Use ofCandidaantigen injections for the treatment of verruca vulgaris: A two-year mayo clinic experience

Intralesional Quadrivalent Human Papilloma Virus Vaccine Versus Candida Antigen in the Treatment of Multiple Recalcitrant Non-Genital Warts

INTRODUCTION

Warts are the most prevalent clinical manifestation of Human Papilloma Virus (HPV) infections, which vary in morphological pattern depending on the site of the body affected.

OBJECTIVES

To evaluate the safety and efficacy of intralesional quadrivalent HPV vaccine versus candida antigen in treatment of multiple recalcitrant non-genital warts.

METHODS

A randomized-control clinical trial included 60 cases with multiple recalcitrant warts who were randomly distributed into three groups; Group I included 20 patients who received intralesional candida antigen at a dose of 0.3 mL of 1/1000 solution, Group II included 20 patients who received intralesional quadrivalent HPV vaccine at a dose of 0.3ml and Group III included 20 patients who received intralesional injection 0.3 ml of normal saline 0.9% as a control group). Each agent was injected at the base of the largest wart every three weeks until it was completely cleared, or for a total of four sessions.

RESULTS

the highest response rate was detected in the quadrivalent HPV vaccine group (75% complete response) followed by the candida vaccine group (40% complete response and 15% partial response). Also, regarding the distant response rate, the highest response rate was detected in the quadrivalent HPV vaccine group (72.7% complete response and 27.3% partial response) followed by the candida vaccine group (33.3% complete response and 50% partial response).

CONCLUSIONS

Intralesional immunotherapy appears to be effective and safe in treating multiple recalcitrant non-genital warts, with intralesional quadrivalent HPV vaccine outperforming intralesional candida antigen.

Rapid resolution of diffuse warts following initiation of dupilumab for severe atopic dermatitis

Cutaneous warts are an exceedingly common cutaneous viral infection for which existing treatment options are often painful, expensive, and only marginally effective. Extensive warts may occur in the setting of primary immunodeficiencies, wherein they can co-occur with other diseases of immune dysfunction, such as atopic dermatitis (AD). Dupilumab, an IL-4 receptor α (IL-4Rα)-blocking monoclonal antibody, is a biologic agent recently approved for the treatment of moderate-to-severe eczema. Here, we report a case of a young girl with both severe AD and diffuse filiform warts, which resolved shortly after initiating treatment for AD with dupilumab.

Intralesional measles, mumps, and rubella vaccine after failure of intralesional Candida antigen for the treatment of recalcitrant pediatric warts

Numerous studies have investigated the efficacy of intralesional immunotherapy for warts, but there are a lack of studies investigating the efficacy of alternative intralesional immunotherapies following failure of initial intralesional immunotherapy. In this retrospective study, we aimed to investigate the efficacy of intralesional measles, mumps, and rubella vaccine for the treatment of pediatric warts following failure of intralesional therapy with Candida antigen. Following intralesional measles, mumps, and rubella vaccine administration, 8/51 (15.5%) patients had complete resolution of their warts, 6/51 (12%) had near complete resolution, 19/51 (37%) had partial improvement, 12/51 (23.5%) had no change, and 6/51 (12%) had worsening. Although limited by retrospective nature and low sample size, our results demonstrate that intralesional immunotherapy with measles, mumps, and rubella vaccine provides an alternative therapeutic option for the treatment of recalcitrant pediatric warts in patients who fail to respond to intralesional Candida antigen.

Efficacy and safety of local candida immunotherapy in recalcitrant warts in pediatric kidney transplantation: A case report

BACKGROUND

Warts are common in recipients of kidney transplantation (KT). Resistant warts which are not amenable to conventional therapies may lead to significant morbidity. Limited data exists on safety and efficacy of local immunotherapy among immunocompromised KT recipients.

CASE SUMMARY

We report a seven-year-old child who presented with recalcitrant plantar periungual warts in the early KT period. Immunosuppression consisted of tacrolimus, mycophenolate and steroid. Due to failure of conventional anti-wart therapies, he was treated with two sessions of intralesional (IL) candida immunotherapy along with liquid nitrogen cryotherapy leading to complete resolution of the warts. Interestingly, de novo BK viremia was seen about three weeks following the last candida immunotherapy. This required reduction of immunosuppression and other anti-BK viral therapies. Allograft function remained stable but there were donor specific antibodies detected. There also was elevated level of plasma donor derived cell-free DNA. A pneumocystis jirovecii pneumonia occurred ten months following completion of immunotherapy that was successfully treated with trimethoprim-sulfamethoxazole. During this ten-month follow-up period, there have been no recurrence of warts, and transplant kidney function has remained stable.

CONCLUSION

Stimulation of cell-mediated immunity against the human papilloma virus induced by the IL candida immunotherapy is thought to be a cause for wart resolution. With this therapy, whether it is necessary to augment the immunosuppression to prevent rejection is unclear as that may come with a risk of infectious complications. Larger, prospective studies in pediatric KT recipients are needed to explore these important issues.

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.

