Intralesional methotrexate versus 5-flurouracil in the treatment of keratoacanthoma.

BACKGROUND: Keratoacanthoma (KA) is a benign neoplasm that affects mainly photodamaged skin. It is locally destructive and may rarely spread. Surgery is not always suitable and usually disfiguring. Thus, non-operative modalities represent good alternatives. OBJECTIVE: To assess and compare the efficacy of intralesional methotrexate (MTX) and 5-flurouracil (5-FU) in the treatment of KA. PATIENTS AND METHODS: Randomized controlled trial included 20 patients with biopsy proven KA divided into 2 equal groups; group (A) received intralesional MTX, 25 mg/ml and group (B) received intralesional 5-FU, 50 mg/ml every 2 weeks till complete clearance or for a maximum 5 sessions. RESULTS: In the MTX group, complete clearance was observed in 7 patients (70%) compared to 8 patients (80%) in the 5- FU group with no statistically significant difference. However, the median number of injections needed to achieve complete response in the MTX group was 3 sessions versus only 2 sessions in the 5-FU group. LIMITATIONS: the small sample size due to the relatively low incidence of KAs in our population. CONCLUSION: Intralesional therapy is a good alternative to surgery in selected cases of KA. Both drugs showed comparable efficacy, but 5-FU may give faster results, hence increasing patient satisfaction and compliance.

Tazarotene is as effective and tolerable as imiquimod in the treatment of verruca plana, a comparative randomized clinical trial.

BACKGROUND: Plane warts when multiple and recurrent present a therapeutic challenge acting as a source of reinfection causing frustration and affecting patient's quality of life. For lesions of large numbers in cosmetically significant sites, topical treatment is preferred to avoid potential sequelae. OBJECTIVES: To evaluate and compare the efficacy and tolerability of tazarotene 0.1% gel versus imiquimod 5% cream for the treatment of plane warts. METHODS: In a parallel three-arm randomized controlled trial, 60 patients were randomized into imiquimod, tazarotene or placebo groups. Patients applied the corresponding treatment once daily at night for a maximum of 12 weeks. Primary outcomes were percentage of respondents with complete clearance in the three studied groups, the type and frequency of side effects in each group. RESULTS: Both active treatments resulted in significant improvement compared to baseline and to placebo group (P=0.001). Imiquimod 5% treated group showed complete clearance in 50% of cases, partial response in 15%, and no response in 35%. Tazarotene 0.1% gel showed complete clearance in 40% of cases, partial response in 40%, and no response in 20%. No significant difference was detected between imiquimod and tazarotene groups (P=0.190). CONCLUSIONS: Compared to imiquimod, tazarotene 0.1% gel for the treatment of plane warts seems to offer equivalent treatment response, maintained efficacy without recurrence, safer profile regarding dyspigmentation with an advantageous cheaper cost.

High versus low dose oral isotretinoin in the treatment of cutaneous and genital warts.

Although oral isotretinoin has been considered as a potential therapeutic option for the treatment of different types of warts, the optimum dosage regimen is not yet well-established. To evaluate the efficacy and adverse effects of high versus low doses of oral isotretinoin in the treatment of cutaneous and genital warts. The study included 100 patients who were randomly assigned to two groups, 50 patients in each. Group 1 received 0.6 mg/kg/day (high dose isotretinoin) and Group 2 received 0.3 mg/kg/day (low dose isotretinoin). In both groups, therapy was given daily until resolution was achieved or for a maximum of 3 months. Complete clearance of warts was observed in 76% of the high dose isotretinoin group and in 46% of the low dose isotretinoin group. There was a statistically significant difference in the therapeutic response between the two groups. Recurrence was higher in the low dose group (26%) than the high dose group (7.8%). Adverse effects were mild and tolerable. High dose of systemic isotretinoin is more effective than low dose and seems to be a promising well-tolerated and effective therapeutic option for the treatment of cutaneous and genital warts.

Intralesional Versus Intramuscular Hepatitis B Virus Vaccine in the Treatment of Multiple Common Warts.

