Immunomodulators in warts: Unexplored or ineffective?

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

Introduction

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

Materials and Methods

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

Results

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

Conclusion

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

Successful treatment of anogenital warts with single dose Bacillus Calmette Guerin vaccine without prior sensitization in tuberculosis endemic country: Two case report

Anogenital Warts (AGWs) are benign proliferations caused by Human Papillomavirus (HPV) infection on the genital or anal areas. Various therapeutic options are available for the treatment of AGWs but there is no best or ideal therapy, and the recurrence of AGWs is significantly high. A promising new therapy that is currently being evaluated is immunotherapy with the intralesional Bacillus Calmette-Guérin (BCG) vaccine. Two cases of a 23-year-old woman and a 41-year-old man were presented with manifestations of condyloma acuminata type AGWs. The patients were immunocompetent and received single dose intralesional BCG vaccine on the largest lesion. Clinical improvements of AGWs lesions were noted starting on the 14th day after receiving therapy by the disappearance of some lesions with no recurrence and side effects. Intralesional BCG vaccine activates the immune system, treats other AGWs lesions that do not receive an intralesional injection, and also prevents recurrence. Although the intralesional BCG vaccine is effective for treating AGWs, further evaluation is still needed for its recurrence.

Oral Cimetidine as an Adjuvant Therapy for Condyloma Acuminata

Introduction Condyloma acuminata (CA) is a sexually transmitted infection caused by the human papillomavirus (HPV), and the recurrence rate is relatively high. A compromised immune system causes CA recurrence. The primary treatment goal is to eradicate the warts; however, the immunomodulatory combination therapy might reduce the recurrence rate, so it might enhance the healing process. Cimetidine is a histamine H2-receptor antagonist which might indicate immunomodulator activity.

Aim This case report aimed to investigate the effectiveness of cimetidine as an immunomodulator agent against CA.

Clinical cases Three patients visited dermatology and venerology outpatient clinic with multiple warts located on the external genital and perianal area. The examination described there were confluent cauliflower-like nodules. Besides, acetowhite examination showed positive reactions. Two patients were HIV-positve and one was negative. The lesions showed clinical improvement in all three patients.

Conclusion Briefly, the cimetidine is effective as an immunomodulator therapy to enhance the healing process and decrease the risk of CA recurrences.

Serum Zinc Level in Patients with Severe Genital Warts: A Case-Control Study in a Dermatology Hospital

Background

Genital warts are a common sexually transmitted disease (STD), and there is no method that completely prevents its recurrence. Recently, zinc has been used in the treatment of cutaneous warts. Nondestructive action, ease of use, and promising results with low chances of relapse were reflected in the treatment. These effects may arise from the immunomodulatory activity of zinc in the event of a viral infection.

Objectives

This study was aimed at identifying the relationship between the serum zinc level and the clinical characteristics of patients with genital warts.

Materials and Methods

A case-control study was conducted. Genital warts were diagnosed by clinical examination, and disease severity was demonstrated based on the number of affected sites or the spread of lesions. The serum zinc level was measured using atomic absorption spectrophotometry.

Results

A total of 78 patients with genital warts and 78 healthy volunteers were enrolled in the study. The mean serum zinc level in the genital wart group was lower than that in the control group (81.83 ± 13.99 μg/dL vs. 86.66 ± 17.58 μg/dL); however, this difference was not statistically significant (P > 0.05). The mean concentrations of serum zinc in patients having more than one affected site, spread > 2 cm², or ten or more lesions were significantly lower than those of the control group (P < 0.05).

Conclusions

The results suggested that severe genital warts may be associated with a low serum zinc level in patients.

Effectiveness of Cimetidine as Adjuvant Therapy in the Treatment of Acute-Extrinsic Atopic Dermatitis: A Double-Blind Randomized Controlled Trial

Introduction

Acute extrinsic atopic dermatitis (AD) requires long-term treatment. Cimetidine could be used as an adjuvant therapy for acute-extrinsic AD due to immunomodulatory effects. This study aims to assess the effectiveness of cimetidine as an adjuvant to standard treatment in acute extrinsic AD.

Methods

This is a double-blind randomized controlled trial involving 26 AD patients aged 12–60 years from 2017 to 2020. Effectiveness of cimetidine was assessed by comparing SCORing Atopic Dermatitis (SCORAD) and objective SCORAD changes in both groups at week 2, 4, 6, and 8. Serum levels of immunoglobulin E (IgE), interferon (IFN)-γ, interleukin (IL)-12, and IL-4 were also documented.

