Cost-effectiveness of cryotherapy versus salicylic acid for the treatment of plantar warts: economic evaluation alongside a randomised controlled trial (EVerT trial)

Topical antimitotic treatments for plantar warts are more beneficial: A Bayesian network meta-analysis of randomized controlled trials

BACKGROUND

Plantar warts are common infectious cutaneous growths causing severe physiological and psychological discomforts in patients and heaving global financial burdens. However, paucity of clear-cut guidelines for plantar warts, selecting appropriate treatments for plantar warts remains challenging. The objective of the study is to evaluate the efficacy and safety of common treatments for plantar warts.

METHODS

PubMed, EMbase, and The Cochrane Library were searched from inception to March 1, 2023 for randomized controlled trials (RCTs) of plantar warts. The primary outcome (complete response) and secondary outcome (recurrence and pain) were extracted and combined using Bayesian network meta-analysis (NMA) with random-effect and fixed-effect models.

RESULTS

Totally, 33 RCTs were included in the systematic review and quantitative NMA. In NMA of complete response, topical application of 1% cantharidin, 20% podophylotoxin, 30% salicylic acid (CPS), microneedles plus bleomycin (MNB), and intralesional bleomycin injection (INB) were the only three treatments significantly superior to no treatment (NT) and CPS was of the highest possibility to be the top-ranked treatment (SUCRA = 0.9363). However, traditional warts treatments, salicylic acid (SA) and cryotherapy were not superior to NT.

CONCLUSIONS

The NMA has produced evidence for using CPS, MNB, and INB, which are all topical antimitotic treatments, to improve the management of plantar warts. The classic treatment modalities for plantar warts, including SA and cryotherapy, may play a less important role in the clinical practice of plantar warts.

Treatment efficacy of 0.9% saline and mepivacaine infiltration with Dermojet® in eliminating plantar warts

BACKGROUND

Plantar warts are benign, epidermal neoformations, viral, and easily transmitted. Although 30% of these warts disappear spontaneously, the American Association of Dermatology recommends treatment if they cause pain or bleeding.

OBJECTIVES

The aim of this study was to determine the efficacy of Dermojet® infiltration using a solution composed of equal parts of 0.9% saline and 2% mepivacaine in the treatment of plantar warts, and to identify the type of necrosis achieved at 7-10 days after the infiltration (M1 sample) and at 15-17 days (M2 sample).

METHOD

In this analytical prospective observational study, 102 histories were reviewed by the same researcher. The patients were treated with this technique at four private podiatry clinics.

RESULTS

A total of 61.8% of the patients were male. The patients' mean age was 26.6 ± 14.10 years. A total percentage of 78.4% of the patients achieved complete elimination of the lesion by the second evaluation and after a single infiltration. Bivariate analysis revealed a significant inverse relationship between treatment efficacy and a history of previous disease (p < 0.001) and the period of evolution of the lesion (p < 0.001; 95% CI [0.78-7.91]). Multivariate linear regression analysis revealed an association with the number of evaluation sessions (p < 0.001) and with previous illnesses (p = 0.014). A total percentage of 82.35% presented partial necrosis in the M1 sample and 76.92% had complete necrosis in the M2 sample.

CONCLUSIONS

In 78.4% of the patients considered, the plantar warts treated disappeared after a single infiltration. The variables associated with treatment efficacy were the number of follow-up visits and the existence of associated diseases.

