Cryotherapy versus imiquimod 5% cream combined with a keratolytic lotion in cutaneous warts in children: A randomized study

Combined intralesional injection of tuberculin purified protein derivative (PPD) plus cryotherapy versus each alone in the treatment of multiple common warts

Different modalities are used for treatment of common warts, but none of them had been proved to be the best in achieving complete cure. We aim to compare the effect of cryotherapy, intralesional injection of tuberculin PPD and cryotherapy combined with intralesional injection of tuberculin PPD in the treatment of multiple common warts. This study is a randomized clinical trial in which the patients were randomly divided into three groups; group (A) included 25 patients subjected to cryotherapy, group (B) included 25 patients subjected to intralesional injection of tuberculin PPD and group (C) included 25 patients subjected to cryotherapy plus intralesional injection of tuberculin PPD. All the three groups showed a significant clinical improvement (p < 0.001) with statistically significant difference between cryotherapy group (A) and intralesional injection of tuberculin PPD group (B) (p < 0.001) & between cryotherapy group (A) and cryotherapy plus intralesional injection of tuberculin PPD group (C) (p < 0.001). However, there was no statistically significant difference between both intralesional injection of tuberculin PPD group alone (B) and cryotherapy plus intralesional injection of tuberculin PPD group (C) (p = 0.213). In Conclusion the cryotherapy combined with intralesional injection of PPD and intralesional injection of PPD alone are better than cryotherapy alone in treatment of multiple common warts. However, better response could be reached in combination of both cryotherapy and intralesional PPD with fewer number of sessions.

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.

Treatment of cutaneous viral warts in children: A review

Viral warts or verruca are very common skin infections in children. Although benign, lesions can be extensive, painful, bleed, or lead to cosmetic disfigurement. Although spontaneous resolution can occur, parents often bring their children for treatment, especially when they are symptomatic. Many publications have assessed the efficacy and safety of treatment of warts in adults. However, treatment in children can be challenging due to their immune responses and lower threshold for pain. We review the current literature on the methods, efficacy, and side effect profile of common treatment modalities for cutaneous viral warts in children. There is evidence that salicylic acid and cryotherapy are effective, and although cryotherapy is more effective, there is a higher risk of side effects such as pain and blistering. Combination treatment with salicylic acid and cryotherapy may reduce these side effects. Although there is limited data, other treatment options such as cantharidin, immunotherapy and other mechanical therapies, for example, carbon dioxide lasers, may also be considered, especially for recalcitrant lesions.

Human-papillomavirus-related disease in pediatrics

PURPOSE OF REVIEW

Human papillomaviruses (HPVs) account for a number of distinct disease entities in pediatrics, ranging from common warts to the stigmatizing condyloma acuminata to life-threatening respiratory papillomatosis. Although there is still a lack of consensus on treatment for each of these HPV-related diseases, scientific investigation continues to progress. Increasing prevention of HPV-related disease with further vaccination and development of new vaccines continues to be the best medical strategy.

RECENT FINDINGS

Although high-quality evidence for treatment of HPV-related disease is still lacking, several new studies have been published in recent years that have refined opinions on therapy. Novel treatments continue to be developed, including new vaccines to further coverage for other strains.

SUMMARY

HPV-related disease in pediatrics is associated with societal stigmatization and a high level of morbidity. Greater understanding of the distinct diseases and high-quality research is necessary to enhance treatment selection in the coming future.

Small cryotherapy devices for the treatment of skin warts

STUDY PURPOSE

Effectiveness of cryotherapy on skin wart models.

MATERIALS AND METHODS

Two small cryotherapy devices, Wartner and Wortie, were administered for 10″-60″ on tomatoes and potatoes used as skin wart models. Frozen surface and depth were evaluated by standardized photography and computer analysis. Tissue temperature at depths of 0.1-10 mm was assessed by an electronic thermometer during treatment.

RESULTS

Cryotherapy induced a transient freezing of the tomato surface. The devices produced similar tomato tissue temperature reduction at all depths examined. At 5 mm, Wortie induced lower tissue temperatures than Wartner. Both devices induced potato tissue destruction to a depth of 0.5-1.2 mm at 40″ and 50″. Wartner induced a maximum destruction at 40″, Wortie led to a partially linear destruction depth with freezing time. The devices produced similar reduction of potato tissue temperature at all depths tested. Wartner induced more rapidly lower temperatures (1.5 mm, 10″, p = .001). Wortie induced lower tissue temperatures with time (0.1 mm, 50″, p = .025; 60″, p = .039; 5 mm, 60″, p = .05). None of the devices reached the lethal temperature of -22 °C.

CONCLUSIONS

Both cryotherapy devices produced sufficient tissue damage, at least in the potatoes, to a depth of 0.5-1.2 mm when applied for 40″ (commercially proposed time).

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.

Giant Condyloma Acuminate Due to Human Papillomavirus Type 16 in an Infant Successfully Treated with Topical Imiquimod Therapy

Anogenital warts related to human papillomavirus (HPV) have been observed in children. Definition of the transmission mode, therapy, and follow-up for long term potential complications is important. A 27-month old girl was admitted with multiple pedunculated red-purple colored cauliflower-like lesions of 1.5 years duration. Clinical/histopathological and microbiological diagnosis was condyloma acuminate due to HPV type 16. After 12 weeks of imiquimod 5% cream application (pea-sized) overnight three times per week, the perianal warts had completely disappeared. The mode of transmission of HPV 16 in our case was probably horizontal, related to the sharing of common personal hygiene items in the women’s shelter. We report herein the case of an infant living in a women’s shelter with giant condyloma acuminata due to HPV 16, which was successfully treated with topical imiquimod therapy. This patient should be followed up for recurrence and potential malignant lesions related to HPV type 16.