Immunotherapy with intralesional Candida albicans antigen in resistant or recurrent warts: a study

An Effective Siddha Management for Dermatosis Papulosa Nigra: A Case Report

Dermatosis papulosa nigra (DPN) is a noncancerous skin growth that is classified as a subtype of seborrhoeic keratoses. DPN is predominantly found in individuals with darker skin tones, namely, those with Fitzpatrick skin types III-VI. This condition primarily affects women of Asian or African American descent. The non-availability of accurate management for this illness presents a challenge to the medical fraternity. Electrodesiccation, laser therapy, and surgery offer expensive solutions. Siddha external medicine provides a solution through appropriate methods. A 70-year-old woman with Fitzpatrick skin type V appeared with many hyperpigmented papules on the malar region that had been present for five years. The dermatological examination revealed the presence of several brown papular lesions, which were particularly pronounced in the malar areas. The dimensions of the lesions typically varied from 1 to 5 mm; however, in the malar area, their size extended up to 1 cm. The Siddha formulation Pachaieruvai was administered externally for five consecutive days. While undergoing treatment, the patient experienced mild pain, burning, slight redness, and swelling in the area where Pachaieruvai was applied. These symptoms persisted for about an hour during and after the procedure but disappeared within 24 hours with the use of coconut oil. The evaluation of treatment response was determined using the recognised quartile grading methodology. During the first-week follow-up appointment after the last treatment, significant improvements were observed in the cheek lesions, particularly in four large lesions.Throughout the treatment, the patient may encounter mild discomfort, a burning sensation, slight redness, and swelling at the administration site of Pachaieruvai. These reactions are positive indicators of disease regression. No adverse symptoms and recurrence were observed during the follow-up. This research specifically examines the Siddha approach to managing DPN. Based on the findings and observations, it can be concluded that Siddha medicine is effective in treating DPN.

Efficacy of Intralesional Candida Antigen Versus Measles, Mumps, and Rubella Vaccine Versus Topical Podophyllin in Treatment of Resistant Genital Warts

BACKGROUND

No single treatment is ideal for genital warts with high rate of resistance using conventional modalities as topical podophyllin; however, several intralesional immunotherapies are being tested nowadays, with variable results. In this study, we compared the safety and efficacy of treating resistant and recurrent genital warts by 2 intralesional immunotherapies [Candida antigen and measles, mumps, and rubella (MMR) vaccine] and compared them with topical podophyllin.

PATIENTS/METHODS

A total of 45 patients with resistant or recurrent genital warts were enrolled in this study. Size and number of warts were detected in each patient, patients were divided into 3 groups. Group A injected with intralesional Candida antigen. Group B with intralesional MMR vaccine. Group C were treated with topical 25% podophyllin. Patients received a session every 2 weeks for 3 treatment sessions.

RESULTS

With regard to the reduction in size and number of all warts, the best response was obtained in Candida antigen group where 46.7% showed complete clearance and 40% showed partial response followed by MMR group and the last was the podophyllin group, with no significant difference between them. Complete clearance of mother warts was noticed in 86.7% of Candida group, 53.3% in MMR group, and last 40% in podophyllin group, with a significantly better response in the Candida group (P = .027).

CONCLUSION

Both intralesional Candida antigen and MMR vaccine are simple, safe, and effective treatment options with comparable results and better response than topical podophyllin.

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.

Intralesional bivalent and quadrivalent human papillomavirus vaccines didn't significantly enhance the response of multiple anogenital warts when co-administered with intralesional Candida antigen immunotherapy. A randomized controlled trial

