Miscellaneous Therapies for the treatment of

ANO-GENITAL WARTS

 

 

 

 

Table of Contents:

 

 

 

Cryotherapy

 

 

Cryotherapy also called as Cryosurgery - works by destroying tissue by freezing. Tissue injury results from intra-cellular and extracellular formation of ice, disruption of cell membranes, and circulatory changes in the skin caused by freezing and thawing. Critical factors influencing cellular necrosis are rate of freezing, temperature, duration of freezing, and rate of thawing.

Cryotherapy is the freezing of Anal / peri-anal / ano-genital warts using very low temperature. The low temperature is achieve by a cryo gun or liquid nitrogen. Various handheld devices or cryotherapy machines are used for the procedure.  This treatment option can be repeated weekly, biweekly or every 3 weeks and is a relatively simple technique, requiring minimal training. However, it requires many clinic visits and a second or third cycle of freezing may be needed. Clearance rates of 46–96% have been reported although treatment can cause pain, necrosis and blistering. Post‐inflammatory hypo/hyperpigmentation after treatment with cryotherapy can occur, as the ultra-low temperature destroys the (melanocytes) melanin pigment producing cells.


In general, a rapid freeze of tissue to at least -20oC followed by a slow thaw will destroy the tissue of benign lesions. For malignant lesions, tissue needs to be frozen to -50oC to kill the cells1. Critical factors influencing cellular necrosis are rate of freezing, temperature, duration of freezing, and rate of thawing.

Technique - The freezing unit is applied to the skin lesion, freezing begins immediately and can be observed as a whitish discoloration of the skin that spreads peripherally from the point of contact and is known as the lateral spread of freeze. Extent of freezing is estimated by the lateral spread of freeze, which closely approximates depth of freeze. Depth of freeze can be increased by applying pressure on the skin with either a cryoprobe. If liquid nitrogen spray is used, depth of freeze can be increased by prolonging duration of freeze. Successful treatment depends on the lesion's being included in the lethal freeze zone. For this reason, the lateral spread of freeze should extend at least 2 mm beyond the margins of benign lesions and 5mm beyond the margins of malignant lesions1. repeat freeze-thaw cycle, will increase tissue destruction. A slow thaw increases the degree of tissue destruction; frozen tissue should be allowed to thaw gradually at room temperature and should never be warmed artificially.

 The cryosurgery can be of two types - direct cryogens using carbon dixode ice or liquid nitrogen or by cryotherapy machines using nitrous oxide or carbon dioxide as cryogens.

 

Cryotherapy -20 C tempe freezes and destroys lesions Applied directly to lesions; repeat for two or three cycles. No anaesthesia required

  90%

(Range: 46-96%)

40%

(Range: 18-39%)

Rapid results

Minimal training

High recurrence rate

Pain, necrosis, hypopigmentation

 

Treatment and technique

The cryogens most commonly used are nitrous oxide,  Argon, carbon dioxide, liquid nitrogen, liquid carbondioxide etc.

Cryosurgical units - use cryogens like Nitrous oxide gas / carbon dioxide gas or argon which are sprayed through a special apparatus to produce cooling. . 

Direct application cryogens - The cryogens like liquid nitrogen, liquid carbon dioxide (dry ice) are directly applied to the lesion to create extreme temperatures to destroy the tissue.

 

Cryosurgical Units

These units operate by the Joulc-Thomson effect. This method o f refrigeration results from the principle or the expansion of
the gas through a small opening. Pressurized nitrous oxide advances down the narrow cryogun barrel. When it reaches the hollow cryoprobc tip, the gas rapidly expands, lowering it to a temperature below freezing. Although the cryo-probe tip visibly cools with unit activation, the tip must actually be considered a heat sink. As the tip removes heat from the tissue, the tissue gradually cools. The size, material, composition, and temperature of the probe’s tip determine its capacity' as a heat sink. Other factors, such as tissue moistness, extent of tissue contact, the duration of freeze, and pressure exerted on the probe, affect heat diffusion.

The extent of cryonecrosis is influenced by the speed at which tissue freezes and thaws. A rapid freeze and a slow thaw maximize results. A freeze-thaw-freeze treatment cycle is also more effective than a single freeze technique.

Cryo - gun


Nitrous oxide


Freezing with nitrous oxide is accomplished with a cryo-gun attached to a nitrous oxide tank. The gas circulates through the gun to a metal probe where rapid expansion of the gas reduces the temperature of the probe to approximately -65oC to -85oC. The probe is applied to the skin lesion through a water-soluble lubricant and held there for an appropriate time. The gas flows continuously to the probe tip while the gun trigger is activated. Thawing begins as soon as the nitrous oxide stops flowing. Nitrous oxide freezing requires longer freeze times because of the higher temperatures and, as a result, there is less likelihood of excessive tissue destruction. It is easy to control freeze times accurately, and a variety of metal probes are available, which means cryoguns can be adapted for treating a variety of lesions. For example, they are often used for gynecologic cryosurgery.
The initial cost of these units is fairly high. The nitrous oxide tanks last a long time, however, and cryogen is not wasted as it might be with liquid nitrogen.

