A Two-week Interval Is Better Than a Three-week Interval for Reducing the Recurrence Rate of Hand-foot Viral Warts after Cryotherapy: A Retrospective Review of 560 Hand-foot Viral Warts Patients

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

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

A Dermoscopic Study of Cutaneous Warts and Its Utility in Monitoring Real-Time Wart Destruction by Radiofrequency Ablation

Context:

Cutaneous warts can affect up to 7–12% of the general population. Usually diagnosed clinically, there may be diagnostic dilemmas in atypical presentations or immunocompromised patients. Radiofrequency ablation is a common method of treatment of warts, but recurrences occur due to incomplete removal. Dermoscopy has been used in the diagnosis of various infectious dermatoses including warts.

Aims:

The study aimed to assess dermoscopic features of various types of viral warts and its efficacy in monitoring the treatment response following radiofrequency ablation.

Settings and Design:

Prospective non-comparative descriptive study in a tertiary care centre.

Subjects and Methods:

A prospective study was conducted comprising 60 patients with clinically diagnosed, previously untreated warts, including common warts, plane warts, palmar and plantar warts. Dermoscopic features of a representative lesion were evaluated in terms of definition, background color, vascularity, surrounding halo, dermatoglyphics, and presence of hemorrhage or crust. It was done at baseline and immediately after radiofrequency ablation of the wart to observe for complete removal of wart.

Results:

Most common dermoscopic features observed were presence of papillae surrounding haloes (61.67%), vascularity (dots>globules>linear vessels>loops; 58.33%), interrupted skin lines (51.67%), and brown colored background (48.3%). Nine cases (15%) demonstrated incomplete removal of the wart that was not visible with the naked eye and picked up only on dermoscopy. On follow up, at 6 months there were four recurrences (6.67%).

Conclusion:

Dermoscopy shows consistent features in the examination of warts. This can be a quick clinical aid in distinguishing it from close differentials. It is also valuable in reviewing the lesion real time after any ablative procedure to check if it has been removed in its entirety.

Study of BCG Immunotherapy in the Management of Multiple, Extensive Non-Genital Cutaneous Common Warts

Background and Aims:

Most of the available treatment therapeutic modalities for warts are aimed at destruction of virus. However, despite adequate treatment, the virus may persist in the surrounding tissues leading to recurrence. Owing to side effects such as pain, scarring, and risk of secondary infection, these modalities may not be suitable for multiple lesions, extensive involvement and for the treatment of warts in the paediatric age group. The aim of the study was to evaluate the efficacy and safety of intra lesional BCG vaccine in the management of patients with multiple extensive non-genital common warts.

Methods:

Thirty patients with multiple, extensive non-genital cutaneous common warts, with age ranging from 6 to 60 years who were not on any treatment for warts and did not have any active infections (including HIV) or past history of tuberculosis attending the department of dermatology of our hospital in a 2-year period were included. Mantoux test was performed in all patients and positive responders were taken up for study. BCG vaccine was administered into the largest wart intradermally and the injection was repeated every 3 weeks for a maximum of five injections or till the complete clearance of warts, whichever was earlier . The efficacy was assessed every 3 weeks and a final assessment was done at the end of the 12^th week. Patients were followed up for another 6 months.

Observations:

Majority of patients were in the age group of 5-14 years. Males (63.3%) were afflicted more than females. Most patients (63.3%) exhibited partial response at the site of injected wart at the end of one month and 70% patients showed complete clearance at the end of 3 months and 36.6% responded with 3 injections and 26.6% patients required 4 for response followed 23.3% requiring 5 injections.

Conclusion:

Intralesional immunotherapy using by BCG vaccine appears to be is a promising treatment modality for the treatment of warts, particularly the multiple and recalcitrant ones. The advantages include the resolution of both the injected and distant warts with negligible recurrence and with minimal side effects.

The Bacillus Calmette-Guérin (BCG) Vaccine: Is it a better choice for the treatment of viral warts?

Objectives

This study aimed to compare the effectiveness of the bacillus Calmette-Guérin (BCG) vaccine with topical salicylic acid (SA) in the treatment of viral warts.

Methods

This non-randomised controlled trial was conducted at the Al-Sader Teaching Hospital, Basrah, Iraq, from January 2016 to April 2017. A total of 201 patients with viral warts were injected with an intradermal purified protein derivative. Subsequently, those with negative tuberculin test results received an intradermal BCG vaccination, while those with positive results underwent conventional treatment with topical SA. Patients were assessed for any signs of improvement at one, two and three months.

Results

Overall, 190 patients completed the trial; of these, 133 (70%) received the BCG vaccine and 57 (30%) were treated with topical SA. Complete response to treatment was observed in 9.8% and 5.3% of patients in the BCG and SA groups, respectively (P <0.001). Cure rates were significantly higher for patients with genital (22.2% versus 7.7%; P = 0.002) and common warts (8.5% versus 0%; P = 0.001) treated with the BCG vaccine; however, the reverse was true for flat warts (12.9% versus 25%; P = 0.041). A binary logistic regression analysis indicated that BCG therapy was the only significant independent predictor of positive treatment response (odds ratio: 7.56, 95% confidence interval: 3.72-15.36; P <0.001).

Conclusion

The BCG vaccine was more effective than topical SA for treating viral warts, with the best response noted in the treatment of genital warts, followed by flat warts. However, plantar warts demonstrated least response to this treatment.