Treatment of anogenital warts (AGWs) is challenging. Candida antigen immunotherapy has been proven to be a safe and relatively effective therapeutic modality; nevertheless, some patients may experience a partial or no response. Combining Candida antigen with other immunotherapies has been proposed to improve the cure rate. Immunotherapy with human papillomavirus (HPV) vaccines has been tried with conflicting outcomes. This study aimed to  assess the efficacy and safety of intralesional Candida antigen, either alone or in combination with intralesional bivalent or quadrivalent HPV vaccines, for treating multiple AGWs. Eighty patients with multiple AGWs were included and randomly assigned to four equal groups: group A treated with intralesional Candida antigen only; group B treated with intralesional bivalent HPV vaccine (Cervarix) and Candida; group C treated with intralesional quadrivalent HPV vaccine (Gardasil) and Candida; and group D (control) treated with intralesional saline. Complete clearance of lesions was detected in 40%, 20%, and 60% of patients in Candida monotherapy, Cervarix/Candida, and Gardasil/Candida groups, respectively, whereas 40%, 60%, and 20% of patients in the three groups, respectively, showed partial response. Only 10% of the control group had a partial response. Therapeutic outcomes were significantly better in the three treatment groups compared to the control group, with no statistically significant difference between the Candida monotherapy group and the combination groups, but the response was significantly better in the Gardasil/Candida group than in the Cervarix/Candida group. No statistically significant difference was found between the studied groups regarding the development of side effects. Moreover, no recurrence was detected in any of the groups throughout the 3-month follow-up period.  Based on our results, combining intralesional HPV vaccines with Candida antigen immunotherapy may have no significant benefit for treating multiple AGWs. Candida antigen may be recommended as a relatively effective and inexpensive therapeutic modality. The combination of Gardasil and Candida was also effective but very expensive. The results of the Cervarix/Candida combination were unsatisfactory.  This clinical trial was registered and approved prospectively by the ethical review board at Faculty of Medicine, Zagazig University.

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.

The efficacy and safety of intralesional Candida vaccine versus topical diphencyproprobenone in immunotherapy of verruca vulgaris: A randomized comparative study

Various therapeutic options are available for verruca. While physical destruction may be associated with scarring, immunotherapy may be effective in treating warts through stimulating body immune response. The objective of the study was to compare the efficacy, safety, and outcome of Candida antigen vs diphencyprone (DPCP) in the treatment of warts. Fifty patients were randomly assigned to receive either intralesional Candida antigen every 3 weeks or weekly DPCP application. Both treatments were applied only to the mother wart. Lesions' clearance and associated side effects were observed up to 4 weeks after treatment. Two blinded physicians evaluated photos of warts before and 4 weeks after the end of treatment. Both modalities granted wart clearance and/or improvement with no statistically significant difference; however, Candida antigen was significantly better in clearing adjacent untreated warts (p = 0.046). Fewer side effects were observed among the Candida antigen group. The response was duration associated in the Candida groups only. Intralesional Candida antigen injection and DPCP treatments for warts yielded improvement with superiority of Candida injection in eradicating distant lesions and fewer side effects. A shorter wart duration may be associated with a better therapeutic response with Candida antigen.

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.

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).

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.

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.

Comparative study between intralesional injection of MMR, BCG, and candida albicans antigen in treatment of multiple recalcitrant warts

BACKGROUND

Cutaneous warts represent a challenging condition to treat.

OBJECTIVE

To evaluate the safety and efficacy of intralesional injection of MMR (mumps, measles, and rubella) antigen, BCG (bacillus Calmette-Guerin) vaccine, and candida antigen for the treatment of multiple warts.

METHODS

A total of ninety (90) clinically confirmed adult patients complaining of recalcitrant extragenital warts of various sizes and durations were recruited in this randomized clinical trial. They were divided into three groups (A, B, and C). Each group consisted of (30) patients. Group (A) subjects received intralesional MMR injections. Group (B) subjects received intralesional BCG injection and Group (C) received intralesional candida antigen injection.

RESULTS

Full clearance of warts was observed in (73.33%, 70%, and 43.33%) in groups A, B, and C, respectively. Infrequent side effects including pain, erythema, and minimal induration were reported in all groups but did not necessitate termination of treatment.

CONCLUSION

All the three modalities used demonstrated a simple, safe modality with low adverse events, and with no recurrence. To achieve an optimal response with an ideal immunotherapeutic agent and ideal dose, further comparative studies are warranted and on different populations and larger sample sizes.

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.

Efficacy of viable BCG vaccine paste in the treatment of common warts: a double-blind randomized control trial

BACKGROUND

Treatment of common warts may be painful or leaves scars, mainly using traditional destructive methods. This study aimed to evaluate the efficacy of the viable Bacillus Calmette-Guérin (BCG) vaccine in paste formula as an immunotherapeutic modality for common warts treatment.

METHODS

This double-blind and randomized, parallel-group, placebo-controlled trial was conducted at the Ahvaz Imam Hospital Dermatology Department from November 2014 to 2015. Overall 80 patients with common warts in two groups (case and control) received BCG vaccine paste once weekly for eight consecutive weeks. Follow-up was done every two weeks during treatment and six months after the treatment to evaluate recurrence in patients with complete resolution.