 

Effects of Cryotherapy / cryosurgery on tissues

Celluar Injury - The cell injury that occurs after freezing is thought to result from a high solute concentration causing cell dehydration. Intracellular ice formation causing intra-cellular organelle and cell membrane disruption has also been implicated. It is known that slow thawing allows solute effects and maximum ice growth during recrystallization to take place. Because solute effects and ice growth are deleterious to cells, complete thawing before the start of another cycle is important in determining the success of cryosurgery for oncological conditions. However, rapid cooling followed by rapid thawing can also be beneficial. During rapid cooling, the ice crystals tend to be small, with high surface energies. The longer the time of thawing, the easier it is for the ice to recrystallize, especially for crystals with high surface energies. The larger ice crystals can be more destructive than the smaller ones, because of the size of the crystals or the forces generated during recrystallization. The hold time – the duration of time the tissue is in the frozen state – is also an important factor in determining the degree of cryoinjury. Another mechanism of direct cell injury is membrane destabilization during freezing and thawing 

Immunological Injury - Another theory is that freezing may stimulate immunological injury. It is believed that the immune system becomes sensitized to the destroyed frozen tissue, and any tissue left behind is attacked by the host’s own immune system after cryosurgery. MECHANISMS OF IMMUNOLOGICAL INJURY - The first theory is the production of antitumour antibodies. When the tumour cells die, the antigens inside the cells are released onto the membrane and phagocytosed by antigen-presenting cells. B cells with antibodies specific for the antigen are stimulated and transformed into plasma cells. Antibody formation induces complement fixation, leading to neutrophil and macrophage chemotaxis. These cells release free radicals and enzymes, which kill tumour cells left behind. The second mechanism of immunological involvement is through the induction of cytotoxic T cells. Normally, intracellular antigens are transferred to the cell membrane and recognized by cytotoxic T cells, which release enzymes and kill the cells. It was proposed that cryosurgery may sensitize the cytotoxic T cells or change the antigen presentation. The third possible mechanism is that cryosurgery may stimulate the activity of natural killer cells 2.

Vascular Injury - It has been theorized that freezing involves vascular injury. The hypothesis is that freezing results in stasis of blood flow, particularly in the capillaries. The resulting ischemia leads to tissue  necrosis.

 


Complications of cryosurgery

In general, cryosurgery is very safe, but some complications do occur.  Cryosurgery is contra-indicated  for patients with cryoglobulinemia, Raynaud's phenomenon, immunosuppression, myeloproliferative disorders such as multiple myeloma, cold intolerance, and various blood dyscrasias.


Severe reaction and tissue destruction following cryosurgery are more likely with lesions on thin skin or skin previously damaged by radiation or sun exposure, with skin lesions over bony prominences, and in patients with impaired vascular supply (such as elderly people).

A short period of moderately intense pain with the freeze and during thawing is followed almost immediately by redness and swelling that might last several hours. Blistering, which often occurs within a few hours of treatment, might be both hemorrhagic and alarmingly large. Blisters tend to dry within 72 hours, and a crust forms. The crust gradually separates over 7 to 14 days.  There can be possibility of  potential hair loss, hypopigmentation, and scarring. steroid ointment can greatly reduce pain and swelling.

 

 

References

1. Wetmore SJ. Cryosurgery for common skin lesions. Treatment in family physicians' offices. Can Fam Physician. 1999;45:964-974. 

2. Yiu WK, Basco MT, Aruny JE, Cheng SW, Sumpio BE. Cryosurgery: A review. Int J Angiol. 2007 Spring;16(1):1-6. doi: 10.1055/s-0031-1278235.

3. Ferris DG, Ho JJ. Cryosurgical equipment: a critical review. J Fam Pract. 1992;35(2):185-193

4. Mahmoudi H, Ghodsi SZ, Tavakolpour S, Daneshpazhooh M. Cryotherapy plus oral zinc sulfate versus cryotherapy plus placebo to treat common warts: A double blind, randomized, placebo-controlled trial. Int J Womens Dermatol. 2017 Oct 20;4(2):87-90. doi: 10.1016/j.ijwd.2017.09.004. PMID: 29872682; PMCID: PMC5986231.