Comparison of the Efficacy and Safety of Two Cryotherapy Protocols in the Treatment of Common Viral Warts: A Prospective Observational Study

Background

Cryotherapy (freezing by liquid nitrogen) is an effective and widely used method for treatment of common warts. Patients often need multiple sessions at variable intervals. Protocols used by different dermatologists vary in terms of freezing time, the number of cycles, and the intervals between sessions.

Aim

To compare the efficacy (cure rates) and safety (complications, early and late) of two cryotherapy treatment protocols for common viral warts.

Method

A prospective observational study was conducted; it involved 80 patients with common warts on the hands and feet who were treated with cryotherapy done by two dermatologists who use different protocols; group 1 (45 patients) were treated by a single cycle of 10 seconds of freezing at 2 weekly intervals, and group 2 (35 patients) received a single cycle of 20 seconds of freezing at 4-weeks intervals. The two protocols were compared in terms of cure rate and complications 1-2 months after the final treatment. Recurrence rate and late complications were assessed at 9-12 months after the final treatment.

Results

Group 1 patients achieved higher cure rate than group 2, 77.8% and 54.3%, respectively (P=0.001). Early (blistering) and late complications (dyspigmentation and scarring) were comparable in both groups. Pain score associated with protocol 1 (5.2/10) was less than protocol 2 (6.4/10) (P=0.004). Recurrence rate (17%) was comparable in both groups. Association between cure rate and duration of warts (P=0.022) and also association between cure rate and the mean number of warts (P=0.001) were demonstrated.

Conclusions

Cryotherapy is an effective and safe treatment for common viral warts of hands and feet. The impact of shorter intervals on cure rate was more significant than increasing freezing time with longer intervals between freezing sessions. The study was approved by the local IRB committee (285-2018).

Real-life treatment of cutaneous warts with cantharidin podophyllin salicylic acid solution

Patients often request treatment of their burdensome cutaneous warts. However, a safe and effective treatment for cutaneous warts is lacking. This study evaluates treatment outcome, side effects, and patient satisfaction after topical application of cantharidin 1% podophyllin 2% salicylic acid 30% (CPS1) solution in a large series of children and adults with cutaneous warts. Fifty‐two children and 83 adults with warts, treated with CPS1 solution between October 2012 and October 2014, were included. Complete clearance of warts occurred in 86.5% of children and 62.7% of adults treated with CPS1 solution (p < .01). Resolution of warts was partial in 3.9 and 24.1% and absent in 9.6 and 13.2% of children and adults respectively. Side effects were present in 41.2% of children and 46.3% of adults (p = .7). Most common side effects were blistering, pain, and burning sensation. No serious adverse events occurred. On a 10‐point scale, median patient satisfaction score was 9.0 (interquartile range 7.8–10.0) and 8.0 (interquartile range 5.1–9.7) for children and adults respectively (p < .01). CPS1 solution is a safe and promising treatment modality with a high clearance and high patient satisfaction rate for the management of cutaneous warts, particularly in children.

Histopathology of pseudoxanthoma elasticum and related disorders: histological hallmarks and diagnostic clues

Among ectopic mineralization disorders, pseudoxanthoma elasticum (PXE)-a rare genodermatosis associated with ocular and cardiovascular manifestations-is considered a paradigm disease. The symptoms of PXE are the result of mineralization and fragmentation of elastic fibers, the exact pathophysiology of which is incompletely understood. Though molecular analysis of the causal gene, ABCC6, has a high mutation uptake, a skin biopsy has until now been considered the golden standard to confirm the clinical diagnosis. Although the histological hallmarks of PXE are rather specific, several other diseases-particularly those affecting the skin-can present with clinical and/or histological characteristics identical to or highly resemblant of PXE. In this paper, we will summarize the histopathological features of PXE together with those of disorders that are most frequently considered in the differential diagnosis of PXE.

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

BACKGROUND

Plantar warts (verrucae) are extremely common. Although many will spontaneously disappear without treatment, treatment may be sought for a variety of reasons such as discomfort. There are a number of different treatments for cutaneous warts, with salicylic acid and cryotherapy using liquid nitrogen being two of the most common forms of treatment. To date, no full economic evaluation of either salicylic acid or cryotherapy has been conducted based on the use of primary data in a pragmatic setting. This paper describes the cost-effectiveness analysis which was conducted alongside a pragmatic multicentre, randomised trial evaluating the clinical effectiveness of cryotherapy versus 50% salicylic acid of the treatment of plantar warts.

METHODS

A cost-effectiveness analysis was undertaken alongside a pragmatic multicentre, randomised controlled trial assessing the clinical effectiveness of 50% salicylic acid and cryotherapy using liquid nitrogen at 12 weeks after randomisation of patients. Cost-effectiveness outcomes were expressed as the additional cost required to completely cure the plantar warts of one additional patient. A NHS perspective was taken for the analysis.

RESULTS

Cryotherapy costs on average £101.17 (bias corrected and accelerated (BCA) 95% CI: 85.09-117.26) more per participant over the 12 week time-frame, while there is no additional benefit, in terms of proportion of patients healed compared with salicylic acid.

CONCLUSIONS

Cryotherapy is more costly and no more effective than salicylic acid.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN18994246 [controlled-trials.com] and National Research Register N0484189151.