RESULTS

In group A, eight patients (20%) had a complete response, 15 patients (37.5%) partial response, four patients (10%) low response, and 13 patients (32.5%) no response (p < .001). All patients in group B had no response to treatment (p < .001). After six months of follow-up, no recurrence was seen. Duration of disease less than 12 months (p = .001) and the number of lesions less than three (p = .01) were determining factors of response to treatment.

CONCLUSION

Topical BCG vaccine paste was an effective treatment for common warts, without recurrence and significant complications.

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.

Intralesional Antigen Immunotherapy in the Treatment of Periungual Warts

BACKGROUND

Intralesional immunotherapy using different types of antigens is considered an effective and safe treatment option for different types of warts. However, there are few studies that illustrate the use of these antigens in the treatment of periungual warts as a distinct type of warts.

OBJECTIVE

To evaluate the efficacy and safety of three antigens: measles, mumps, rubella (MMR) vaccine, Candida antigen, and purified protein derivative (PPD) in the treatment of periungual warts.

METHODS

The study included 150 patients who were randomly assigned to 3 groups with 50 patients in each. Each agent was injected intralesionally at a dose of 0.1 mL into the largest wart at 2-week intervals until complete clearance or for a maximum of 5 sessions.

RESULTS

Complete clearance of warts was observed in 70%, 80%, and 74% in PPD, Candida antigen, and MMR vaccine groups, respectively. There was no statistically significant difference regarding the therapeutic response between the 3 studied groups. Adverse effects were transient and insignificant in the 3 groups. No recurrence of the lesions was reported in any of the studied groups.

CONCLUSIONS

Intralesional antigen immunotherapy seems to be an effective therapeutic option for the treatment of periungual warts.

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.

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 antigen immunotherapy for the treatment of plane warts: A comparative study

Intralesional immunotherapy by different antigens has shown promising efficacy and safety in the treatment of warts. However, the use of these antigens for the treatment of plane warts has been investigated in two studies only. To evaluate the efficacy and safety of three antigens; Measles Mumps, Rubella vaccine (MMR), Candida antigen, and purified protein derivative (PPD) in the treatment of multiple plane warts. The study included 120 patients who were randomly assigned to three groups, 40 patients in each group. Each agent was injected intralesionally at a dose of 0.1 mL into the largest wart at 2-week intervals until complete clearance or for a maximum of five sessions. Complete clearance of warts was observed in 55% of the PPD group, in 70% of the Candida antigen group, and in 62.5% of the MMR group. No statistically significant difference in the therapeutic response was found between the three groups. Intralesional antigen immunotherapy seems to be a promising well-tolerated and effective therapeutic option for the treatment of multiple plane warts, with relatively higher efficacy of Candida antigen.

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.

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.

Extragenital cutaneous warts - clinical presentation, diagnosis and treatment

Extragenital cutaneous warts are benign epidermal tumors caused by human papillomaviruses (HPVs) and a frequent reason for patients to consult a dermatologist. Depending on wart type and site involved, the clinical presentation is highly varied. Given that warts represent a self-limiting condition, a wait-and-see approach may be justified. However, treatment is always indicated if the lesions become painful or give rise to psychological discomfort. Factors to be considered in this context include subjective disease burden, patient age, site affected, as well as the number and duration of lesions. Destructive treatment methods involve chemical or physical removal of diseased tissue. Nondestructive methods consist of antimitotic and antiviral agents aimed at inhibiting viral proliferation in keratinocytes. Some of the various immunotherapies available not only have localized but also systemic effects and are thus able to induce remission of warts located at any distance from the injection site. Especially patients with warts at multiple sites benefit from this form of treatment. Intralesional immunotherapy using the mumps-measles-rubella (MMR) vaccine is a particularly promising option for the treatment of recalcitrant warts in adult patients. For children, on the other hand, HPV vaccination is a novel and promising approach, even though it has not been approved for the treatment of cutaneous warts. At present, there is no universally effective treatment available. Moreover, many frequently employed therapies are currently not supported by conclusive clinical trials.

