Comparative Study Among CO 2 Laser, Intralesional Vitamin D3, and Combined Intralesional Vitamin D3 and CO 2 Laser in Treatment of Palmoplantar Warts

BACKGROUND

Many therapeutic modalities are used for palmoplantar warts; whether destructive, such as chemical cautery, electrocautery, cryocautery, surgical removal, and laser ablation, or immunotherapeutic, stimulating the immune system against the virus such as intralesional vitamin D3 injection.

OBJECTIVE

To compare the efficacy of intralesional vitamin D injection combined with CO 2 laser to the efficacy of either modality alone.

PATIENT AND METHODS

Eighty age- and sex-matched patients with palmoplantar warts were divided into 4 groups: Group A received intralesional vitamin D3 injections, group B received ablative CO 2 laser, group C received CO 2 laser and intralesional vitamin D3 injection, and group D (control group) were injected intralesionally with normal saline. Assessment was performed clinically, photographically, and dermoscopically before and after treatment to evaluate the response, and then, another assessment was performed after 3 months to detect any recurrence.

RESULTS

Complete clearance was seen in 90% of cases in group C, in 80% in group A, and in 75% in group B with no statistically significant difference.

CONCLUSION

Intralesional vitamin D, CO 2 laser, and the combination show comparable efficacy and recurrence rates. Intralesional vitamin D maybe a better option for people with a relative contraindication to CO 2 laser.

Intralesional Vitamin D3 Versus Bleomycin for Difficult-to-Heal Palmoplantar Warts: A Comparative Study

Introduction

Difficult-to-heal or recalcitrant palmoplantar warts are notoriously resistant to treatment, making treatment difficult and challenging. To improve the outcome and overcome the difficulties, various treatment options have been tried, but none is gold standard. Many comparative studies have been undertaken to assess the efficacy of various drugs; however, none of them are standardized, and no single treatment is effective. Various comparative efficacy studies have been conducted but, to the best of our knowledge, no study has been conducted comparing intralesional (IL) injection (inj) vitamin D3 (Vit D3) with the chemotherapy drug IL inj Bleomycin for difficult-to-heal palmoplantar warts. We conducted a trial to evaluate the efficacy of IL inj Vit D3 versus IL inj Bleomycin in the treatment of difficult-to-heal palmoplantar warts. The purpose of this study was to compare the efficacy of IL inj vitamin D3 versus IL inj Bleomycin as biological response modifier therapy in difficult-to-heal palmoplantar warts.

Materials and Methods

A cohort of 48 patients with difficult-to-heal warts were consecutively assigned to one of two groups: Group 1 IL inj Vit D3 (0.2-0.5 mL inj vitamin D3 600,000 IU solution 15 mg/mL) or Group 2 IL inj Bleomycin (0.2-0.4 mL of 1 U/mL solution) for a maximum of four treatments spaced 2 weeks apart, with a maximum of five warts treated at each visit for both groups. Warts were measured at baseline and at each subsequent visit. Wart's resolution was measured as 1-25%, 2-50%, 3-75%, and 4-100% reduction. Patients were followed-up for 3 months after treatment.

Results

All the 48 patients completed the study, with 26 receiving IL inj Vit D3 with complete resolution in 88.5%, partial resolution in 11.5%, and side effects in 6.2%. In 22 patients receiving IL inj Bleomycin, 95.5% had complete resolution, 4.5% had partial resolution, and 8.2% had side effects. Maximum resolution was observed in the third session. We found no recurrence after 3 months.

Conclusion

IL inj Vit D3 and IL inj Bleomycin are both safe and effective in treating difficult-to-heal palmoplantar warts with better outcomes and patient satisfaction. IL Bleomycin was significantly more effective than IL Vit D3, although the difference was not statistically significant.

A prospective randomized controlled study of Mycobacterium Indicus Pranii vaccine, Measles Mumps Rubella vaccine and Vitamin D3 in extragenital cutaneous warts

DESIGN

Interventional, prospective, four arm randomized control.