Finger Necrosis After Cutaneous Wart Intralesional Injection with Candida albicans Antigen: A Case Report

CASE

A 25-year-old man presented 18 hours after Candida albicans antigen injection into a left index finger cutaneous wart by his dermatologist. He experienced a rapid-onset inflammatory response, which was indistinguishable from gangrenous infection. Urgent incision and drainage was performed; however, no purulent collection was noted and no organism isolated. At 1-year follow-up, he made a full recovery.

CONCLUSION

Intralesional C. albicans antigen injection in digital cutaneous warts may cause an exaggerated immune response resulting in partial necrosis of the finger pulp. The clinical presentation may be difficult to distinguish from coexisting infection, but in some cases, observation may be an appropriate course of action.

Intralesional Candida albicans antigen versus intralesional zinc sulfate in treatment of cutaneous warts

Immunotherapy represents a promising therapeutic option for treatment of warts. Different concentrations of Candida antigen (1/100 and 1/1000) and zinc sulfate 2% were not previously compared regarding their efficacy in treatment of cutaneous warts. The present study compared the safety and efficacy of intralesional candida antigen versus intralesional 2% zinc sulfate for treatment of cutaneous warts. This prospective controlled clinical trial included one hundred and five patients presented with common, plantar, and plane warts. Patients were divided randomly into three groups, each group included 35 patients. Group 1 were treated with intralesional candida antigen (Ag) 1/100, Group 2 were treated with intralesional candida Ag 1/1000, and Group 3 were treated with intralesional zinc sulfate 2%. This study found that target warts of group 1 displayed higher rate of complete clearance compared to group 2 and group 3 (94.3%, 77.1, 74.2%), respectively. The present study concluded that intralesional immunotherapy with Candida antigen was more effective than Intralesional 2% zinc sulfate in treatment of cutaneous warts and less painful. Clinical trial registration number is (Clinical Trials.gov Identifier: NCT03158168).

Triple Intralesional Antigen Immunotherapy versus Monoantigen in the Treatment of Multiple Recalcitrant Warts

Introduction

Warts can be resistant to treatment or recur despite the use of various destructive and immunotherapeutic modalities. Combination immunotherapy might contribute to better response rates. The aim of this study was to assess the effectiveness and safety of a triple intralesional immunotherapy combination composed of purified protein derivative (PPD), Candida antigen, and measles–mumps–rubella vaccine (MMR), versus each agent alone, in the management of multiple recalcitrant warts.

Methods

In total, 160 patients with numerous resistant extragenital warts were included in the research. They were randomly assigned to one of four groups (each with 40 patients): PPD, Candida antigen, and MMR, or combination of the three antigens. Injections into the biggest wart were repeated every 2 weeks until clearance or for a total of five sessions.

Results

Complete wart clearance was reported in 31 patients (77.5%) who received triple-antigen immunotherapy, 23 patients (57.5%) who received intralesional PPD, 29 patients (72.5%) injected with Candida antigen, and 25 patients (62.5%) who received MMR. The combined therapy was found to be superior to the other therapies and had the lowest recurrence rate, but the difference was not statistically significant.

Conclusions

Triple intralesional antigen immunotherapy is as safe as, and more effective than, monoantigen immunotherapy, and can be added to the armamentarium against recalcitrant human papilloma virus (HPV) infections.

Tips, Tricks, and Pearls to Expertly Treat Common Pediatric Dermatologic Conditions

Pediatric dermatology is an incredibly rewarding field. Children are resilient and funny and just want to know that you are advocating for their best interests. Teaming up with children and their parents can lead to fantastic therapeutic alliances and success. The author has divided this chapter based on a handful of common pediatric dermatologic diseases and what he sees as some of the main clinical and therapeutic tips and tricks that have helped him in his practice.

Complement component 3c and tumor necrosis factor-α systemic assessment after Candida antigen immunotherapy in cutaneous warts

BACKGROUND

Cutaneous warts are the commonest benign lesion produced by human papillomavirus. Lesions often regress spontaneously yet have a high rate of recurrence. They impair patients' quality of life and carry the potential risk of cancer. Nowadays, Candida antigen immunotherapy has become an encouraging therapeutic modality for warts. We tried to assess the role of the complement pathway and T helper 1 immune response in clinical response to Candida antigen immunotherapy via complement component 3c (C3c) and tumor necrosis factor (TNF)-α, respectively.

METHODS

A total of 44 patients with cutaneous warts were enrolled in the study. Patients were injected with Candida antigen at 2-week interval until complete clearance of the lesion or for a maximum of 5 sessions. Blood samples were collected before initiation and after completion of immunotherapy. C3 and C4 were measured using an automated turbidimetric method. Mannose-binding lectin (MBL), C3c, and TNF-α were measured using enzyme-linked immune sorbent assay.

RESULTS

A total of 56.4%, 17.9%, and 25.7% of the patients showed complete, partial, and no response to immunotherapy, respectively. Lesions on the dorsum of the foot and sole showed significant clearance (p value = 0.037). All patients had no deficient C3, C4, and MBL serum levels. C3c and TNF-α serum levels were significantly higher in non-responder group (p value < 0.001 and < 0.001, respectively). C3c and TNF-α serum levels were strongly correlated in all the studied patients (r = 0.8, p value < 0.001).