5. Goel R, Anderson K, Slaton J, et al. Adjuvant approaches to enhance cryosurgery. J Biomech Eng. 2009;131(7):074003. doi:10.1115/1.3156804

6. Cooper SM, Dawber RP. The history of cryosurgery. J R Soc Med. 2001 Apr;94(4):196-201.

 

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Thuja (Homeopathic remedy)

 

Thuja is a tree (Thuja occidentalis Linn. of the family cupressaceae) is cultivated as an ornamental tree, being known as the “tree of life” or “white cedar”. The first mention of Thuja Occidentalis was first reported in 1891 in English literature1. The leaves and leaf oil have been traditionally used as medicine. Thuja occidentalis tree also called as Cedar tree (देवदार का पेड़) or Devadaar ka ped in Hindi. Cedar tree oil extract from leaves is used for treatment of the warts in Homeopathic medicines. It has immuno-modulator properties. The mother tincture of T. occidentalis (ethanolic extract made from fresh leaves) is used in homeopathy against a number of diseases including viral warts. The leaves & twigs on steam distillation yield 0.6 to 1.0% camphor like essential oil called oil of thuja or white cedar leaf oil, easily soluble in alcohol3. Homeopathy uses thuja as one of the main remedies for the proliferation or pathological vegetation (Warts)3.  
 
Thuja occidentalis extract has varied range of pharmacological activities, such as antioxidant activity,  anti-inflammatory, antibacterial, antifungal, antitumoral, antidiabetic, hypolipidemic, antiatherosclerotic, gastroprotective, antiviral, immunostimulant, radioprotector and sedative 2. Its antimicrobial effect is thought to be due to the high concentration of α- and β-thujone2.
 
Symptoms of intoxication from the fresh Thuja plant include vomiting, stomach ache, diarrhea and gastroenteritis followed by absorption disorders, headache, nervous agitation and chronic convulsions, and symptoms of liver and renal toxicity extending to yellow liver atrophy, arrhythmia and myocardial bleeding. In cases of overdose and abuse, the oral intake of Thuja extracts induced severe metabolic disturbances. Intoxication was accompanied by an irritant effect on the gastrointestinal tract, uterus, liver and kidney. These reactions can be explained by the high contents of thujone in the fresh plant. an oral dose of up to 1.25 mg thujone/kg BW is considered harmless in humans 4.
 
Though some research shows that the effect of homeopathic treatment is equal to the placebo effect5,6,7.

 

References
1. Thuja Occidentalis. Hospital (Lond 1886). 1891 Jul 25;10(252):203. PMID: 29834711; PMCID: PMC5258536.
 
2. Caruntu S, Ciceu A, Olah NK, Don I, Hermenean A, Cotoraci C. Thuja occidentalis L. (Cupressaceae): Ethnobotany, Phytochemistry and Biological Activity. Molecules. 2020 Nov 19;25(22):5416.
 
3. Rajatrashmi, Sarkar M, Vikramaditya. Pharmacognostic Studies of Thuja Occidentalis Linn. - A Good remedy for warts & tumours, used in Homeopathy. Anc Sci Life. 1999 Jul;19(1-2):52-8. PMID: 22556920; PMCID: PMC3336456.
 
4. Naser B, Bodinet C, Tegtmeier M, Lindequist U. Thuja occidentalis (Arbor vitae): A Review of its Pharmaceutical, Pharmacological and Clinical Properties. Evid Based Complement Alternat Med. 2005 Mar;2(1):69-78. doi: 10.1093/ecam/neh065. Epub 2005 Feb 9. PMID: 15841280; PMCID: PMC1062158.
 
5. Labrecque M, Audet D, Latulippe LG, Drouin J. Homeopathic treatment of plantar warts. CMAJ. 1992 May 15;146(10):1749-53.
 
6. Gerring D. Homeopathy treats people, not the soles of their feet. CMAJ. 1992 Nov 15;147(10):1407; author reply 1408-9.
 
7. Morgan PP. Homeopathy--will its theory ever hold water? CMAJ. 1992 May 15;146(10):1719-20, 1723-5. PMID: 1596807; PMCID: PMC1488710.
 
 

 

 

 

 

Salicyclic acid

 

Salicyclic acid family of chemicals known as beta hydroxy acids (formula is C7H6O3 or HOC6H4COOH), Salicylic acid is a monohydroxybenzoic acid that is benzoic acid with a hydroxy group at the ortho position. It is obtained from the bark of the white willow and wintergreen leaves. It has a role as an antiinfective agent, an antifungal agent, a keratolytic drug.

When applied to the skin, salicylic acid works to break bonds inside the skin’s pores that are holding dead skin cells to living ones also called as a “keratolytic” medication because it has exfoliating properties.(Keratolytic Agents are those agents that soften, separate, and cause desquamation of the cornified epithelium or horny layer of skin). Salicylic acid softens and destroys the stratum corneum by increasing endogenous hydration (water concentration), probably because of decreased pH, which causes the cornified epithelium (horny layer) of the skin to swell, soften, and then desquamate.