Efficacy of cryotherapy for plantar warts: a systematic review and meta-analysis

Recent systematic reviews of plantar warts continue to consider cryotherapy as one of the treatments of choice, but this method appears to have lower cure rates than alternative treatments. A systematic review using meta‐analyses of the efficacy of cryotherapy in plantar warts treatment was performed. Systematic electronic searches were conducted. The primary endpoint was complete clearance of plantar warts. Risk‐of‐bias assessment was based on Cochrane Handbook recommendations. Meta‐analyses used Review Manager v5.4.1 software. Cryotherapy appears to have lower cure rates than other treatments (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.12–0.78) with substantial heterogeneity (I² = 80%). A second subgroup analysis had low heterogeneity (I² = 28.2%). Subgroup analysis showed that plantar wart cure rates were significantly lower with cryotherapy compared to the physical treatment group (OR 0.05, 95% CI 0.01–0.49) with substantial heterogeneity (I² = 79%), and antiviral, chemotherapy, and retinoid group (OR 0.30, 95% CI 0.14–0.66) without heterogeneity (I² = 0%). Intralesional versus spray‐on cryotherapy appears to be more effective (OR 0.21, 95% CI 0.09–0.48). No difference in efficacy between two rounds of 10‐s and four rounds of 5‐s freeze–thaw cycles in cryotherapy was found. Evidence of the superiority of antivirals and chemotherapy over cryotherapy in the treatment of plantar warts was found. However, no evidence supports the superiority or inferiority of cryotherapy compared to other treatments.

The status of treatment for plantar warts in 2021: No definitive advancements in decades for a common dermatology disease

Plantar warts are among the most common skin conditions and are classically resistant to treatment. To perform an evidence-based evaluation of the efficacy and safety of available treatment options for plantar warts, we conducted a systematic review of PubMed and Cochrane databases to identify large interventional and observational studies involving more than 100 patients who were treated for plantar warts from inception to October 2020. We identified only nine contributions meeting our inclusion criteria (N ≥ 100), representing 1,657 adult and pediatric patients with plantar warts. Treatments included in this review were topical keratolytic agents, cryotherapy, laser therapies, and intralesional and systemic treatments. Our evidence-based review of the larger studies suggests keratolytic agents and destructive treatments, in particular salicylic acid and cryotherapy, remain the primary treatments for plantar warts. Treatment with pulsed dye laser had the lowest rate of recurrence. Newer treatments and intralesional treatments were not represented owing to lack of large studies involving these modalities.

Topical treatment for plantar warts: A systematic review

There are a wide variety of treatments for plantar warts, but none has been shown to be effective in all patients. We aimed to perform a systematic review of the efficacy of different topical treatments on plantar warts. Systematic electronic searches (Pubmed, Cochrane Library, Embase, and Web of Science) were conducted in April 2020. Meta-analyses, systematic reviews, and retrospective or prospective clinical trials of the effects of topical and nonsurgical treatments of plantar warts were included. Two authors performed the study selection and data extraction. Any discrepancies between the two reviewers were discussed with a third reviewer. Forty-four studies were included. The average cure rates of the most frequent treatments were variable across the studies: cryotherapy (45.61%), salicylic acid (13.6%), cantharidin-podophyllin-salicylic acid formulation (97.82%), laser (79.36%), topical antivirals (72.45%), intralesional bleomycin (83.37%), and intralesional immunotherapy (68.14%). Twenty-two studies (50%) had a level of evidence 1b and grade of recommendation A, five studies (11.4%) had a level of evidence 2b and grade of recommendation B, two studies (4.5%) had a level of evidence 3b and grade of recommendation B, and 15 studies (34,1%) with a level of evidence 4 and grade of recommendation C. First-choice treatments for common warts, such as cryotherapy and salicylic acid, have low-cure rates for plantar warts. Other treatments, such as CPA formulation, immunotherapy, and intralesional bleomycin, which have compassionate use, have higher cure rates. This review should stimulate future high-quality research to evaluate these specialized treatments.

A Retrospective Study of a Chinese Traditional Medicine YIKEER in the Treatment of Verruca Patients in Liaoning District

Background

There are many possible ways to treat verruca, but no one is the single perfect treatment. YIKEER is a kind of compound preparation of Chinese traditional medicine, which has been used in the treatment of verruca for several years.

Aim

To confirm the effects of YIKEER for verruca.

Method

Patients with verruca vulgaris, verruca plantaris, or verruca plana were instructed to apply YIKEER stock solution or diluent to the lesions once or twice daily for 5–7 days. Then, the YIKEER was ceased for 3–4 days, and sea buckthorn oil was used for wound repairing. The total procession was defined as one session.