Results

Significant differences were observed in SCORAD changes at week 2, 4, 6, and 8 (p = 0.004; p = 0.001; p < 0.001; and p < 0.001 respectively), objective SCORAD changes at week 2, 4, 6, and 8 (p = 0.004, p = 0.001, p < 0.001, and p < 0.001 respectively), and IgE level changes at week 8 (p = 0.002) between the two groups. However, there were no significant changes in IFN-γ, IL-12, and IL-4 levels between the two groups.

Conclusion

Cimetidine is a safe and effective adjuvant therapy for acute-extrinsic AD.

Trial Registration

NCT04018131.

Intralesional Agents in Dermatology: Pros and Cons

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

Predictors of the Therapeutic Response to Intralesional Bivalent HPV Vaccine in Wart Immunotherapy

Variable intralesional immunotherapies have recently been proposed as a means of achieving a successful eradication of recurrent and recalcitrant human papillomavirus (HPV)-induced cutaneous and anogenital warts. The bivalent HPV vaccine is one of the newly proposed immunotherapeutic agents. We investigated the role of interleukin-4 (IL-4) and interferon-gamma (IFN-γ) as ex vivo immunologic predictors to estimate the response to the bivalent HPV vaccine as a potential immunotherapy for cutaneous and anogenital warts. Heparinized blood samples were withdrawn from forty patients with multiple recurrent recalcitrant cutaneous and anogenital warts and forty matched healthy control subjects. Whole blood cultures were prepared with and without bivalent HPV vaccine stimulation. Culture supernatants were harvested and stored for IL-4 and IFN-γ measurements using an enzyme-linked immunosorbent assay. A comparative analysis of IL-4 and IFN-γ levels in culture supernatants revealed a non-significant change between the patient and control groups. The bivalent HPV vaccine stimulated cultures exhibited a non-significant reduction in IL-4 levels within both groups. IFN-γ was markedly induced in both groups in response to bivalent HPV vaccine stimulation. The bivalent HPV vaccine can give a sensitive IFN-γ immune response ex vivo, superior to IL-4 and sufficient to predict both the successful eradication of HPV infection and the ultimate clearance of cutaneous and anogenital warts when the bivalent HPV vaccine immunotherapy is applied.

Cidofovir Intralesional Injection for Recalcitrant Common Warts: A Comparison with Sodium Tetradecyl Sulfate Intralesional Injection

Background

A novel treatment method is required for recalcitrant common warts.

Objective

This study aimed to compare the complete wart removal rate of cidofovir, a broad-spectrum antiviral agent, intralesional injection and sodium tetradecyl sulfate intralesional injection.

Methods

This retrospective study included 45 patients with recalcitrant common warts on the hands and/or feet, treated with cidofovir or sodium tetradecyl sulfate intralesional injection.

Results

The treatment results were evaluated in three groups as follows: (1) failure - recalcitrant common warts remaining despite three or more injections, (2) success - free from warts for more than 6 months after the injection, and (3) recurrence. The cidofovir group (n=22) showed significantly higher treatment success rates than the sodium tetradecyl sulfate group (n=23) (90.91% vs. 26.09%, p<0.001). Two immunosuppressed patients in the cidofovir group had recurrent lesions after 2 months of being declared free from warts. Considering adverse effects, two patients in the cidofovir group complained of bulla formation with severe pain requiring narcotic painkillers.

Conclusion

Although this study has the limitations of a small sample size and retrospective design, patients with recalcitrant common warts showed a dramatic response to the treatment with cidofovir intralesional injection, with minimal complications.

Update on human papillomavirus - Part II: complementary diagnosis, treatment and prophylaxis

In this nonsystematic review, the complementary diagnosis, treatment, prevention, and control of human papillomavirus are discussed. The histopathology is addressed regarding its indications, main findings and limitations, as a complementary diagnostic method largely used by dermatologists. Electron microscopy is briefly reviewed, along with its contribution to the accumulated knowledge on HPV, as well as the relevance of research in using this technology for future advances in diagnosis and treatment. Molecular information about the virus is continuously increasing, and the practical applications of HPV serology, molecular identification and genotyping are discussed. Vaccines are a valuable tool in primary HPV infection prevention and are now available in many countries; their composition, indications, and adverse effects are revisited. Local and systemic treatment options are reviewed and off-label prescriptions are discussed. Finally, health education focusing on HPV infection as a sexually transmitted infection of worldwide relevance and the many barriers to improve primary and secondary prevention are addressed.