Salicylic acid works to remove warts by exfoliating the skin cells until the wart is gone. The acid may also trigger an immune response to build healthy skin cells in the area. With continued daily application, the salicylic acid solution will often remove the wart. Salicylic acid is a first-line treatment for home use or self application for non-genital warts but not recommended for the genital warts as the skin of genitals is very sensitive and salicylic acid is highly irritant to the genital skin. In case the salicylic acid does not work for more than 2 weeks application then it is best to try some other alternative treatment. Salicylic acid will remove one layer of wart at a time and has slow action. concentration of 15 % or higher is used for warts. While salicylic acid for warts is a generally mild treatment, it can cause some side effects like skin irritation, discolored skin, and discomfort at the site of the wart. It is also not recommended on face application as it can cause hypo or hyper pigmentation of facial skin.

Care has to be taken while using salicylic acid application for warts as full thickness burns have been reported with  its use3,7. Usually salicylic acid is used alone as Over the Counter Drug (OTC) being self applied or used in combination of cryotherapy6. The efficacy of the salicylic acid is equal to cryotherapy4,5.

References

1. Bruggink SC, Gussekloo J, Berger MY, Zaaijer K, Assendelft WJ, de Waal MW, Bavinck JN, Koes BW, Eekhof JA. Cryotherapy with liquid nitrogen versus topical salicylic acid application for cutaneous warts in primary care: randomized controlled trial. CMAJ. 2010 Oct 19;182(15):1624-30. doi: 10.1503/cmaj.092194. Epub 2010 Sep 13.

2.Stamuli E, Cockayne S, Hewitt C, Hicks K, Jayakody S, Kang'ombe AR, Turner G, Thomas K, Curran M, Hashmi F, McIntosh C, McLarnon N, Torgerson DJ, Watt I; EVerT team. Cost-effectiveness of cryotherapy versus salicylic acid for the treatment of plantar warts: economic evaluation alongside a randomised controlled trial (EVerT trial). J Foot Ankle Res. 2012 Feb 27;5:4.

3. Sjökvist O, Smolle C, Jensson D, Huss F. A full-thickness chemical burn to the hand using formic acid-based anti-wart treatment: a case report and literature review. Scars Burn Heal. 2020 Feb 5;6:2059513119897888.

4.Cockayne S, Hewitt C, Hicks K, Jayakody S, Kang'ombe AR, Stamuli E, Turner G, Thomas K, Curran M, Denby G, Hashmi F, McIntosh C, McLarnon N, Torgerson D, Watt I; EVerT Team. Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae): a randomised controlled trial. BMJ. 2011 Jun 7;342:d3271. doi: 10.1136/bmj.d3271. PMID: 21652750; PMCID: PMC3109952.

5. Redzic N, Benoy I, Vanden Broeck D, Bogers JP. Efficacy of AV2-Salicylic acid combination therapy for cutaneous warts: Study protocol for a single-center randomized controlled trial. Contemp Clin Trials Commun. 2020 Jan 21;17:100534.

6. Thomas KS, Keogh-Brown MR, Chalmers JR, Fordham RJ, Holland RC, Armstrong SJ, Bachmann MO, Howe AH, Rodgers S, Avery AJ, Harvey I, Williams HC. Effectiveness and cost-effectiveness of salicylic acid and cryotherapy for cutaneous warts. An economic decision model. Health Technol Assess. 2006 Aug;10(25):iii, ix-87.

7. Tavakkolizadeh A, Povlsen B. A serious complication of topical wart treatment on the hand. J R Soc Med. 2004 Apr;97(4):180.

 

 
 

Intra-lesional Vitamin D3 injections

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. Various antigens have been tried including measles, mumps, rubella (MMR); tuberculin purified protein derivative (PPD); Mycobacterium w vaccine and Candida antigen.

Injection of the Vitamin D3 at the base of the warts is a new treatment option which causes immunomodulation. It has been observed that there is receptor activation of human macrophages which upregulated the expression of Vitamin D receptor (VDR) and Vitamin D-1-hydroxylase genes, leading to induction of the antimicrobial peptide.

The exact mechanism of action of Vitamin D in the clearance of warts is not known. Experimental evidence suggests that it has immunomodulatory effects by inhibiting the expression of interleukin-6 (IL-6), IL-8, tumour necrosis factor (TNF)-α and TNF-γ mediated through VDR-dependent pathway.

The dose of Vitamin D3 injection is - 0.2 ml (15 mg/ml) injection is given to the base of warts. The injections can be repeated 2 weeks apart for a maximum of 4 sessions or until complete clearance, whichever was earlier. 

The idea of intra-lesional vitamin D3 arose after it was observed that patients with viral warts had deficiency of Vitamin D in serum3-6. And there may be deficiency of folate, vitamin B12 and ferritin in patients with viral warts3.Though this claim that patients with viral warts are deficient in vitamin D levels has been contested7. The intra-lesional effect of Vitamin D3 is not that effective as compared to intra-lesional injection of BCG (Purified protein Derivative - which is used for Montoux test in T.B)8.