Result

Respective 88.05% verruca vulgaris patients, 86.03% verruca plantaris patients, and 82.42% verruca plana patients achieved complete response. Most patients gained complete or partial responses after 4 treatment sessions. The percentage of patients who achieved at least 50% improvement was 90.34% for verruca vulgaris, 90.60% for verruca plantaris, and 80.91% for verruca plana after 4-session treatment. The efficacy of verruca vulgaris or verruca plantaris was better than that of verruca plana.

Conclusion

YIKEER is an effective, safe, and well-tolerated agent for treating verruca including verruca vulgaris, verruca plantaris, and verruca plana.

Does implantation of verruca plantaris into the abductor hallucis muscle belly in conjunction with CO2 laser ablation prevent recurrence?

Often times, conservative treatment is unsuccessful in long-term resolution of recalcitrant verrucae plantaris lesions. In addition to being aesthetically displeasing, severe cases that are left untreated can be debilitating, often leading to chronic pain, gait abnormalities, and further cutaneous spread. Inoculation through implantation of verrucae plantaris into a muscle was previously postulated to provoke an immune response against the human papilloma virus, resulting in auto-immunization. The purpose of this study was to determine the rate of recurrence following two methods of treatment: A) Surgical removal and subsequent implantation of verruca plantaris into the contralateral abductor hallucis muscle belly and B) Surgical excision of verrucae plantaris. A retrospective chart review of 43 consecutive patients was performed. Group A was comprised of 25 patients who underwent surgical removal of verrucae plantaris followed by implantation of a biopsied specimen into the contralateral abductor hallucis muscle belly. Group B was comprised of 18 patients who underwent only surgical removal of the verrucae. The presence or absence of verrucous lesions was recorded at a post-operative follow-up at an average of 27.5 months. Correlations between recurrence of disease and age, sex, and medical comorbidities were evaluated. Our results suggest that implantation of verruca plantaris into the abductor hallucis muscle belly yields no significant difference in clinical recurrence rates when compared to surgical removal.

Cryotherapy versus CO2 laser in the treatment of plantar warts: a randomized controlled trial

Background

Warts are one of the most common infections in humans. Plantar warts are a subtype of non-genital warts, and several procedures and topical treatments have been used in its treatment. Cryotherapy is one of the most popular modalities, but it is time-consuming and remission rates vary in different studies. CO₂ laser was the first laser used for treating warts. To date, no clinical trial has been done to compare CO₂ laser with cryotherapy in the treatment of plantar warts.

Patients and Methods

This randomized controlled trial was performed in order to compare the efficacy and number of sessions needed to treat plantar warts in 60 patients who had received no previous treatment in the previous 3 months. They were randomly allocated to the cryotherapy or CO₂ laser group. The number of sessions needed for response and the recurrence rate after a 3-month follow-up was compared in the 2 groups.

Results

Sixty patients with plantar warts were randomly allocated to either the CO₂ laser or cryotherapy groups. Median age was 25 (range=18–53) and 27 (range= 18–75) years in the cryotherapy group and CO₂ laser groups, respectively. Both groups were matched for age and sex (56% male and 44% female in the cryotherapy group and 34% male and 66% female in the CO₂ laser group). The median number of sessions needed for complete resolution of the warts in the CO₂ laser and cryotherapy groups were 1 (range=1–2) and 3 (range=1–12), respectively. The difference in the number of sessions was statistically significant between the 2 groups (P-value≤0.001). Recurrence rates after a 3-month follow-up was not statistically significant (P-value= 0.069).

Conclusion

The number of sessions needed to treat plantar warts was less using CO₂ laser than cryotherapy; therefore, this modality can be a good addition to the already existing anti-wart armamentarium.

The cost-effectiveness of 5-FU-SA in the treatment of actinic keratoses of the face and scalp in the UK secondary care setting

OBJECTIVE

The objective of this analysis was to estimate the relative cost-effectiveness of Actikerall ¹ (5-FU-SA) vs cryotherapy in a secondary care setting in the UK, for lesion-directed treatment in patients with actinic keratoses (AK) of the face and scalp.

