Cantharidin (1%), podophyllin (5%), and salicylic acid (30%) formulation in recalcitrant plantar warts: Analysis of 48 patients.

A plantar wart is a benign hyperplasia that appears on the feet due to the human papillomavirus (HPV). One method used for the treatment of recalcitrant plantar warts, those lasting over 2 years or persisting after at least two treatment attempts, is the cantharidin (1%), podophyllin (5%), and salicylic acid (30%) formulation, also known as the CPS formulation. Although this method is in use, there are few studies on it. This study's objective was to ascertain its cure rate. For this retrospective observational study, we reviewed the medical records of patients treated with the CPS formulation at a podiatric clinic specializing in plantar wart treatment. Our sample size was 48 subjects. The CPS formulation had a cure rate of 62.5%. Out of the cured patients, 86.67% (26/30) required one or two applications. There was no observable correlation (p > 0.05) between wart resolution and virus biotype, evolution time, patient's morphological and clinical attributes, location, number of warts, or preceding treatments. The CPS formulation presents a relatively high efficacy rate for treating recalcitrant HPV plantar warts. Still, additional studies are necessary to evaluate its safety and efficiency.

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

BACKGROUND: No single treatment is ideal for genital warts with high rate of resistance using conventional modalities as topical podophyllin; however, several intralesional immunotherapies are being tested nowadays, with variable results. In this study, we compared the safety and efficacy of treating resistant and recurrent genital warts by 2 intralesional immunotherapies [Candida antigen and measles, mumps, and rubella (MMR) vaccine] and compared them with topical podophyllin. PATIENTS/METHODS: A total of 45 patients with resistant or recurrent genital warts were enrolled in this study. Size and number of warts were detected in each patient, patients were divided into 3 groups. Group A injected with intralesional Candida antigen. Group B with intralesional MMR vaccine. Group C were treated with topical 25% podophyllin. Patients received a session every 2 weeks for 3 treatment sessions. RESULTS: With regard to the reduction in size and number of all warts, the best response was obtained in Candida antigen group where 46.7% showed complete clearance and 40% showed partial response followed by MMR group and the last was the podophyllin group, with no significant difference between them. Complete clearance of mother warts was noticed in 86.7% of Candida group, 53.3% in MMR group, and last 40% in podophyllin group, with a significantly better response in the Candida group (P = .027). CONCLUSION: Both intralesional Candida antigen and MMR vaccine are simple, safe, and effective treatment options with comparable results and better response than topical podophyllin.

Ingenol Mebutate Gel 0.05% in the Treatment of Anogenital Warts: A Prospective Controlled Trial Comparing It With Topical Podophyllin Solution 25.

BACKGROUND: Anogenital warts (AGWs) are a common therapeutic challenge. All therapies are associated with burning, pain, and frustrating high rate of recurrence. The search for a new alternative continues. Recently, a diterpene ester extracted from the Euphorbia peplus plant (ingenol mebutate [IM]) has been shown to possess activity against AGWs. OBJECTIVE: This study aimed to compare and evaluate the therapeutic efficacy and safety of topical 0.05% ingenol gel with another herbal extract medication (topical 25% podophyllin solution) in treatment of AGWs. METHODS: This was a comparative single blinded nonrandomized, 2-arm trial of ingenol 0.05% gel versus podophyllin solution 25% administered up to 6 times to patients with AGWs. To evaluate the therapeutic efficacy, the complete clearance rate and recurrence rate were assessed 1 and 12 weeks after last treatment, respectively. Safety was assessed by occurrence and severity of pain and local skin reaction (LSR). RESULTS: Of 31 and 36 patients in the IM group and podophyllin group who completed the study, initial complete resolution was observed in 20 (64.5%) and 14 (38.9%) patients, respectively (P = 0.03). The initial clearance was faster in the IM group (2.00 ± 0.91 weeks) compared with the podophyllin group (4.21 ± 1.05 weeks, P = 0.00). After 3 months, recurrence was seen in 13 (65.0%) of 20 patients in the IM group and 6 (42.8%) of 14 in the podophyllin group (P = 0.20). The number of patients with complete resolution after 3 months was not different between the 2 groups (7/31 in the IM group and 8/36 in the podophyllin group, P = 0.97). The mean ± SD severity scores for LSR and pain in the IM group were 6.65 ± 1.76 and 6.13 ± 2.57, respectively, which was significantly higher than their scores (3.39 ± 1.57 and 2.58 ± 1.38) in the podophyllin group (P = 0.00). CONCLUSION: Ingenol mebutate 0.05% gel is effective as podophyllin 25% solution in treating AGWs, with further benefit of being much more rapid. However, high recurrence rate, sever pain, and LSR limit its use.