 

 

References

1. Kavya M, Shashikumar BM, Harish MR, Shweta BP. Safety and Efficacy of Intralesional Vitamin D3 in Cutaneous Warts: An Open Uncontrolled Trial. J Cutan Aesthet Surg. 2017 Apr-Jun;10(2):90-94.

2. Rind T, Oiso N, Kawada A. Successful Treatment of Anogenital Wart with a Topical Vitamin D(3) Derivative in an Infant. Case Rep Dermatol. 2010 Apr 20;2(1):46-49.

3. Tamer F, Yuksel ME, Karabag Y. Pre-treatment vitamin B12, folate, ferritin, and vitamin D serum levels in patients with warts: a retrospective study. Croat Med J. 2020 Feb 29;61(1):28-32.

4.El Mongy, Naglaa N.a; Hilal, Rana F.a; Badr, Amul M.b; Alraawi, Samah A.a Serum vitamin D level in patients with viral warts, Journal of the Egyptian Women's Dermatologic Society: September 2018 - Volume 15 - Issue 3 - p 133-138.

5. Luciano Moscarelli, Filomena Annunziata, Anduela Mjeshtri, Nunzia Paudice, Aris Tsalouchos, Maria Zanazzi, Elisabetta Bertoni, "Successful Treatment of Refractory Wart with a Topical Activated Vitamin D in a Renal Transplant Recipient", Case Reports in Transplantation, vol. 2011, Article ID 368623, 3 pages, 2011.

6. Jinhee Shim, Adriana Pérez, Elaine Symanski, Alan G. Nyitray, Association Between Serum 25-Hydroxyvitamin D Level and Human Papillomavirus Cervicovaginal Infection in Women in the United States, The Journal of Infectious Diseases, Volume 213, Issue 12, 15 June 2016, Pages 1886–1892.

7. Goodarzi, A., Farshidzadeh, M., Roohaninasab, M., Atefi, N., Behrangi, E. Assessment of serum vitamin D level in patients with cutaneous warts: a case-control study. Iranian Journal of Dermatology, 2020; 23(2): 64-71. doi: 10.22034/ijd.2020.110927.

8. Mohamed, E., El Taieb, M., Abd El- sabour, G. Intralesional Vitamin D3 versus Purified Protein Derivatives in The Treatment of Multiple Cutaneous Warts: Comparative Study. The Egyptian Journal of Hospital Medicine, 2019; 76(2): 3589-3594. doi: 10.12816/ejhm.2019.39165

 

 

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Topical retinoic acid

There are some reports of use of topical application of retinoic acid (Vitamin A) for the warts. But the treatment is prolong 6 to 10 weeks or even lasting for 6 months for resolution of warts1,2. It is difficult to recommend the topical use of retinoic acid for treatment of warts with the current evidence available in literature. Topical application of retinoic acid be at the most kept as unproven effect on viral warts unless sufficient data is available on its efficacy, duration of treatment and strength to be applied or to be taken orally2,3.

References

1. de Bersaques J. Vitamin A acid in the topic treament of plantar warts. Dermatologica. 1975;150(6):369-71. doi: 10.1159/000251460. PMID: 1201813.

2. Gaston A, Garry RF. Topical vitamin A treatment of recalcitrant common warts. Virol J. 2012 Jan 17;9:21. doi: 10.1186/1743-422X-9-21. PMID: 22251397; PMCID: PMC3274422.

3. Barchitta M, Maugeri A, La Mastra C, Rosa MC, Favara G, Lio RMS, Agodi A. Dietary Antioxidant Intake and Human Papillomavirus Infection: Evidence from a Cross-Sectional Study in Italy. Nutrients. 2020 May 12;12(5):1384.

 

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Apple cider vinegar

 

The use of vinegar to fight infections and other acute conditions dates back to Hippocrates (460-377 BC; the father of modern medicine), who recommended a vinegar preparation for cleaning ulcerations and for the treatment of sores1. Recent scientific investigations clearly demonstrate the antimicrobial properties of vinegar, but mainly in the context of food preparation, vinegar is not longer recommended for the treatment of wounds.

In the popular media, vinegar is commonly recommended for treating nail fungus, head lice, and warts, yet scientific support for these treatment strategies is lacking. Scattered reports suggest that the successive topical application of highly concentrated acetic acid solutions (up to 99%) alleviated warts, presumably due to the mechanical destruction of wart tissue. 

In popular media vinegar is explained as acid which can kill some types of bacteria and viruses on contact just like salicylic acid and the irritation produced may lead to immune response against viruses. These are all conjectures and no proof is available that vinegar does help in control of warts. In general, apple cider vinegar is most commonly used for this purpose, but it has led to burns of skin rather then treat warts. Anyway vinegar is not recommended for genital warts as it causes lot of irritation to the sensitive skin of ano-genital region nor does it have any effect on warts in that region when used in dilute quantities. 