Intralesional measles-mumps-rubella is associated with a higher complete response in cutaneous warts: a systematic review and meta-analysis of randomized controlled trial including GRADE qualification

INTRODUCTION

Warts can be difficult to treat and progressing to chronic and resistant disease. Several studies have reported the successful application of mumps-measles-rubella (MMR) vaccine resulting in clearance of warts via immunomodulation and induction of immune system.

METHODS

We performed a comprehensive search on the role of intralesional MMR in warts from several electronic databases. Complete response is defined as complete clearance of warts lesion.

RESULTS

There were a total of 425 subjects from five studies. Intralesional injection of MMR was associated with an increased complete response (OR 9.43 [5.78, 15.37], p < .001; I²: 5%, p = .38). Subgroup analysis on patients receiving injection for every 2 weeks for a maximum of five injections revealed an OR of 11.70 [6.40, 21.38], p < .001; I²: 20%, p = .29. Patients receiving intralesional MMR were associated with a lower partial response (OR 0.54 [0.33, 0.88], p = .01; I²: 0%, p = .66). Intralesional MMR was associated with a reduced no-response (OR 0.16 [0.06, 0.43], p < .001; I²: 69%, p = .01). Funnel plot analysis for complete response was asymmetrical, indicating the risk of publication bias. There were statistically significant small-study effects for intralesional MMR on complete response upon analysis using Harbord's test (p = .047). Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment showed that intralesional MMR injection has high level of certainty (quality of evidence) for complete response in warts with an absolute increase of 505 per 1000.

CONCLUSION

Intralesional MMR injection was associated with a higher complete response and lower no-response with a high level of certainty.

Bacillus Calmette-Guerin Immunotherapy for Recurrent Multiple Warts: An Open-Label Uncontrolled Study

Background:

Cutaneous warts present a therapeutic challenge because of recurrence and multiplicity and may become a frustrating condition for both patients and physicians. In the past few years, there has been an increase in intralesional immunotherapy for recurrent multiple warts not only because of its encouraging results in the treatment but also due to its ability to clear distant warts and preventing recurrence.

Objective:

The objective of this study was to evaluate the efficacy and safety of intralesional bacillus Calmette–Guerin (BCG) vaccine immunotherapy in the treatment of recurrent multiple warts.

Materials and Methods:

This study included 40 adult patients with multiple recurrent extragenital warts of different sizes, numbers, and duration, with or without distant warts. Patients were injected intralesionally with 0.1 ml BCG vaccine into the largest wart at a 3-week interval, directly without a pre-sensitization skin test, until complete clearance or for a maximum of three sessions. Follow-up was done every month for 3 months to detect any recurrence.

Results:

Out of the 40 patients enrolled in the study, 34 patients completed the treatment protocol of three injections and 3 months of follow-up and six patients discontinued for various reasons. Complete clearance of the lesions was achieved in 25 (73.53%) patients, partial clearance in 8 (23.53%) patients, and no response in 1 (2.94%) patient. Complete response was demonstrated in 75% of those presenting with distant warts. Therapy-related side effects were mild in the form of pain during injection, itching, erythema at the site of injection, and flu-like symptoms. None of the patients with complete response showed recurrence of lesions in a 3-month follow-up period.

Conclusion:

Intralesional BCG immunotherapy is a safe, effective, and promising treatment modality for recurrent multiple warts.

Intralesional Vitamin D3 Injection in the Treatment of Recalcitrant Warts: A Novel Proposition

Background:

Verruca vulgaris (viral warts) is a fairly common condition with a plethora of treatment options having variable success rates. Recalcitrant warts are refractory to treatment with often disappointing response and high recurrence rates. Lately, treatment with intralesional injections has gained momentum due to its effectiveness in clearing warts by stimulating the cell-mediated immunity. Vitamin D, when applied topically, regulates epidermal cell proliferation and is involved in the formation of antimicrobial peptides. We have attempted to use vitamin D3 to exploit its reported action as an immunotherapeutic molecule in addition to its topical effects. To our knowledge, there are no reports of intralesional vitamin D3 injections used in the treatment of extragenital recalcitrant warts.

Methods:

Sixty-four patients with recalcitrant warts of varying sizes and duration were included in the study. About 0.2- to 0.5-mL vitamin D3 solution (600,000 IU, 15 mg/mL) was injected to the base of the wart. A maximum of 5 warts were injected per session at 3-week intervals until resolution or for a maximum of 4 treatments. Patients were followed up for 6 months after the last injection to detect any recurrence.