BACKGROUND: Hepatitis B virus (HBV) vaccination is associated with stimulation of humoral and cell-mediated immunity. Intralesional HBV vaccine has been recently used as an immunotherapy of common warts with relatively low success rate. AIM: To assess the efficacy and safety of intralesional versus intramuscular (IM) HBV vaccine in the treatment of multiple common warts. PATIENTS AND METHODS: The study included 60 patients with multiple common warts who were randomly assigned to 2 groups: intralesional HBV vaccine or IM HBV vaccine. In the intralesional HBV vaccine group, the vaccine was injected into the largest wart at 2-week intervals until complete clearance or for a maximum of 5 sessions. Intramuscular HBV vaccine group received 3 injections in the deltoid muscle at 0, 1, and 6 months. RESULTS: Complete wart clearance was reported in 7 patients (23.3%) of the intralesional HBV vaccine group and 15 patients (50%) of the IM HBV vaccine group. The difference was statistically significant in favor of the IM group ( p = .0479). Adverse effects were mild and insignificant in the 2 groups. CONCLUSION: HBV vaccine, particularly the IM form seems to be a promising, well-tolerated therapeutic option for the treatment of warts. LIMITATIONS: Short follow-up period and small sample size.

Topical calcipotriol combined with urea 20% versus intralesional injection of triamcinolone acetonide, 5-fluorouracil, and methotrexate in the treatment of nail psoriasis: A comparative study.

There is no consistently effective treatment for psoriatic nails. Topical and intralesional modalities have been recently investigated and showed promising efficacy and safety. To compare the efficacy and safety of intralesional injection of 5-fluorouracil (5-FU), methotrexate (MTX), triamcinolone acetonide (TA) versus topical calcipotriol plus urea 20% in the treatment of nail psoriasis. This study included 60 patients with nail psoriasis who were randomly assigned to 4 groups, each containing 15 patients. The first 3 groups received intralesional injection of 0.1 ml of 5-FU (group A), MTX (group B), and TA (group C) into the nail matrix and bed monthly for 3 months. Group D received a topical combination of calcipotriol/urea 20% twice daily for 3 months. Therapeutic response was assessed every month for 3 months using the target nail psoriasis severity index (NAPSI). The mean percentage of improvement was significantly higher in topical calcipotriol/urea combination (57.1 ± 26.4) than intralesional TA (44.2 ± 32.7), intralesional MTX (37.7 ± 14.2), and intralesional 5-FU (29.6 ± 14). Adverse effects were mild and insignificant in the studied groups. Topical calcipotriol/urea combination seems to be more effective and safe than intralesional injections of 5-FU, MTX, and TA.

Oral isotretinoin versus acitretin in male patients with multiple recalcitrant common warts: A randomized, double-blinded placebo-control study.

BACKGROUND: Management of multiple recalcitrant common warts represents a therapeutic challenge. Both oral isotretinoin and acitretin have shown a promising efficacy in the treatment of various types of warts. However, a comparative study of the two medicines in wart treatment has not yet been conducted. OBJECTIVE: The aim of this study was to assess the efficacy and adverse effects of oral isotretinoin versus acitretin in the treatment of multiple recalcitrant common warts. METHODS: This study was conducted on 75 adult male patients with recalcitrant multiple common warts. The patients were randomly assigned to three groups: group 1 (30 patients) received oral isotretinoin, group 2 (30 patients) received acitretin, and group 3 received oral placebo (15 patients). The treatment was given daily until complete clearance or for a maximum of 3 months. RESULTS: Complete clearance of the treated lesions was observed in 18 patients (60%) of the isotretinoin group, in 22 patients (73.3%) of the acitretin group, and in 0 patients (0%) of the placebo group. A statistically significant difference was observed in the therapeutic response between the treatment groups, and the placebo group was observed. Adverse effects of the used drugs were mild and transient. CONCLUSION: Oral isotretinoin and acitretin are promising effective modalities with minimal side effects for the treatment male patients with multiple recalcitrant common warts with a relative superiority of acitretin.

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.

Intralesional immunotherapy for multiple recalcitrant plantar warts: Candida antigen is superior to intralesional purified protein derivative.