SETTING

Outpatient department, Department of Dermatology, Venereology and Leprology, AIIMS Jodhpur (Rajasthan), India.

PARTICIPANTS

Two hundred patients.

METHODS

The intervention administered in the groups were normal saline (A), vitamin D₃ (B), MIP (C), and MMR (D). The injections were given into the largest wart at 2-weekly intervals until complete clearance or for a maximum of seven sittings. Post-treatment clearance of the injected wart and the distant wart was compared on the basis of change in wart number, percentage clearance, and mean time to complete clearance. Side effects were recorded.

RESULTS

A total of 197 patients were recruited. The mean percentage improvement in the injected and non-injected warts was 68.4% and 66.8%, respectively. Intention to treat analysis (ITT) showed that complete clearance of lesions in injected wart occurred in placebo, vit D₃ , MMR, and MIP arms in 64%, 66%, 58%, and 55% patients, respectively (p > 0.05), while in the non-injected warts in 62%, 64%, 52%, and 53%, respectively (p > 0.05). The mean time to achieve complete clearance of wart was fastest in MIP at 7.1 weeks followed by MMR at 7.2 weeks, VIT D₃ at 7.4 weeks and in placebo group 7.8 weeks (p > 0.05). Side effects noted were fever, pain, erythema, and swelling which was highest in VIT D₃ group (p < 0.05).

CONCLUSION

The efficacy of immunotherapies was comparable to placebo with minimal side effects.

A comparative clinico-dermoscopic study of intralesional injection of combined digoxin and furosemide, Candida antigen, and vitamin D3 for multiple warts

BACKGROUND

Immunostimulatory and antiproliferative therapies have been widely used for the treatment of multiple warts. Recently, anti-HPV activity of ionic contra viral therapy (ICVT) which is comprised of combined digoxin and furosemide has been demonstrated.

AIM

To evaluate and compare the effectiveness and safety of intralesional injection of Candida antigen, vitamin D3, and combined digoxin and furosemide in the treatment of multiple warts.

PATIENTS AND METHODS

Seventy-five patients with numerous warts were randomly assigned to one of three equal groups: Candida antigen, vitamin D3, or a combination of digoxin and furosemide. In the Candida antigen group, injections into the biggest wart were done. In the vitamin D3 and combined digoxin/furosemide groups, the agent was injected into each wart with a maximum of five injected warts. Injections were repeated every 2 weeks until clearance or for a total of five sessions.

RESULTS

There was a statistically significant difference in the overall therapeutic response among the studied groups in favor of the intralesional Candida antigen group (60%), followed by the vitamin D3 group (48%) and the ionic contraviral therapy group (28%) (p = 0.02). However, the difference between both Candida antigen and vitamin D groups was not significant (p = 0.59).

CONCLUSIONS

Intralesional Candida antigen immunotherapy and vitamin D3 antiproliferative therapy are significantly more effective than ICVT.

LIMITATIONS

Short follow-up period and relatively small sample size.

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.

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.

Evaluation of the Efficacy of Intralesional Measles, Mumps, and Rubella Vaccine with Intralesional Vitamin D3 as Immunotherapies in the Treatment of Recalcitrant Cutaneous Warts in Adult- A Randomized Placebo-Controlled Study

Introduction:

Currently, various destructive and ablative treatment options are conventionally used for warts, but all of them are limited in some form by their adverse effects, high recurrences, suboptimal effectiveness, and the need to treat every wart. Lately, immunotherapy has emerged as a safe treatment relying on biological substances that modulate the immune system to achieve disease control.

Aims and Objectives:

We aimed at conducting a placebo-controlled study to compare the rate of efficacy of intralesional MMR vaccine with vitamin D3 in the management of recalcitrant extragenital warts in immune-competent adults. Follow-up was done at third and sixth month.