CONCLUSIONS

Candida antigen immunotherapy is an effective therapeutic modality for cutaneous warts. C3c and TNF-α serum levels were higher in patients who failed to respond to immunotherapy.

CLINICAL TRIAL REGISTRY NUMBER

NCT04399577 , May 2020 "retrospectively registered".

Photodynamic therapy versus candida antigen immunotherapy in plane wart treatment: a comparative controlled study

INTRODUCTION

Plane warts, mostly found on the face, present a challenge to treat as most destructive methods can lead to unpleasant cosmetic outcome. Alternative therapeutic methods should be evaluated. The aim of this study is to evaluate the clinical efficacy and adverse effects of photodynamic therapy with methylene blue and intense pulsed light in comparison to candida antigen immunotherapy in the treatment of plane warts.

METHODS

The study included 39 patients with plane warts assigned into 3 groups. Group I received photodynamic therapy using methylene blue followed by IPL illumination, group II received immunotherapy using 0.1 ml of candida albicans antigen and group III received 0.1 ml saline as a control.

RESULTS

Complete response was detected in (46.1%) of patients in group I compared to (61.5%) in group II and no response in group III.

CONCLUSION

Candida antigen immunotherapy is superior to photodynamic therapy in plane warts treatment with absence of recurrence and comparable side effects in both groups.

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.

Intralesional immunotherapy for pediatric warts: A review

Cutaneous warts are a common pediatric complaint with modest response to first-line treatments. Warts are a manifestation of human papillomavirus (HPV) infection and are cleared by cell-mediated immunity (CMI). Intralesional immunotherapy treatments have been studied as alternative therapies, particularly for recalcitrant or multiple warts, including Candida antigen, mumps antigen, the combined measles, mumps, and rubella (MMR) vaccine, tuberculin purified protein derivative (PPD), and bacille Calmette-Guerin (BCG) vaccine. These treatments are thought to increase HPV recognition by stimulating CMI. In this review, we evaluate and compare the efficacy and adverse effects of intralesional immunotherapy in the treatment of pediatric warts. Articles met inclusion criteria if they specifically evaluated the effects of intralesional immunotherapy (candida, MMR, tuberculin PPD, or BCG) as treatment for cutaneous warts in a pediatric population, and if they quantified treatment effect in a reproducible manner. Twenty-one studies met criteria. Many studies demonstrated complete clearance of injected common warts in pediatric patients with clearance rates ranging from 23.3% to 95.2%. Distant wart resolution was common. Intralesional immunotherapy is a promising treatment option for cutaneous warts in children.

Role of mannose binding lectin in response to candida antigen immunotherapy of warts

BACKGROUND

Warts is the commonest cutaneous manifestation of human papillomavirus (HPV) infection. Intralesional Candida antigen immunotherapy is used for wart treatment.

AIM

To identify the role of mannose binding lectin (MBL) in susceptibility to HPV infection and to explore the relationship between MBL and response to intralesional Candida antigen immunotherapy of wart.

PATIENTS AND METHODS

A case-control study was enrolled with 96 participants; 48 wart cases and 48 healthy controls. MBL serum level assay baseline and after six settings of intralesional candida antigen injection was done by ELISA technique. MBL2 gene exon 1 codon 54 polymorphism was detected by using restriction fragment length polymorphism-polymerase chain reaction (RFLP-PCR).

RESULTS

A statistically significant difference in MBL serum level between wart cases and controls was found. An association between MBL2 exon1 codon 54 polymorphism and susceptibility to HPV infection and development of warts was proved. Carriage of genotype AB was more frequent wart cases (95.8%) than in controls (20.8%). No statistical significance association could be found between the therapeutic response to Candida antigen immunotherapy in wart cases and MBL as regards its serum level and genotypes.

CONCLUSIONS

MBL play an important role in host defense against HPV infection.

Peripheral blood toll-like receptor 4 correlates response to candida immunotherapy of warts

Human papilloma virus infection may be self-limiting; however, some cases may spread. There are no factors predicting the prognosis of such infections. The present study aimed to evaluate the significance of TLR4 expression in predicting the response of warts to candida immunotherapy. A total of 60 patients with different types of warts were included in the present study. A total volume of 2 ml venous blood was collected and real-time polymerase chain reaction was used to determine expression of TLR4. Patients were subjected to intralesional injection of Candida antigen into the largest wart at 2-week intervals until complete clearance or for a maximum of six sessions. Of the total 58 patients available for analysis of study results, 44 patients (75.9%) showed complete resolution with better response in younger ages. The TLR4 expression in patients with complete and partial response was significantly higher than that in patients who had no response (p = .006). Among our patients, 48.3% showed no side effects, 44.8% showed local reactions, and 6.9% showed systemic side effects. Only four patients showed recurrence after 6 months. Using receiver operating characteristic curve analysis, at cutoff of expression level >12 is accompanied by 100% specificity of TLR4 in predicting treatment response to candida immunotherapy. Candida immunotherapy is an effective warts treatment, especially in young patients. Higher PMBC TLR4 levels can predict response to candida immunotherapy.

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.