Treatment of recalcitrant plantar warts represent a highly challenging issue for both patients and physicians. Candida antigen and purified protein derivative (PPD) have shown promising efficacy in the treatment of warts, however no previous studies have compared both antigens for recalcitrant plantar warts. To assess the efficacy and safety of intralesional Candida antigen versus intralesional PPD in the management of recalcitrant plantar warts. The study included 120 adult patients with multiple recalcitrant plantar warts. They were randomly assigned to one of three groups; Candida antigen, PPD, or normal saline. Injections into the largest wart were repeated every 2 weeks until clearance or for a maximum of five sessions. Complete wart clearance was reported in 33 patients (82.5%) of the Candida antigen group, in 22 patients (55.6%) of the PPD group, and in one patient (5%) of the control saline group. A statistically significant difference was found between the studied groups in favor of Candida antigen. Adverse effects were mild and insignificant in the three groups. Intralesional antigen immunotherapy by Candida antigen or PPD is a promising, safe, and cost-effective therapeutic option for multiple recalcitrant plantar warts, with statistically significant superiority of Candida antigen.

Intralesional immunotherapy for the treatment of anogenital warts in pediatric population.

BACKGROUND: The prevalence of anogenital warts is increasing in adults as well as in pediatric population. The treatment of anogenital warts is challenging, particularly in children as most conventional modalities are painful and associated with high recurrence rates. OBJECTIVES: To evaluate the efficacy and safety of intralesional immunotherapy for the treatment of anogenital warts in pediatric patients. METHODS: Forty child presenting with multiple anogenital warts were randomly assigned into 3 groups. The first group (15 patients) received intralesional MMR vaccine, the second group (15 patients) received intralesional Candida antigen and the third group (10 patients) received intralesional saline as a control. Each modality was injected into the largest wart at 2-week intervals until complete clearance or for a maximum of 5 sessions. RESULTS: Highly significant difference was found between the therapeutic response of anogenital warts to both MMR vaccine and Candida antigen compared to intralesional saline (p = .005). No significant difference was observed between MMR vaccine and Candida antigen groups (p = .885). Side effects were mild and no recurrence was detected in the 6 month follow-up period. CONCLUSIONS: Intralesional immunotherapy is a promising effective and well-tolerated treatment modality for multiple anogenital warts in children.

Combined oral isotretinoin and Candida antigen versus either agent alone in the treatment of plane warts.

BACKGROUND: Oral isotretinoin and intralesional immunotherapy by Candida antigen have shown promising efficacy and safety for the treatment of plane warts in a few studies. OBJECTIVE: To evaluate the efficacy and safety of a combination of oral isotretinoin and Candida antigen versus either agent alone in the treatment of multiple plane warts. METHODS: The study included 108 patients who were randomly assigned to three groups, 36 in each. Group 1 received oral isotretinoin alone at a dose of 0.3 mg/kg/day. Group 2 received intralesional injection of Candida antigen alone at a dose of 0.1 ml of 1/1000 solution into the largest wart. Group 3 received a combination of Candida antigen and oral isotretinoin by the same method and dose mentioned above. RESULTS: Complete clearance of warts was observed in 44.4% of the oral isotretinoin alone group, in 55.6% of the Candida antigen alone group, and in 38.8% of the combination therapy group. A statistically significant difference in favor of the Candida antigen alone group was demonstrated. CONCLUSIONS: Candida antigen, oral isotretinoin and a combination of both represent potential effective and safe modalities for the treatment of plane warts, with the Candida antigen alone as the most effective.

Immunotherapeutic modalities for the treatment of recalcitrant plantar warts: a comparative study.