Materials and Methods:

Patients were divided into three groups, namely, group A, B, and C. Groups A, B, and C received intralesional MMR vaccine, vitamin D3 and normal saline, respectively, in the largest wart. The injections were repeated every 2 weeks, for a maximum of four injections.

Results:

Among injected warts, in group A, complete clearance was seen in 29 (87.8%) patients, partial clearance in two (6.1%) and no response in two (6.1%) patients. In group B, 24 (77.4%) patients, five (16.1%) patients, and two (6.5%) patients showed signs of complete, partial, and no clearance, respectively, in injected warts. Complete response in distant warts was seen in 25 (75.7%) patients in group A and 20 (64.5%) patients in group B. There was no statistically significant difference between responses of the two groups. In group C, only three (12.5%) patients had complete clearance in injected warts, and none in distant warts. Recurrence was seen in two (6.4%) patients, each in group B and C. However, for management of verruca plana MMR was found to be superior to vitamin D3.

Limitations:

Our study was limited by a small sample size, absence of immunological analysis, and limited follow-up period.

Conclusion:

MMR vaccine and vitamin D3 are equally effective and safe treatment option for multiple, recalcitrant warts, as well as warts on difficult to treat sites with minimal recurrence.

Intralesional Agents in Dermatology: Pros and Cons

Since introduced in 1961, intralesional (IL) agent has become an essential part of the dermatological practice. The term IL referred to the direct delivery of agent percutaneously into skin lesions. This therapeutic approach is relatively safe, easy to perform and applicable for a broad range of dermatological conditions. On the other hand, immediate side effects, including pain during administration, bleeding, high risk of infection and allergic reaction, and subsequent side effects involving skin changes such as atrophy, telangiectasia, pigmentary changes, and striae are usually associated with this modality. This review paper highlights the pros and cons of IL agents in modern dermatology practice.

How far is vitamin D implicated in cutaneous infections

Vitamin D is an important cornerstone in the immunologic cascade of many skin infections, systemic infections with cutaneous presentations, and other infectious dermatologic diseases where infections could be a culprit. Vitamin D supplementation is proposed as a protective measure against their occurrence and exacerbation, especially with the emergence of several viral pandemics in recent years. Vitamin D plays a key role in the maintenance of a balanced immunologic profile which could be reflected by a lowered incidence and morbidity of infections. Vitamin D screening and supplementation in patients with deficiencies or insufficiencies should be a part of the dermatologic approach to patients with these diseases.

Intralesional Candida antigen versus intralesional vitamin D3 in the treatment of recalcitrant multiple common warts

BACKGROUND

There are various therapies available for recalcitrant common warts; however no specific therapy has been established as entirely effective.

AIMS

To assess the efficacy and safety of intralesional Candida antigen injection of vs. intralesional vitamin D3 injection in the treatment of multiple recalcitrant common warts.

PATIENTS AND METHODS

A total of 80 adult patients with multiple common warts were randomly assigned to one of three groups in this study. Thirty patients were assigned to Group I, who received a 0.3 ml intralesional injection of Candida antigen. Thirty patients were assigned to Group II, who received a 0.6-ml (60 000 IU) intralesional injection of vitamin D3. Twenty patients were in Group-III, who received 0.3 ml of normal saline as a control. Each agent was injected at the base of largest wart every 3 weeks until full clearance has been obtained, or for a maximum of four sessions.

RESULTS

In the Candida antigen, vitamin D3, and saline groups, complete wart clearance was observed in 76.7 percent, 20%, and 0.0 percent, respectively. The side effects were negligible and transient, and there was no recurrence of the lesions.

CONCLUSION

Intralesional injection of Candida antigen is as a safe, simple, cost-effective treatment modality for multiple recalcitrant common warts and it outperforms intralesional vitamin D3.