Results:

Sixty patients completed the study. Complete response was seen in 54 of 60 (90%), partial response in 4 of 60 (6.66%), and no response in 2 of 60 (3.33%). The average number of injections required to achieve a complete resolution was 3.66. Complete resolution of distant warts was noticed in all patients.

Conclusions:

Intralesional vitamin D3 is a safe, effective, and an inexpensive treatment option for recalcitrant warts.

Safety and Efficacy of Intralesional Vitamin D3 in Cutaneous Warts: An Open Uncontrolled Trial

Background:

Cutaneous warts are treated primarily with destructive methods such as cryotherapy or electrocautery. These modalities of treatment are time-consuming and may be associated with scarring in multiple warts. Immunotherapy is emerging as a new modality of treatment which acts on enhancing cell-mediated immunity against human papillomavirus for clearance of both treated and distant warts.

Aims:

This study aims to evaluate the safety and efficacy of intralesional Vitamin D3 for the treatment of cutaneous warts.

Materials and Methods:

Patients with multiple warts were selected for immunotherapy. Vitamin D3 (0.2 ml, 15 mg/ml) was injected to the base of warts after injecting with lignocaine (0.2 ml, 20 mg/ml). The injections were repeated 2 weeks apart for a maximum of 4 sessions or until complete clearance, whichever was earlier. A maximum of 2 warts were treated per session and patients were followed up for 6 months after the last injection.

Results:

Forty-two patients with multiple warts were recruited for the study who completed the 6-month follow-up period and were available for analysis. Of these, 23 had palmoplantar warts, 18 had verruca vulgaris and 1 patient had filiform wart. In total, 33 of 42 patients (78.57%) showed complete response, 6 patients (14.28%) showed moderate response and three patients (7.14%) showed mild response. Recurrence was observed in one patient with the palmoplantar wart. No serious adverse effects were reported.

Limitations:

Lack of control group was the main drawback in our study.

Conclusion:

Intralesional Vitamin D3 is safe and effective for treatment of multiple cutaneous warts.

Efficacy of intralesional immunotherapy for the treatment of warts: A review of the literature

Warts are common epidermal growths caused by human papillomavirus that often cause significant discomfort and embarrassment. Current treatment options include topical therapies, cryotherapy, laser vaporization, and surgical excision. Many of these options are destructive and may result in scarring, while less aggressive approaches can lead to lesion recurrence. Additionally, these local modalities are not practical for patients with a large number of warts. Systemic approaches such as immunotherapy have demonstrated success in treating multiple lesions by combining a targeted approach with upregulation of the host immune system. An extensive literature review was performed to evaluate the various vaccine antigens that have been used intralesionally to treat cutaneous and anogenital warts. The specific intralesional immunotherapies that have been studied include: Candida albicans; measles, mumps, and rubella; Trichophyton; and tuberculin antigens such as purified protein derivative, Mycobacterium w vaccine, and Bacillus Calmette-Guerin. Intralesional vaccine injection represents a safe, effective, and tolerable treatment for warts, including recalcitrant and anogenital warts. This approach has been somewhat overlooked in the past despite substantial evidence of high response rates with a low side effect profile. Large comparative trials are necessary to determine the most effective immunotherapy treatment option as well as the most appropriate dosing parameters.

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.

Candida albicans Immunotherapy for Verrucae Plantaris

BACKGROUND

Verrucae plantaris is a viral disease caused by human papilloma virus that is commonly seen in the office setting and is often challenging to treat owing to its high recurrence rate and recalcitrant profile. Candida albicans intralesional injections have been hypothesized to incite an immunogenic response toward the virus.

METHODS

We report on the immunotherapeutic effect of intralesional injection of C albicans into plantar verrucae with a retrospective medical record analysis of 80 patients. Using a luer-lock syringe, 0.1 to 0.3 mL of C albicans antigen was injected into either the first known lesion or the largest lesion.

RESULTS

The success rate of intralesional C albicans, defined as total clearance of the lesion, was 65%, which may be underestimated because patients lost to follow-up were included in the 35% failure rate. It was also found that female patients with a previous tissue-destructive treatment process were more than four times more likely to respond to C albicans therapy, whereas this effect was less pronounced in the male patient population.