BACKGROUND: Plantar warts are sometimes resistant or they tend to recur after every possible destructive therapy. Immunotherapy has been used as a promising alternative therapeutic option in such recalcitrant cases. AIM: To evaluate and compare the efficacy and safety of the intralesional injection of vitamin D3, zinc sulfate 2%, and Candida antigen in the treatment of recalcitrant plantar warts. PATIENTS AND METHODS: The study included 152 adult patients with single or multiple recalcitrant plantar warts. They were equally subdivided into four groups (38 patients in each): 2% zinc sulfate, vitamin D3, Candida antigen, and normal saline respectively. Injections were done at 3-week intervals until complete resolution or for a maximum of 4 sessions. RESULTS: Complete response was achieved in 20 patients (52.7%) of the zinc sulfate group, 34 patients (89.5%) of the intralesional vitamin D3 group, 25 patients (65.7%) of the intralesional Candida antigen group and 8 patients (21.2%) of the saline group. The difference between the groups was statistically significant in favor of vitamin D3 (p = .037). CONCLUSIONS: Recalcitrant plantar warts were best treated with vitamin D3 that also has the advantages of better response on distant warts, minimal side effects, and low rate of wart recurrence.

Correlation of serum interleukin 17 and macrophage migration inhibitory factor levels with clinical response to intralesional Candida antigen and their potential use as predictors of clinical outcome in patients with multiple common warts.

BACKGROUND: Candida antigen injection is one of the most widely used intralesional immunotherapy in the treatment of warts. It acts through the induction of systemic immune response. The pattern of cytokines production may play an integral role in its mechanism of action. AIM: To investigate the possible relation between serum levels of IL17 and MIF, and the clinical response to intralesional Candida antigen in multiple common warts. METHODS: A total of 90 patients with multiple common warts were divided into 2 groups. Sixty patients received intralesional Candida antigen injection into the largest wart, controlled against thirty patients who had intralesional saline, as placebo. The injection was done at a 2-week interval for 5 doses. Blood samples were obtained from both groups, and serum levels of IL17A and MIF were estimated at baseline and 2 weeks after the last session using ELISA kits. RESULTS: Complete clearance of warts was statistically higher in the Candida antigen group (40% of the patients) compared to the saline group (p < 0.05). The serum levels of IL17 had significantly declined from baseline, while the level of MIF had risen after intralesional Candida antigen injection, but not in the saline group. At a cutoff level of 316 pg/ml, IL17 had a sensitivity of 83.3% to predict therapeutic response. CONCLUSION: IL17A and MIF may have possible roles in the mechanism of action of Candida antigen in the treatment of common warts. At a certain level, serum IL17A may be a potential predictor of response to treatment.

Microneedling combined with pimecrolimus, 5-fluorouracil, and trichloroacetic acid in the treatment of vitiligo: A comparative study.

Treatment of vitiligo represents a highly therapeutic challenge in spite of the continuous development of new modalities. Combination therapies of vitiligo can help improve treatment response, and reduce recurrence potential. To compare the efficacy and adverse effects of microneedling combined with-fluorouracil, pimecrolimus, and trichloroacetic acid (TCA) in the treatment of localized, stable vitiligo. The study included 75 patients with non-segmental, stable vitiligo who were randomly assigned to three equal groups: group received a combination of microneedling and -FU, group 2 received microneedling and pimecrolimus, and group 3 received microneedling and TCA. The procedure was done every 2 weeks for a maximum of six sessions. Combined microneedling and TCA was associated with the highest + 5-fluorouracil, and lastly combined microneedling + pimecrolimus. The difference between the three groups was statistically significant in favor of the combined microneedling and TCA. Pain, erythema, post-inflammatory hyperpigmentation, infection, and scarring were variably reported adverse effects in the three groups. Combination therapy seems to be a promising modality for the treatment of vitiligo. Combined microneedling and TCA is superior to combined microneedling with either-fluorouracil or pimecrolimus.

H syndrome: A review of treatment options and a hypothesis of phenotypic variability.

H syndrome is a rare autosomal recessive disorder with clinical features comprising: hyperpigmentation, hypertrichosis, hearing loss, heart anomalies, low height, hypogonadism and hepatosplenomegaly. H syndrome results from loss-of-function mutations in SLC29A3 which leads to abnormal proliferation and function of histiocytes. Herein, we discuss the considerable phenotypic heterogeneity detected in a consanguineous Egyptian family comprising of four affected siblings, two of which are monozygotic twin and the possible therapeutics. The phenotypic variability may be attributed to the role of histiocytes in the tissue response to injury. Such variable expressivity of H syndrome renders the diagnosis challenging and delays the management. The different treatment approaches used for this rare entity are reviewed.