Management of Difficult-to-Treat Warts: Traditional and New Approaches

Warts are regularly treated by dermatologists, and while many respond readily to first-line treatments, others may represent a therapeutic challenge. Large, deep, numerous, and extensive warts; treatment-resistant lesions with higher risk for side effects, such as hypopigmentation; or patients unable to tolerate or comply with our treatment regimen, may need alternative treatment options. In this work we review the characteristics of select modalities that should be considered for difficult-to-treat warts. We discuss efficacy and tolerability data as well as practical features that can guide us to select the best treatment for every scenario. Novel approaches, still in an investigational phase, are also discussed to illustrate potential future directions of wart treatment.

Diagnostic and therapeutic implications of vitamin D deficiency in patients with warts: A case-controlled study

BACKGROUND

Cutaneous warts are frequent conditions that possess much challenge to treat.

OBJECTIVE

To verify the potential role of vitamin D in the pathogenesis of viral warts by measuring the serum levels of vitamin D in patients diagnosed with viral warts compared to healthy controls and to verify whether oral vitamin D supplementation of those vitamin D-deficient patients would result in wart clearance.

METHODS

To evaluate the serum vitamin D levels, the study recruited 80 subjects, including 40 patients diagnosed with viral warts and 40 age- and sex-matched healthy controls. All patients were subjected to detailed history taking and examination to detect duration and type of warts. Serum vitamin D levels were measured using ELISA.

RESULTS

Thirty-five percent of patients had sufficient vitamin D levels (54-90 nmol/L), and 40% of patients had insufficient levels (50-80 nmol/L), while 25% of them had deficient levels (<50 nmol/L). In healthy group, 30% had sufficient levels, and 45% had insufficient levels, while 25% had deficient levels. There was an insignificantly lower serum level of vitamin D as well as an insignificantly deficient vitamin D status among patients compared to healthy controls.

CONCLUSION

Vitamin D serum levels appear to be lower among viral wart patients, and oral supplementation studies need to be more intensely investigated before elucidating its role; if any, in wart clearance.

Does involucrin have a role in verruca vulgaris? A clinical and immunohistochemical study

Introduction:

Aim of the Work:

Subjects and Methods:

Results:

Conclusions:

Role of intralesional vitamin D3 in the treatment of cutaneous warts

Background:

Cutaneous warts are common benign skin lesions caused by human papillomavirus. Various treatment options are available for these but immunotherapy is becoming more and more popular over the past few years. It stimulates cell-mediated immunity causing clearance of warts.

Aims and Objectives:

The aim is to determine the role of intralesional vitamin D3 in the treatment of warts.

Materials and Methods:

Consecutive patients with verruca vulgaris attending OPD were included. Around two to three warts were injected first with 0.2 mL of lignocaine (20 mg/mL). After a few minutes, the same warts were injected with 0.2 mL (4 U) of vitamin D3 (15 mg/mL). The injections were given2 weeks apart for a maximum of six sessions, and the patient was followed up 3 months after the last injection.

Results:

A total of 41 patients of cutaneous warts completed the study. Complete clearance was seen in 27 (65.85%) patients, partial response was seen in 11 (26.83%) patients, and three patients (7.32%) showed no response at all. The mean number of injections required for complete response was four. Recurrence was seen in two patients (4.88%) and one patient had keloid formation at the sight of injection.

Limitation:

This is a small sample sized study and lacks a control group.

Conclusion:

Intralesional vitamin D3 is an effective treatment option for common warts.

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

BACKGROUND

Several destructive and immunotherapeutic methods are used in treatment of plantar warts, but an effective method with no or reduced recurrence has not been found till now.

OBJECTIVES

To evaluate the efficacy and safety of intralesional (IL) vitamin D₃ (Vit.D₃ ) injection vs IL tuberculin purified protein derivative (PPD) injection in the treatment of plantar warts.