METHODS

The model was a simple decision tree, with a 6-month time horizon. The perspective was that of the UK National Health Service (NHS). Modeled treatment effects included reported per-patient histological clearance and recurrence rates. Cost inputs comprised professional consultation time and cost of medication. Health-related utility estimation followed previously published methodology. Adverse events were not modeled. The key data and model structural assumptions followed expected UK practice. One-way and probabilistic sensitivity analyses were conducted to assess structural and parameter uncertainty.

RESULTS

5-FU-SA was found to be less costly (-£204) and more effective (+0.001 QALY) in base case and sensitivity analyses. In the probabilistic analysis there was 100% probability of being cost-effective over cryotherapy at £20,000 willingness to pay. Cost of professional time was a key driver of the model outcome. 5-FU-SA remained dominant across a range of scenario analyses, including exploration of assumptions around setting of care.

LIMITATIONS

The time horizon of the analysis was short and data were not extrapolated beyond the duration of the clinical trial; however, this approach is consistent with likely follow-up of an AK patient. The clinical outcomes observed in the trial were based on a large proportion of cryotherapy patients undergoing an additional cycle of treatment; this may not occur or be required in an experienced secondary care setting.

CONCLUSION

5-FU-SA could be considered as a cost-effective choice for treatment of AK lesions of the face and scalp in secondary and mixed care settings in the UK. Use of 5-FU-SA in patients who would otherwise be managed with cryotherapy has the potential to result in cost savings.

Evaluating the success of Nd: YAG laser ablation in the treatment of recalcitrant verruca plantaris and a cautionary note about local anaesthesia on the plantar aspect of the foot

BACKGROUND

There are various methods advocated for the treatment of verruca plantaris. However, many verrucas do not respond to simple treatment.

OBJECTIVE

This study presents our results using Nd: YAG laser ablation therapy for such recalcitrant cases.

METHODS

We performed a retrospective audit by sending a questionnaire to all patients with recalcitrant verrucas who had been treated with Nd:YAG laser ablation over the previous 12 months. The questionnaire asked whether treatment had been successful, successful but new lesions had emerged, partially successful with improvement or unsuccessful. A Fontana Nd:YAG laser was used at the following specifications; long pulsed mode with pulse width 25 ms, frequency 1.0 Hz; fluence 240 J/cm(2) and spot size 2 mm. Some patients requested local anaesthesia and had direct infiltration with 0.5% plain lidocaine.

RESULTS

Fifty-three of the original 87 patients responded (60.9% response rate) with a male to female ratio of 24:29, mean age of 47 years and an age range between 22-72. Thirty-seven patients reported complete success post treatment (69.8%) and a further five reported improvement. The remaining 11 felt their treatment was unsuccessful. The cure rate was 81.8% in unilateral single cases, 68.1% in unilateral multiple cases and 65% in bilateral cases. Ten patients requested sublesional lidocaine injections of which 4 had skin breakdown after Nd: YAG ablation.

CONCLUSION

Nd:YAG laser ablation is effective in the treatment of recalcitrant verruca plantaris. However, we caution against the use of direct local anaesthesia infiltration before laser treatment.

Cryosurgery as an Effective Alternative for Treatment of Oral Lesions in Children

Children can exhibit a wide variety of oral pathologies, such as oral lesions, bone lesions, tumors, cysts and cutaneous lesions. Different techniques have been described for the treatment of these lesions, but all of them are invasive. This paper presents a series of cases that demonstrate the clinical efficacy of cryosurgery as an alternative to invasive surgical treatments of the most common oral lesions in children. This technique has been well tolerated by patients due to the absence of anesthesia, rapid healing and minimal bleeding. Cryotherapy has many applications in oral medicine and is an extremely useful alternative in patients to whom surgery is contraindicated due to age or medical history. It is a simple procedure to perform, minimally invasive, low-cost and very effective in pediatric dentistry clinic.