CONCLUSIONS

These results indicate that a series of intralesional injections of C albicans is an effective and efficient method of treatment for verrucae plantaris.

Intralesional Vitamin D Injection May Be an Effective Treatment Option for Warts

Background:

Plantar warts are typically resistant to treatment. In recent years, treatments have included administration of intralesional tuberculin; measles, mumps, rubella vaccine; and Candida albicans antigen immunotherapy. To the best of our knowledge, there are no reports of intralesional vitamin D administration for the treatment of warts.

Aim:

To evaluate the efficacy and safety of intralesional vitamin D treatment for plantar warts.

Methods:

Twenty patients with single or multiple plantar warts were included in this study. Vitamin D3 (0.2 mL, 7.5 mg/mL) was injected into the base of the warts after prilocaine (0.1 mL, 20 mg/mL) injection. A maximum of 5 warts were treated in 1 session, with at maximum 2 injections performed at 4-week intervals.

Results:

In total, 16 of 20 patients (80%) showed complete resolution of warts, and 1 patient showed partial resolution. Three patients failed to show any response. No recurrence or serious adverse effects were observed.

Conclusion:

Intralesional vitamin D3 may be an effective treatment option for warts.

Advancements in Pharmacotherapy for Noncancerous Manifestations of HPV

Human papillomavirus (HPV) is the most common sexually transmitted disease. Via infection of the basal epithelial cells, HPV causes numerous malignancies and noncancerous cutaneous manifestations. Noncancerous cutaneous manifestations of HPV, including common, plantar, plane, and anogenital warts, are among the most common reasons for an office visit. Although there are various therapies available, they are notoriously difficult to treat. HPV treatments can be grouped into destructive (cantharidin, salicylic acid), virucidal (cidofovir, interferon-α), antimitotic (bleomycin, podophyllotoxin, 5-fluorouracil), immunotherapy (Candida antigen, contact allergen immunotherapy, imiquimod) or miscellaneous (trichloroacetic acid, polyphenon E). The mechanism of action, recent efficacy data, safety profile and recommended regimen for each of these treatment modalities is discussed.

Immunomodulators in warts: Unexplored or ineffective?

Cutaneous warts are known to be recurrent and often resistant to therapy. Resistant warts may reflect a localized or systemic cell mediated immune (CMI) deficiency to HPV. Many modalities of treatment are in use; most of the provider-administered therapies are destructive and cause scarring, such as cryotherapy, chemical cauterisation, curettage, electrodessication and laser removal. Most patient-applied agents like podophyllotoxin have the risk of application-site reactions and recurrence. Thus immunotherapy is a promising modality which could lead to resolution of warts without any physical changes or scarring and in addition would augment the host response against the causative agent, thereby leading to complete resolution and decreased recurrences. Immunomodulators can be administered systemically, intralesionally or intradermally, and topically. A few agents have been tried and studied extensively such as cimetidine and interferons; others are new on the horizon, such as Echinacea, green tea catechins and quadrivalent HPV vaccine, and their efficacy is yet to be completely established. Though some like levamisole have shown no efficacy as monotherapy and are now used only in combination, other more recent agents require large and long term randomized placebo-controlled trials to clearly establish their efficacy or lack of it. In this review, we focus on the immunomodulators that have been used for the treatment of warts and the studies that have been conducted on them.

Subcutaneous intralesional Ksharodaka injection: A novel treatment for the management of Warts: A case series

Warts are generally managed using cryosurgery, keratolytic ointments, curettage and electrodessication. Warts, vis-a-vis Charmakila, in Ayurvedic classical texts are classified into different types depending on the dominance of dosha. Ayurveda prescribes oral medications, topical use of Kshara (alkaline ash of herbs), Agni (thermal cautery) and Shastrakarma (surgery) for removal of Charmakila. Use of topical Kshara in the form of powder, aqueous solution i.e. Ksharodaka and Ksharasutra (thread smeared with Kshara) for warts has been reported. However, these methods necessitate multiple sittings and takea longer duration for removal of the warts. Herewith, we report a case series of different types of warts treated with intralesional infiltration of Apamarga Ksharodaka (AK), i.e. aqueous solution of Apamarga (Achyranthes aspera) Kshara. We observed that all these warts took a minimum of 2-6 days to shed off, leaving minor scars. There were no adverse reactions reported in any of these cases.