METHODS

Sixty patients with plantar warts were randomized into 3 equal groups: group I treated using IL tuberculin PPD every 2 weeks, group II treated using IL Vit.D₃ every 4 weeks, and group III treated with IL saline every 2 weeks till complete clearance or for a maximum of 3 sessions. The follow-up period was 6 months.

RESULTS

There was a statistically significant improvement in therapeutic groups than control with more significant improvement in group II than I. Regarding number of sessions required for complete response, there was a positive significant correlation in both groups, but more significant in group I. There was a negative correlation between the number of lesions and the response to treatment in both groups. Group II showed significantly better response to treatment in male patients. Both modalities were well tolerated, with no remarkable side effects and no recurrence in cured patients of both groups.

CONCLUSIONS

Both IL PPD and Vit.D₃ injection are safe and effective for treatment of plantar warts even recalcitrant or multiple, with no postprocedural downtime, better results, and patient satisfaction. IL Vit.D₃ injection has a superior advantage than PPD.

A comparative study of the efficacy and safety of intralesional measles, mumps, and rubella vaccine versus intralesional vitamin D3 for the treatment of warts in children

BACKGROUND

Intralesional vitamin D3 has recently emerged as a new treatment for cutaneous warts. The use of the measles, mumps, and rubella (MMR) vaccine for this purpose is an established modality. However, relevant data on the efficacy of either the MMR vaccine or vitamin D3 as immunotherapy for cutaneous warts in the pediatric population are limited.

OBJECTIVES

To compare the efficacy and safety of intralesional injections of MMR vaccine to intralesional injections of vitamin D3 in children aged 8-16 years with multiple warts.

METHODS

A total of 74 children were randomly allocated into two groups. Group A patients received intralesional MMR vaccine into the largest wart, and group B received intralesional vitamin D3 into the largest wart. The injections were repeated every 4 weeks until clearance or for a maximum of three treatments. After the last injection, children were followed up every 2 weeks for 3 months, and at the sixth month, a final clinical assessment was conducted.

RESULTS

Of 74 children, 60 completed the study, with 30 children in each group. Complete clearance of the injected wart was observed in 26 (86.67%) patients in the MMR group (group A) and 23 (76.7%) patients in the vitamin D3 group (group B). Distant warts cleared in 23 (76.7%) patients in group A compared to 20 (66.6%) patients in group B. There was no significant difference between groups. No recurrence was seen in group A, whereas two (6.6%) children in group B exhibited recurrence in the ensuing 6-month follow-up. The most common adverse events were injection site pain and swelling.

CONCLUSION

Both intralesional MMR and vitamin D3 are safe, generally well-tolerated, and equally effective in children for the treatment of cutaneous warts.

Intralesional vitamin D3 versus new topical photodynamic therapy in recalcitrant palmoplanter warts Randomized comparative controlled study

BACKGROUND

Recalcitrant palmoplanter warts represent a therapeutic challenge. Side effects of local destructive methods necessitates the need for other less morbid modalities. Recently immunotherapy as well as light based devices and lasers have emerged as therapeutic approaches.

AIM OF THE STUDY

To compare between the safety and efficacy of intralesional vitamin D3 injection and photodynamic therapy (PDT) using eosin in treatment of recalcitrant palmoplanter warts.

PATIENTS AND METHODS

Prospective, randomized, controlled comparative study. Fifty -six patients with recalcitrant palmoplanter warts were randomly divided into 3 groups. Group A was injected with intralesional vitamin D3. Group B was subjected to PDT using eosin loaded in trasferosomes as a photosensitizer. Group C is the control group. Clinical improvement was assessed by photographic records and dermoscopic assessment, at baseline, before each session and after completion of treatment. Patients were followed up for 6 months after cure to detect recurrence.

RESULTS

Group A and B showed complete clearance in 88.89 % and 86.36 % respectively compared to 18.75 % in the control group. These results were statistically significant (P value<0.001). No side effects were reported except for pain during injection in group A.

