendance, were adverse prognostic indicators (p less than 0.001, and p = 0.05 respectively). Cervical human papilloma virus (HPV) infection, exophytic or subclinical, was present in 58.3% and 77.2% of females in the IFN and placebo groups respectively, at trial entry. Although these lesions were not directly treated, colposcopic resolution was seen in 12.5% of affected women, in both treatment groups, by the end of the 7 week treatment period. Systemic side effects were significantly more common in the IFN than in the placebo group, 50% versus 10.7% of patients (p less than 0.01). Severe influenza like symptoms occurred, after the first three injections only, in one patient treated with IFN; all other reported side effects were mild. CONCLUSIONS Subcutaneous IFN alpha 2a combined with cryotherapy is no more effective than cryotherapy alone in the treatment of primary AG warts. The presence of multiple warts and perianal/anal canal warts are adverse prognostic indicators.
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Affiliation(s)
- J M Handley
- Department of Genitourinary Medicine, Royal Victoria Hospital, Belfast
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Stone KM, Becker TM, Hadgu A, Kraus SJ. Treatment of external genital warts: a randomised clinical trial comparing podophyllin, cryotherapy, and electrodesiccation. Genitourin Med 1990; 66:16-9. [PMID: 2179111 PMCID: PMC1194434 DOI: 10.1136/sti.66.1.16] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Four hundred and fifty patients were enrolled into a randomised clinical trial in a public sexually transmitted diseases clinic to evaluate the efficacy of podophyllin, cryotherapy, and electrodesiccation for treatment of external genital warts. Complete clearance of warts was observed in 41%, 79%, and 94% of patients who received up to six weekly treatments of podophyllin, cryotherapy, and electrodesiccation, respectively. Relapses occurred in 25% of all patients, yielding 3 month clearance rates of 17%, 55%, and 71% for podophyllin, cryotherapy, and electrodesiccation, respectively. Wart volume and duration did not influence treatment outcome. Response to therapy was greater in women than in men, and did not differ by treatment modality. Electrodesiccation and cryotherapy were more effective than podophyllin for the treatment of external genital warts, but none of these three treatments were highly successful.
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Affiliation(s)
- K M Stone
- Division of Sexually Transmitted Diseases Centers for Disease Control, Atlanta, Georgia
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Davidson-Parker J, Dinsmore W, Khan MH, Hicks DA, Morris CA, Morris DF. Immunotherapy of genital warts with inosine pranobex and conventional treatment: double blind placebo controlled study. Genitourin Med 1988; 64:383-6. [PMID: 2465265 PMCID: PMC1194272 DOI: 10.1136/sti.64.6.383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In a multicentre, prospective, randomised, placebo controlled study of 55 patients with histories of genital warts for at least one year, a four week course of inosine pranobex 3 g a day improved the clinical response to conventional treatment (primarily podophyllin or trichloroacetic (now called trichlorethanoic) acid). Although more patients given inosine pranobex improved than those given placebo, the difference in general response between the two groups was not significant. When other variables (numbers of warts and extent of lesions) were considered, however, the patients given inosine pranobex fared significantly better. These results suggest that inosine pranobex may be worth considering as adjunct to treatment of patients with refractory genital warts.
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Godley MJ, Bradbeer CS, Gellan M, Thin RN. Cryotherapy compared with trichloroacetic acid in treating genital warts. Genitourin Med 1987; 63:390-2. [PMID: 3323028 PMCID: PMC1194123 DOI: 10.1136/sti.63.6.390] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
In an observer blind comparative study, 130 men with penile warts were randomly allocated to treatment with either cryotherapy or trichloroacetic acid (TCAA). There was no significant difference in response to treatment, side effects, or recurrence rates between the two treatments. Warts resolved in 81% of patients treated with TCAA compared with 88% of those treated with cryotherapy. Early recurrence occurred in 36% of patients treated with TCAA and in 39% of those treated with cryotherapy.
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Affiliation(s)
- M J Godley
- Department of Genitourinary Medicine, St Thomas' Hospital, London
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Abstract
A method of scissor excision of perianal warts, which is suitable for use in outpatient departments, is described. The low recurrence rate (two of 24 patients) three months after treatment is encouraging.
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Mohanty KC, Scott CS. Immunotherapy of genital warts with inosine pranobex (Imunovir): preliminary study. Genitourin Med 1986; 62:352-5. [PMID: 2429908 PMCID: PMC1011990 DOI: 10.1136/sti.62.5.352] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
One hundred and sixty five heterosexual men and women with genital warts were treated with inosine pranobex (Imunovir) or conventional treatment, or both. Inosine pranobex was found to be more effective in lesions of longer duration, whereas conventional treatment was more effective in genital warts of a shorter duration. Supplementation of conventional treatment with inosine pranobex increased the success rate from 41% to 94%. Immunological studies in 134 patients with genital warts showed an increased number of B cells in 21% of peripheral blood samples. Absence of major defects among circulating lymphocytes suggested that patients with genital warts may have a local immune reaction.
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