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.

Efficacy of combination therapy of oral zinc sulfate with imiquimod, podophyllin or cryotherapy in the treatment of vulvar warts.

AIM: Zinc sulfate is beneficial in the treatment of epithelial warts. We conducted this study to compare the efficacy of combination therapy of oral zinc sulfate with conventional treatments in the treatment of vulvar warts. MATERIAL AND METHODS: This study was a randomized controlled trial. The sample size was 42 in each group. Women aged 20-50 years were placed by the block randomized method into six groups: the podophyllin-, imiquimod- and cryotherapy-treated groups, and another three groups receiving 8-week combination therapy of 400 mg oral zinc sulfate with one of the above-mentioned treatments. Data were analyzed using anova and Fischer's exact test with spss16. RESULTS: A total of 228 patients were recruited and completed the study in six treatment groups. No significant difference was observed in the response to treatment among these groups. Relapse after 6 months was significantly higher in the podophyllin-, imiquimod- and cryotherapy-treated patients compared to patients receiving these treatments in combination with oral zinc sulfate (P<0.05). CONCLUSIONS: Combined therapy of oral zinc sulfate with conventional treatments of vulvar warts appears to reduce the relapse rate.

Identification of Epstein-Barr virus after topical treatment for oral hairy leukoplakia: A preliminary study.

BACKGROUND: This study evaluated the presence of Epstein-Barr virus type 1 (EBV-1) DNA in patients living with HIV, before and after three different topical therapy protocols for oral hairy leukoplakia (OHL). METHODS: The sample consisted of five patients treated with topical solution of 25% podophyllin resin; six with 25% podophyllin resin plus 5% acyclovir cream; and four with 25% podophyllin resin plus 1% penciclovir cream. DNA was extracted from OHL scrapings and amplified by the PCR using specific primers for EBV-1 (EBNA-1). RESULTS: Clinical healing of OHL lesions was observed across all treatment groups over time. At baseline, EBNA-1 was detected in all OHL lesions. After treatment, OHL samples from three patients treated with 25% podophyllin resin plus 5% acyclovir cream and from one patient treated with 25% podophyllin resin plus 1% penciclovir cream exhibited negative EBNA-1 viral gene encoding. Despite the clinical resolution of OHL, 11 patients (73.3%) showed EBNA-1 positivity immediately after the lesion disappeared. Three patients (20%) treated with podophyllin resin displayed both EBNA-1 positivity and a recurrence of OHL, in contrast to no recurrence in the other two groups. CONCLUSIONS: These findings suggest potential associations between treatment formulations, EBNA-1 persistence, and the recurrence of OHL lesions.

Giant disseminated condylomatosis in SLE.

INTRODUCTION: Females with systemic lupus erythematosus (SLE) have higher prevalence of human papillomavirus (HPV) infection, which can lead to the development of warts. Herein we report the first case of giant disseminated condylomatosis (GDC) in a SLE female on mycophenolate mofetil (MMF). CASE REPORT: The patient, a 33-year-old, Black female, was diagnosed with SLE during her first pregnancy in 2003 based on the features of arthritis, skin rash, seizures, nephritis and presence of antinuclear antibodies. Her pregnancy resulted in preterm delivery of a stillborn fetus at 28 weeks. Since that time she has been treated with steroids and different regimens of immunosuppressive drugs such as cyclophosphamide, azathioprine and lately MMF. In the last few years she presented GDC involving the genital area in addition to skin on the lower abdomen. Topical therapy with trichloroacetic acid, imiquimod and podophyllin was only partially effective. Different types of HPV were identified in the lesions, being HPV-11 in abdomen, HPV 6, 11, 42 in vulva, HPV-6, 11 in vagina and HPV-6, 11 in endocervix. CONCLUSIONS: GDC may be a complication of SLE, secondary to the disease itself, its treatment or other factors not yet identified.

