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.

Mycobacterium Indicus Pranii (MIP) Vaccine: Pharmacology, Indication, Dosing Schedules, Administration, and Side Effects in Clinical Practice

Mycobacterium indicus pranii (MIP), previously called Mw vaccine, is a one-of-a-kind immunomodulatory vaccine. It was indigenously developed in India for use in leprosy. MIP is heat-killed Mycobacterium w, which is a non-pathogenic atypical mycobacterium belonging to Class IV of Runyon classification. It shares epitopes with Mycobacterium leprae and Mycobacterium tuberculosis, which forms the rationale behind its use in leprosy and tuberculosis. MIP activates both innate and acquired immunity. It induces a Th1 and Th17 immune response along with downregulation of Th2 pathway and activates macrophages and dendritic cells. MIP vaccine is safe with adverse effects such as local site erythema, swelling, and rarely fever and other systemic reactions. Apart from leprosy, MIP has been used in dermatological diseases such as warts and psoriasis. Clinical trials have evaluated the efficacy of MIP in a plenitude of non-dermatological conditions such as category II tuberculosis, Gram-negative sepsis, non-small cell lung cancer, human immunodeficiency virus (HIV), muscle-invasive bladder cancer, and very recently, coronavirus 2019 (COVID-19). In vitro and animal studies have also demonstrated its utility in leishmaniasis, melanoma, and as a vaccine for the prevention of pregnancy. The PubMed database was searched using "Mycobacterium indicus pranii, MIP, Mycobacterium w" as the keyword in title. This comprehensive review provides useful information for healthcare professionals about immunotherapeutic potential of MIP vaccine, its composition, dosing schedule, administration, and side effects besides its efficacy in various indications other than leprosy.

Intralesional immunotherapy for non-genital warts: A systematic review and meta-analysis

Background

Intralesional immunotherapy has been reported to be effective for warts and to show good safety profiles, but this has not yet been systematically studied.

Aims

To determine the efficacy and safety of intralesional immunotherapy for treating non-genital warts.

Methods

We comprehensively searched the MEDLINE, Embase, Web of Science and Cochrane Library databases from the times of their inception to January 3, 2020. The primary outcome was the rate of complete response of all lesions. The distant complete response rate of warts located in an anatomically different body part and the recurrence rate were also analyzed.

Results

A total of 54 prospective studies was ultimately included. The immunotherapeutic agents used were Mycobacterium w vaccine, measles, mumps and rubella vaccine, purified protein derivative, Candida antigen, interferon, bacillus Calmette-Guérin vaccine and others. The pooled rate of complete response among all patients with non-genital warts treated using intralesional immunotherapy was 60.6% (95% confidence interval 54.8–66.5%). The pooled recurrence rate was 2.0% (95% confidence interval, 1.1–2.9%). All reported adverse events were mild and transient.

Limitations

The heterogeneity among studies

Conclusion

Intralesional immunotherapy is suggested for use in patients with multiple warts, given its promising results, good safety profile and low recurrence rate.

Efficacy and safety of intralesional tuberculin purified protein derivative versus cryotherapy in the treatment of warts: An assessor-blinded, randomized controlled trial

Cryotherapy is a standard treatment for warts. Tuberculin immunotherapy is a novel therapeutic option. We compared the efficacy and safety of cryotherapy versus tuberculin immunotherapy in a randomized, assessor-blinded study. 15 patients were treated with intralesional tuberculin and 15 patients received cryotherapy every 2 weeks until complete wart resolution or a maximum of six sessions. Wart diameter, total number of warts and adverse effects were documented. Complete clearance of treated warts was achieved in 13(86.7%) and 11(73.3%) of patients with immunotherapy and cryotherapy respectively. Immunotherapy showed greater wart size reduction (51.88 ± 89.36 mm) than cryotherapy (32.99 ± 36.19 mm), (p = 0.46). Immunotherapy resulted in 64% reduction in total number of warts compared to 23.2% with cryotherapy, p < 0.01. More blisters developed with cryotherapy (46.7%) than immunotherapy (6.7%), (p = 0.01). Compartment syndrome-like features complicate immunotherapy in 1 patient. Tuberculin immunotherapy and cryotherapy are equally effective in treating warts. Immunotherapy has added benefit with resolution of distant warts. Safety profiles were similar except for blisters which were more common with cryotherapy.

A comprehensive review of treatment options for recalcitrant nongenital cutaneous warts

Introduction: The treatment of recalcitrant nongenital cutaneous warts has always been challenging for dermatologists as they often recur and relapse. Multiple treatment options have been investigated to improve the outcome. This review provides an overview of the current treatment modalities and summarizes the efficacy and side effects of each treatment option for recalcitrant nongenital cutaneous warts.Methods: A PubMed search was performed through July 2019 to include all English language reports investigating the treatment for recalcitrant nongenital cutaneous warts, regardless of design.Results: A total of 144 studies were included in this review. The treatment options for recalcitrant nongenital cutaneous warts can be divided into three groups: destructive treatment, immunotherapy, and cytotoxic agents. Although both destructive therapies and cytotoxic agents demonstrated high complete response rates, immunotherapy, which is a minimally invasive method, was superior in terms of the clearance of distant warts. Intralesional mumps-measles-rubella injections and purified protein derivatives currently demonstrate high efficacy with well-established clinical evidence.Conclusions: Many upcoming treatment modalities, especially immunotherapy, are promising. However, more comparative studies are required to verify the efficacy and safety profile.

Efficacy of Intralesional Cryosurgery in the Treatment of Multiple Extragenital Cutaneous Warts: A Randomized Controlled Study

BACKGROUND

The efficacy of intralesional (IL) cryosurgery in the treatment of cutaneous warts has not been previously studied.