Apple cider vinegar should not be applied to open wounds or directly to the face and neck. Also, it is not recommended to use apple cider vinegar on genital warts. There are lot of cases of deep and dangerous burns by vinegar when used by lay persons following the popular media2-7

References
1. Johnston CS, Gaas CA. Vinegar: medicinal uses and antiglycemic effect. MedGenMed. 2006 May 30;8(2):61.
 
2. Bunick CG, Lott JP, Warren CB, Galan A, Bolognia J, King BA. Chemical burn from topical apple cider vinegar. J Am Acad Dermatol. 2012 Oct;67(4):e143-4. doi: 10.1016/j.jaad.2011.11.934. PMID: 22980269.
 
3.Korkmaz A, Sahiner U, Yurdakök M. Chemical burn caused by topical vinegar application in a newborn infant. Pediatr Dermatol. 2000 Jan-Feb;17(1):34-6.
 
4. Coban YK. Superficial burns secondary to misuse of acetic acid solution. J Burn Care Res. 2007 Mar-Apr;28(2):359-60.
 
5.Ching JA, Kuykendall LV, Troy JS, Smith DJ Jr. Estrogen treatment of acetic acid burns to the vagina, cervix, and perineum: a case report and review of the literature. J Burn Care Res. 2014 Sep-Oct;35(5):e368-71.
 
6. Feldstein S, Afshar M, Krakowski AC. Chemical Burn from Vinegar Following an Internet-based Protocol for Self-removal of Nevi. J Clin Aesthet Dermatol. 2015 Jun;8(6):50.
 
7. Irkoren S, Sivrioglu N. Unusual burn injury due to application of white vinegar and aspirin mixture. Int Wound J. 2014 Aug;11(4):348-9.
 
8. Conzuelo-Quijada AE, Rodríguez-Cuevas SA, Labastida-Almendaro S. Treatment of large lower genital tract condylomata acuminata with local excision plus topical acetic acid. A preliminary study. The Journal of Reproductive Medicine. 2003 Jul;48(7):506-508.
 
 

 

 

 

Intra-lesional MMR vaccine (measles, mumps and Rubella)

 

Intralesional Immunotherapy with Measles Mumps Rubella Vaccine for the Treatment of Anogenital Warts. MMR vaccine which is known to stimulate cellular immunity is injected to the base of the warts (0.5 ml per session) under the single largest wart and it is repeated after every 3 weeks to maximum of 3 injections1-8. Very few trials have been published to recommend the wide spread use of intra-lesional MMR vaccine. The complications of MMR vaccine like joint pains, fever, local pain at site of injections do remain even with intra-lesional use of vaccine.

References

1. Sharma S, Agarwal S. Intralesional Immunotherapy with Measles Mumps Rubella Vaccine for the Treatment of Anogenital Warts: An Open-label Study. J Clin Aesthet Dermatol. 2020 Aug;13(8):40-44. Epub 2020 Aug 1. PMID: 33178381; PMCID: PMC7595364.

2. Zamanian A, Mobasher P, Jazi GA. Efficacy of intralesional injection of mumps-measles-rubella vaccine in patients with wart. Adv Biomed Res. 2014 Mar 31;3:107. doi: 10.4103/2277-9175.129701. PMID: 24804181; PMCID: PMC4009748.

3. Chauhan PS, Mahajan VK, Mehta KS, Rawat R, Sharma V. The Efficacy and Safety of Intralesional Immunotherapy with Measles, Mumps, Rubella Virus Vaccine for the Treatment of Common Warts in Adults. Indian Dermatol Online J. 2019 Jan-Feb;10(1):19-26. doi: 10.4103/idoj.IDOJ_142_18. PMID: 30775294; PMCID: PMC6362737.

4. Rezai MS, Ghasempouri H, Asqary Marzidareh O, Yazdani Cherati J, Rahmatpour Rokni G. Intralesional Injection of the Measles-Mumps-Rubella Vaccine into Resistant Palmoplantar Warts: A Randomized Controlled Trial. Iran J Med Sci. 2019 Jan;44(1):10-17. PMID: 30666071; PMCID: PMC6330524.

5. Awal G, Kaur S. Therapeutic Outcome of Intralesional Immunotherapy in Cutaneous Warts Using the Mumps, Measles, and Rubella Vaccine: A Randomized, Placebo-controlled Trial. J Clin Aesthet Dermatol. 2018 May;11(5):15-20. Epub 2018 May 1. PMID: 29785233; PMCID: PMC5955628.

6. Sinha S, Relhan V, Garg VK. Immunomodulators in warts: Unexplored or ineffective? Indian J Dermatol. 2015 Mar-Apr;60(2):118-29. doi: 10.4103/0019-5154.152502. PMID: 25814698; PMCID: PMC4372902.