CONCLUSION

In the current study, both vitamin D3 and PDT using Eosin are safe, highly effective and well tolerated modalities in treatment of viral warts.

Pre-treatment vitamin B12, folate, ferritin, and vitamin D serum levels in patients with warts: a retrospective study

Aim

To compare the serum levels of 25-hydroxyvitamin D, ferritin, folate, vitamin B12, zinc, and thyroid stimulating hormone between patients with warts and healthy individuals.

Methods

This retrospective study enrolled 40 patients with warts and 40 healthy individuals treated at the Ufuk University Hospital, Ankara, between July and December 2017. Serum levels of 25-hydroxyvitamin D, ferritin, folate, vitamin B12, zinc, and thyroid stimulating hormone status were evaluated retrospectively.

Results

Participants with and without warts had similar mean serum 25-hydroxyvitamin D, ferritin, folate, zinc, and thyroid stimulating hormone levels. However, patients with warts had significantly lower mean serum vitamin B12 level (P = 0.010). Patients with warts non-significantly more frequently had decreased serum levels of 25-hydroxyvitamin D, ferritin, and folate (P = 0.330, P = 0.200, P = 0.070, respectively).

Conclusion

Patients with warts may require evaluation of serum levels of vitamin B12, folate, ferritin, and vitamin D.

Intralesional injection of vitamin D in verruca vulgaris increases cathelicidin (LL37) expression; therapeutic and immunohistochemical study

Introduction: Despite the promising results of intralesional vitamin D in verruca treatment; its precise mechanism of action is not fully understood.Aim of the work: To investigate immunohistochemical expression of cathelicidin (LL 37) before and after injection of vitamin D in verruca vulgaris and to clarify its possible role in pathogenesis of verruca.Patients and methods: This study included 20 patients with multiple verrucae vulgaris. Vitamin D was intralesionally injected every 2 weeks for a maximum of 4 sessions or clearance of verrucae. Skin biopsies were taken from the patients before and at the end of the study and compared to skin samples from ten apparently healthy, age and sex matched individuals for histopathological and immunohistochemical assessment of LL37 expression.Results: Eight (40%) verrucae showed complete response, seven (35%) showed partial response and five (25%) showed no response. Decreased epidermal thickness and reduced density of inflammatory cells in dermis were observed after injection. Significant increase in LL37 intensity of expression was observed after intralesional injection of vitamin D3 (p = .003) and in verrucae showing complete clinical response (p = .022).Conclusions: Intralesional injection of vitamin D is effective and safe treatment for verruca vulgaris and causes increase in LL37 expression.

Successful clearance of extensive/recalcitrant cutaneous warts by acitretin monotherapy: A case series study

Most available options for the treatment of warts are limited by the potential for scarring, pain, lack of response, or recurrences, and the patients are often unable to tolerate and accept those experiences. The aim of this study was to evaluate the clinical efficacy and safety of oral systemic acitretin monotherapy in patients with extensive/recalcitrant cutaneous warts. The patients were given a dose of acitretin of 0.8 mg kg^-1 day^-1 , and the clinical efficacy and safety of acitretin was assessed every 2 weeks for 2 months. A total of 14 patients (12 males and 2 females) were included, with an age of 14-60 years (mean 33 ± 14.7 years) and a course of 4-48 months (mean 21.6 ± 13.4 months). After 2 months of acitretin treatment, 42.9% (6/14) of patients (including warts of the feet, legs, and hands) exhibited complete response, 28.6% (4/14) excellent response, and 28.6% (4/14) good response. All patients demonstrated significant improvement, and the drug was well tolerated, with no patients discontinuing therapy due to side effects. Common mild side effects included dry skin and cheilitis. There were no recurrences during a follow-up period of 6 months. Acitretin monotherapy is an effective, safe, and well-tolerated treatment for patients with extensive/recalcitrant cutaneous warts who are unsuitable for or unwilling to accept traditional treatment methods.

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.