OBJECTIVE

To compare the efficacy and safety of IL cryosurgery versus electrosurgery in multiple extragenital warts and investigate their effect on serum interleukin (IL)-12 and interferon-gamma (IFN-γ).

MATERIALS AND METHODS

Thirty-one patients were included; 18 received IL cryosurgery, and 13 had electrosurgery. Treatment was performed for the largest or few (2-3) small warts (target) until cleared, leaving the remaining (distant) warts untreated. Clinical response of the target and distant warts and adverse effects were evaluated. Serum IL-12 and IFN-γ levels were assessed before and after treatment.

RESULTS

All patients had complete clearing of the treated wart in both groups. IL cryosurgery was well tolerated; infection, ulceration, and recurrence occurred only with electrosurgery. Complete/near-complete resolution of the distant untreated warts was seen in 33.3% versus none of patients in the IL cryosurgery and electrosurgery groups, respectively (p = .003). Furthermore, IL-12 and IFN-γ levels showed a tendency to increase after IL cryosurgery, and their increase correlated with distant wart response.

CONCLUSION

Intralesional cryosurgery is effective not only in clearing treated warts but also resolving untreated warts and possibly enhances human papillomavirus-directed immune response.

The Effectiveness of Cutaneous Wart Resolution with Current Treatment Modalities

Non-venereal warts are a frequent dermatological presentation with potential spontaneous regression in immunocompetent adults and children within 2 years. Evidence shows that conventional wart treatments are not a guaranteed treatment modality and can carry concerns regarding safety. The aim of this literature review was to identify the most effective treatments for wart resolution to guide clinical practice while identifying areas for further research.

A systematic literature review was performed to determine the current treatment modalities for non-anogenital cutaneous warts in immunocompetent individuals and their effectiveness. Articles were categorized into one of eight groups depending on anatomical location, population age, or recalcitrant status with ranked levels of evidence.

This literature review highlights a variety of treatments for non-venereal warts shown to be effective. In this instance where optimal evidence-based treatments are not available, clinical experience determines the most appropriate clinical practice.

Further reproducible immunotherapy research on wart resolution is required to enable clear comparisons of these treatment modalities to conventional methods. Future clinical practice will require the human papillomavirus type to target the wart treatment accordingly; however, further research is required to determine these correlations.

Intralesional immunotherapy for the treatment of warts: A network meta-analysis

BACKGROUND

Without clear evidence, selecting among the existing immunotherapeutic options for warts remains challenging.

OBJECTIVE

Through network meta-analyses, we aimed to evaluate the comparative efficacy of different intralesional immunotherapeutic modalities.

METHODS

We included randomized controlled trials comparing intralesional immunotherapeutic modalities to cryotherapy, placebo, or imiquimod. All outcomes were presented as odds ratios (ORs) with 95% confidence intervals. Both conventional and network meta-analyses (with a frequentist approach) were conducted on R software. The P-score was used to rank different treatments.

RESULTS

Network meta-analysis of 17 randomized controlled trials (1676 patients) showed that PPD (purified protein derivative vaccine, OR 39.56), MMR (measles, mumps, rubella vaccine, OR 17.46) and interferon β (OR 15.55) had the highest efficacy in terms of complete recovery at the primary site compared with placebo. Regarding complete recovery at the distant site, autoinoculation (OR 79.95), PPD (OR 42.95), and MMR (OR 15.39) were all statistically superior to placebo. According to the P-score, MMR was more effective than other modalities in reducing the recurrence rate at the same site.

LIMITATIONS

Relatively small sample size in some comparisons and variability in baseline characteristics.

CONCLUSION

PPD and MMR were the most effective in achieving complete primary and distant recovery (along with autoinoculation for distant recovery) and reducing the recurrence rate at the same site compared with cryotherapy and other immunotherapeutic modalities.

Treatment of warts and molluscum: what does the evidence show?

PURPOSE OF REVIEW

Warts and molluscum contagiosum are very common viral skin infections, usually presenting in childhood. Despite the large number of people affected by them, high-quality trials of treatment are few and treatment is often chosen on the basis of cost, convenience and tradition.

RECENT FINDINGS

Over recent years, two further trials of the most commonly used treatments for warts, salicylic acid and cryotherapy, have been performed and for molluscum contagiosum, there is growing evidence for the use of irritants. For both infections, there are new evaluations of immunological approaches to therapy.

SUMMARY

Strong, high-quality evidence for treatments used very frequently for warts or molluscum is still lacking, but recent publications have helped to strengthen or weaken belief in commonly used therapies and to add weight to the immunological approach to management.

Evolving role of immunotherapy in the treatment of refractory warts

Cutaneous and genital warts are common dermatological conditions caused by the human papilloma virus (HPV). Although it is a benign condition, it causes disfigurement, has a tendency to koebnerize, and can be transmitted to others. This makes adequate and timely treatment important. There are several conventional treatments available with variable response. Topical and systemic immunotherapy has now found a significant place in the treatment of warts because of its nondestructive action, ease of use, and promising results. Through this review, we would like to present a brief overview of the various immunotherapeutic agents used. These include more established agents such as imiquimod, Mycobacterium w vaccine, bacillus Calmette-Guérin vaccine, measles, mumps, and rubella vaccine, Candida antigen, trichophyton antigen, tuberculin, zinc, cimetidine, levamisole, HPV vaccine, and autoimplantation therapy. Other agents such as contact immunotherapy which is sparsely used now than before and newer agents such as Corynebacterium parvum, sinecatechins, echinacea, propolis, glycyrrizinic acid, and Vitamin D have also been discussed. The mechanism of action of these agents, along with their dosage, mode of administration, duration of use, expected outcomes and comparative efficacy, evidence for their use, and expected side effects, if any, are reviewed.