Estimating the Impact of Extragenital Warts versus Genital Warts on Quality of Life in Immunocompetent Indian Adult Patients: A Comparative Cross-Sectional Study

Background:

Extra-genital warts (EGWs) affect 7-10% of population. Even though a plethora of studies have been conducted to assess the impact of genital warts (GWs) showing a significant impact on the quality of life but surprisingly, barely any data has been collected on the impact of EGWs on quality of life.

Aims and Objective:

This cross-sectional study aimed at comparing the magnitude of EGWs on health-related quality of life and various variables with that of GWs.

Patients and Methods:

The study consisted of two groups of immunocompetent adults, each with 100 patients aged 18 years or above, attending the skin outpatient department at our tertiary center between April 2018 and March 2019 and consented to participate. Group A consisted of patients with EGWs and group B comprised of patients with GWs. All patients were asked to fulfill the validated Hindi hard copy of the Dermatology Life Quality Index (DLQI) questionnaire.

Results:

The mean DLQI score of patients with EGWs was 8.73 ± 0.84 and that of patients with GWs was 5.83 ± 0.83 (P = 0.026). In group A, those affected the most were patients with warts on multiple exposed sites (mean DLQI score of 14), followed by warts on feet (mean DLQI score of 10.69), followed by warts on hands (DLQI score of 9.12), and facial warts (DLQI score of 6.80). Patients with a prior history of failed treatment and/or a longer duration of illness had a higher level of dissatisfaction. To the best of our knowledge, no such study has been conducted in the past in our country.

Conclusions:

EGWs inflict a severe negative impact on the quality of life. Owing to its notorious persistence and recurrence, healthcare professionals must educate patients on how to prevent the spread and recurrence, discuss details of available treatment modalities while keeping in view the psychological and sociological impact.

Intralesional Immunotherapy with Measles Mumps Rubella Vaccine for the Treatment of Anogenital Warts: An Open-label Study

INTRODUCTION: Anogenital warts (AGWs) are one of the leading sexually transmitted infections in the world. This condition poses a number of challenges to dermatologists, including the reluctance of patients to consult a physician and the high likelihood of relapse. Individuals with AGWs suffer a substantial psychological morbidity. Intralesional immunotherapy with the measles, mumps, and rubella (MMR) vaccine has been reported to be an effective treatment for warts. However, literature on the efficacy of intralesional immunotherapy with the MMR vaccine for the treatment of anogenital warts is sparse. OBJECTIVE: We sought to determine the efficacy of the MMR vaccine for the treatment of anogenital warts at an outpatient dermatology department in Government Medical College Haldwani in India. METHODS: This was a hospital-based, longitudinal study the included 35 patients. In patients with genital warts, 0.5mL of the MMR vaccine after reconstitution with distilled water was injected intradermally into their single largest wart. Injections were given every three weeks until a maximum of three injections was achieved. Pre- and posttreatment photographs were assessed to compare the degree of reduction in the size and number of warts. The therapeutic response was evaluated as follows: No response (<50% reduction in the number of warts), Relative response (50%-99% reduction), complete response (100% reduction). RESULTS: On average, a 42.4-percent response was observed in the first three weeks after administering the MMR vaccine, which increased to 75.8 percent after the second vaccine at six weeks and nearly 98 percent after the last vaccine at nine weeks. CONCLUSION: Our results suggest that intralesional immunotherapy with the MMR vaccine can serve as a safe and effective therapy for the treatment of AGWs.

Smoking: Is it a Risk Factor for Common Warts?

Introduction: Common warts are one of the most prevalent infections affecting the skin. Common warts are caused by human papillomaviruses (HPV), which are ubiquitous in our environment. Most HPV infections are directly controlled and cleared by host immune system, although each case has the potential to persist and transform into a recalcitrant form. It is not exactly clear why certain populations are more susceptible to common warts. Aim: To investigate factors affecting the occurence and outcome of common warts. Material and methods: A total of 188 consecutive patients with common warts (106 men, 82 women) and 188 controls were prospectively enrolled. Demographic and clinical characteristics were recorded. The Chi-square, Mann-Whitney U and Kruskal-Wallis tests were used for statistical analysis, with a significance threshold of p<0.05. Results: There were not any significant associations between cigarette smoking, alcohol consumption, accompanying diseases, medications, family history of warts and the duration of warts (p=0.102, p=0.317, p=0.535, p=0.535, p=0.535, respectively). There were not any significant associations between cigarette smoking, alcohol consumption, accompanying diseases, medications, family history of warts and the number of warts (p=0.232, p=0.762, p=0.389, p=0.389, p=0.824, respectively). Conclusions: Our study has revealed that smoking is not a risk factor for common warts. However, we suspect the lack of statistical differences are likely due to small sample size of the study. Further studies with larger sample sizes are needed.