7.Shaheen MA, Salem SA, Fouad DA, El-Fatah AA. Intralesional tuberculin (PPD) versus measles, mumps, rubella (MMR) vaccine in treatment of multiple warts: a comparative clinical and immunological study. Dermatol Ther. 2015 Jul-Aug;28(4):194-200. doi: 10.1111/dth.12230. Epub 2015 Apr 6. PMID: 25847793.

8. Gupta P, Tegta GR, Verma GK, Gupta A, Gupta M, Sharma S. A Study to Evaluate the Role of Intradermal and Intralesional Measles, Mumps, Rubella (MMR) Vaccine in Treatment of Common Warts. Indian Dermatol Online J. 2020 Jul 13;11(4):559-565. doi: 10.4103/idoj.IDOJ_144_19. PMID: 32832442; PMCID: PMC7413434.

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Intra-lesional / Topical Bleomycin injections

References

1. Lee JY, Kim CW, Kim SS. Preliminary study of intralesional bleomycin injection for the treatment of genital warts. Ann Dermatol. 2015 Apr;27(2):239-41. doi: 10.5021/ad.2015.27.2.239. Epub 2015 Mar 24. PMID: 25834378; PMCID: PMC4377428.

2. Al-Naggar MR, Al-Adl AS, Rabie AR, Abdelkhalk MR, Elsaie ML. Intralesional bleomycin injection vs microneedling-assisted topical bleomycin spraying in treatment of plantar warts. J Cosmet Dermatol. 2019 Feb;18(1):124-128. doi: 10.1111/jocd.12537. Epub 2018 Apr 23. PMID: 29687566.

3. Soni P, Khandelwal K, Aara N, Ghiya BC, Mehta RD, Bumb RA. Efficacy of Intralesional Bleomycin in Palmo-plantar and Periungual Warts. J Cutan Aesthet Surg. 2011 Sep;4(3):188-91. doi: 10.4103/0974-2077.91250. PMID: 22279384; PMCID: PMC3263129.

4.Pasquali P, Freites-Martinez A, Gonzalez S, Spugnini EP, Baldi A. Successful treatment of plantar warts with intralesional bleomycin and electroporation: pilot prospective study. Dermatol Pract Concept. 2017 Jul 31;7(3):21-26. doi: 10.5826/dpc.0703a04. PMID: 29085716; PMCID: PMC5661162.

5. Rausch LJ. Dermatology-important advances in clinical medicine: immunotherapy and bleomycin in the treatment of recalcitrant warts. West J Med. 1983 Jun;138(6):863-4. PMID: 18749384; PMCID: PMC1010841.

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Multiple puncture technique

References

1. Mclaughlin JS, Fischer TJ, Merrell GA. Treatment of Cutaneous Warts With Multiple Puncture Technique. Hand (N Y). 2019 Sep;14(5):689-690. doi: 10.1177/1558944718771389. Epub 2018 May 15. PMID: 29761740; PMCID: PMC6759976.

2. De Vita V, Goldust M. Efficacy and Safety of Microneedling for the Treatment of Cutaneous Warts. Hand (N Y). 2019 Sep;14(5):705-706. doi: 10.1177/1558944718810895. Epub 2018 Nov 8. PMID: 30406683; PMCID: PMC6759969.

3. Kolte SR Jr, Sardesai VR. Comparison of Intralesional Measles, Mumps, Rubella Vaccine and Needling in the Treatment of Recurrent Warts. J Cutan Aesthet Surg. 2020 Jul-Sep;13(3):217-221. doi: 10.4103/JCAS.JCAS_164_19. PMID: 33208998; PMCID: PMC7646425.

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Topical Garlic extract

 

References

1. Rouf R, Uddin SJ, Sarker DK, Islam MT, Ali ES, Shilpi JA, Nahar L, Tiralongo E, Sarker SD. Antiviral potential of garlic (Allium sativum) and its organosulfur compounds: A systematic update of pre-clinical and clinical data. Trends Food Sci Technol. 2020 Oct;104:219-234. doi: 10.1016/j.tifs.2020.08.006. Epub 2020 Aug 19. PMID: 32836826; PMCID: PMC7434784.

 

 

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Intra-lesional BCG/ PPD

 

 References

1. Al-Yassen AQ, Al-Maliki SK, Al-Asadi JN. The Bacillus Calmette-Guérin (BCG) Vaccine: Is it a better choice for the treatment of viral warts? Sultan Qaboos Univ Med J. 2020 Aug;20(3):e330-e336. doi: 10.18295/squmj.2020.20.03.013. Epub 2020 Oct 5. PMID: 33110649; PMCID: PMC7574799.

2. Jaisinghani AK, Dey VK, Suresh MS, Saxena A. Bacillus Calmette-Guerin Immunotherapy for Recurrent Multiple Warts: An Open-Label Uncontrolled Study. Indian J Dermatol. 2019 Mar-Apr;64(2):164. doi: 10.4103/ijd.IJD_558_16. PMID: 30983619; PMCID: PMC6440180.