Recent patents in anti-wart treatment

Warts, small skin protuberances caused by human papillomavirus, are not life-threatening, but can be unsightly, embarrassing, uncomfortable and potentially contagious. They may regress naturally but over a prolonged time. Hence wart-afflicted people seek prescribed or over-the-counter therapies. Out of the innumerable marketable anti-wart medications, only a few are effective. Besides, frequent applications over months and certain undesirable side effects limit their success rates. Recurrences are also known. Hence the search for an effective, safe, cheap and quick medicine that is easy to apply continues. A number of patents for anti-wart therapies have been filed in the last few years. In this article, we enlist the recent anti-wart patents and find out those holding promise in the future.

Efficacy of fulguration combined with imiquimod cream on condyloma acuminatum, and the effect on immune functions and serums levels of IL-2 and IL-10

The objective of the present study was to investigate the clinical efficacy of high-frequency fulguration combined with 5% imiquimod cream for condyloma acuminatum (CA), and the effect on T cell immune function and serum levels of interleukin (IL)-2 and IL-10. We enrolled 112 patients with CA between January 2014 and January 2016. Patients were randomly divided into the control group (n=56) and observation group (n=56). The control group received high-frequency fulguration combined with intramuscular injection of Bacillus Calmette-Guérin polysaccharide nucleic acid, and the observation group received high-frequency fulguration combined with external application of 5% imiquimod cream. In both groups, the course of treatment lasted for 12 weeks, and the follow-up period was 6 months. Clinical efficacy was compared between the groups. The total effective rate in the observation group was higher than that in the control group (p<0.05), but no significant differences were identified in comparisons of effectiveness and recurrence rate between the two groups (p>0.05). After treatment, the levels of CD3⁺ and CD4⁺ cells, and CD4⁺/CD8⁺ ratio in both groups were increased compared with those before treatment (p<0.05), while no significant difference was identified in comparison of the levels of CD8⁺ cells in both groups before and after treatment (p>0.05); in both groups before and after treatment, there was no significant difference in the comparison of T cells (p>0.05). After treatment in both groups, the serum levels of IL-2 were increased, and the levels of IL-10 were decreased compared with those before treatment; the improvement in the observation group was superior to that in the control group (p<0.05). In conclusion, good efficacy can be achieved with the combined treatment of high-frequency fulguration and 5% imiquimod cream for CA, which is correlated with enhanced immune functions of T cells, and improvements in the serum levels of IL-2 and IL-10.

Human papillomavirus (HPV): systemic treatment with Gene-Eden-VIR/Novirin safely and effectively clears virus

PURPOSE

This paper reports the results of a clinical study that tested the effect of systemic treatment with the botanical product Gene-Eden-VIR/Novirin on the clearance rate (also called time to clearance) of the human papillomavirus (HPV). The study compared the clearance rate in treated and untreated individuals suffering from a symptomatic HPV infection. The data on the untreated individuals were obtained by reverse engineering of the Kaplan-Meier figures in five published papers.

MATERIALS AND METHODS

The study included 59 treated participants. All participants were suffering from a symptomatic HPV infection prior to the commencement of treatment. The treatment was one to four capsules of Gene-Eden-VIR/Novirin per day. The duration of treatment was 2-12 months. The study included five groups of external controls with diverse characteristics.

RESULTS

The mean time to clearance in Gene-Eden-VIR/Novirin-treated individuals was 5.1 months or 151.5 days (95% CI: 4.2-5.9 months or 95% CI: 125.7-177.3 days, respectively). The median time to clearance was 3.5 months. The mean time to clearance in the five untreated groups ranged from 6.9 to 20.0 months (P<0.0001 for the difference between treatment group and each untreated group). Also, 100% of the participants in the treatment group were HPV free at the end of 12 months vs 53%, 52%, 65%, 20%, and 77% in the untreated control groups. The treated participants reported no adverse experiences.

CONCLUSION

This clinical study has two major contributions. First, it showed that systemic treatment with the natural Gene-Eden-VIR/Novirin decreased the time to HPV clearance, increased the percentage of HPV-free individuals, and caused no adverse experiences in individuals suffering from a symptomatic HPV infection. Since there are no other systemic treatments for symptomatic HPV infections, this study presents highly valuable information on the clinical effects of the first treatment in this category. Second, the study presents a new method for conducting clinical studies that addresses one of the major deficiencies associated with the practice of the randomized controlled trial method.