 3. Rao AG, Haqqani R. Study of BCG Immunotherapy in the Management of Multiple, Extensive Non-Genital Cutaneous Common Warts. Indian Dermatol Online J. 2020 Sep 19;11(5):784-788. doi: 10.4103/idoj.IDOJ_461_19. PMID: 33235846; PMCID: PMC7678529.

 

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Duct Tape

 References

1. Kim SY, Jung SK, Lee SG, Yi SM, Kim JH, Kim IH. New alternative combination therapy for recalcitrant common warts: the efficacy of imiquimod 5% cream and duct tape combination therapy. Ann Dermatol. 2013 May;25(2):261-3. doi: 10.5021/ad.2013.25.2.261. Epub 2013 May 10. PMID: 23717030; PMCID: PMC3662932.

2. Goldman RD. Duct tape for warts in children: Should nature take its course? Can Fam Physician. 2019 May;65(5):337-338. PMID: 31088871; PMCID: PMC6516695.

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Zinc Sulphate

 

References

1. Mohamed EE, Tawfik KM, Mahmoud AM. The Clinical Effectiveness of Intralesional Injection of 2% Zinc Sulfate Solution in the Treatment of Common Warts. Scientifica (Cairo). 2016;2016:1082979. doi: 10.1155/2016/1082979. Epub 2016 Mar 31. PMID: 27123361; PMCID: PMC4830730.

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Podophyllin / Podophyllotoxin

 

References

1. Nguyen AL, Quint KD, Bouwes Bavinck JN, Erceg A, de Kort WJA, Körver JEM. Real-life treatment of cutaneous warts with cantharidin podophyllin salicylic acid solution. Dermatol Ther. 2019 Nov;32(6):e13143. doi: 10.1111/dth.13143. Epub 2019 Nov 20. PMID: 31664756; PMCID: PMC6916542.

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Auto-inocculation of warts

 

 

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Diphenylcyclopropenone (DPCP)

 References

1. Choi JW, Cho S, Lee JH. Does immunotherapy of viral warts provide beneficial effects when it is combined with conventional therapy? Ann Dermatol. 2011 Aug;23(3):282-7. doi: 10.5021/ad.2011.23.3.282. Epub 2011 Aug 6. PMID: 21909196; PMCID: PMC3162255.

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Photodynamic therapy

 References

1. Caucanas M, Gillard P, Vanhooteghem O. Efficiency of photodynamic therapy in the treatment of diffuse facial viral warts in an immunosuppressed patient: towards a gold standard? Case Rep Dermatol. 2010 Dec 29;2(3):207-13. doi: 10.1159/000323215. PMID: 21537372; PMCID: PMC3085036.

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Intra-lesional 5% KOH

 References

1. Camargo CL, Belda Junior W, Fagundes LJ, Romiti R. A prospective, open, comparative study of 5% potassium hydroxide solution versus cryotherapy in the treatment of genital warts in men. An Bras Dermatol. 2014 Mar-Apr;89(2):236-40. doi: 10.1590/abd1806-4841.20141702. PMID: 24770498; PMCID: PMC4008052.

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Intra-lesional Candida albicans antigen

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Nitric zinc Complex

Nitric–zinc complex is a solution for topical application containing nitric acid, zinc, copper and organic acids, currently used to treat common warts. It has a caustic effect on the wart through mummification and protein denaturation or a coagulation action. The solution can be applied topically once, or up to four times, at 2‐week intervals until a complete clinical cure rate is observed. Clearance rates in one study ranged from 90 to 99%, and the product was well tolerated with no serious adverse events recorded. Initial data suggest promising result, however, additional studies are needed.

 

Nitric–zinc complex topical solution

Induces a caustic effect on the wart through mummification and protein denaturation/

coagulation action

repeat at 2‐week intervals if needed

99%

(Range:90-99%)

 still under research / study

Easy Application Recurrence rate is still under study / evaluation

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Sinecatechins

Sinecatechins consist of green tea polyphenols, which have anti‐inflammatory, anti‐proliferative, pro‐apoptotic and antiviral properties, although their exact mode of action is unknown. They are available for the treatment of warts as a 15% ointment or cream, which is self‐applied by the patient three times per day for a maximum of 16 weeks. In comparison, imiquimod 5% is applied three times weekly while application of imiquimod. Sinecatechin 15% ointment is a brown formulation, which could stain light‐coloured clothing and bedding, reducing patient adherence. Clinical studies of sinecatechins have shown similar clearance rates to that of imiquimod 5% therapy. Sinecatechins have resulted in complete clearance rates of 40–81%, No long‐term data are available for sinecatechins. The most commonly observed application site reactions are erythema, pruritus, irritation, pain and ulceration; these side‐effects may indicate the greater likelihood of a clinical response.

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