Current therapy for condyloma acuminata of the patients attending female STD Unit, Siriraj Hospital.

OBJECTIVE: To describe the treatment pattern of condyloma acuminata in female. MATERIAL AND METHOD: The 5-year medical records of 449 women treated for genital condyloma acuminata at the Gynecologic Infectious Diseases and Female Sexually Transmitted Disease (GID-FSTD) unit were reviewed. Data included the distribution of age, client by category, anatomical site and size, serologically coexisting sexually transmitted infection (STI), and treatment modalities. RESULTS: About half, 50.1%, of treatment was the application of topical trichloroacetic acid; followed by podophylline in the proportion of 35.5%. While the electric cauterization and imiquimod applications were uncommon therapy. Two-fifth ofthe subjects, 40.7%, was completely cured, and the remaining cases required additional management. CONCLUSION: The present setting, the wide range of treatment available is reflection of the fact that there is no ideal management.

Podophyllin, but not the constituents quercetin or kaempferol, induced genotoxicity in vitro and in vivo through ROS production.

The genotoxic potential of podophyllin (PD) was investigated in this study. PD increased bacterial revertants and abnormal chromosomal structures in a concentration-dependent manner, both with and without metabolic activating enzymes, and increased the incidence of micronuclei in imprinted control region mouse reticulocytes. Results from three studied constituents of PD, such as podophyllotoxin, kampferol, and quercetin, suggested that the mutagenic effect of PD was not due to the presence of podophyllotoxin, kampferol, and quercetin and might be related to other components and the formation of reactive oxygen species. The detailed mutagenic mechanisms need further investigation, and the medicinal use of PD needs to be cautioned against.

ß-Apopicropodophyllin functions as a radiosensitizer targeting ER stress in non-small cell lung cancer.

AIMS: In this study, we examined whether ß-apopicropodophyllin (APP) could act as a radiosensitizer in non-small cell lung cancer (NSCLC) cells. MAIN METHODS: The in vitro radiosensitizing activity of APP was demonstrated with clonogenic assay, immunoblotting, Annexin V-Propidium iodide (PI) assay, BrdU incorporation, detection of mitochondrial ROS/intracellular of H2O2, mitochondrial membrane potential detection, and performing of isolation of mitochondrial and cytosolic fractions. The in vivo radiosensitizing activity of APP was determined in xenografted mice with co-treatment of APP and IR based on measurement of tumor volumes and apoptotic cell death. KEY FINDINGS: The results of a clonogenic assay indicated that a combination of APP and γ-ionizing radiation (IR) inhibits cell growth and increases cell death in NSCLC cells. Several signal transduction pathways were examined for their potential involvement in the apparent radiosensitization effect of APP, as assessed by immunoblotting analyses and mitochondrial potential determination in vitro. Treatment of NCI-H460 cells with 15 nM APP and NCI-H1299 cells with 10 nM APP yielded dose-enhancement ratios of 1.44 and 1.24, respectively. Enhanced ER stress, disrupted mitochondrial membrane potential, and increased reactive oxygen species (ROS) were observed in cells co-treated with APP and IR, and this was followed by the cytosolic release of cytochrome c and consequent activation of caspase-3 and -9. Notably, inhibition of JNK, which prevents caspase activation, blocked the APP/IR-induced activations of ER stress and apoptotic cell death. In NCI-H460 or NCI-H1299 cell-xenografted mice, APP/IR treatment delayed the time it took tumors to reach a threshold size by 22.38 and 16.83 days, respectively, compared with controls, to yield enhancement factors of 1.53 and 1.38, respectively. SIGNIFICANCE: APP has a radiosensitizing function derived from its ability to induce apoptotic cell death via activation of ER stress, disruption of mitochondrial membrane potential, and induction of the caspase pathway.

Podophyllin reaction mimicking Bowen's disease in a patient with delusions of verrucosis.

A 40-year-old woman presented with a delusion of warts on the forehead, for which she was applying podophyllin toxin. A skin biopsy was taken, which showed prominent mitotic figures in the basal and suprabasal layers of the epidermis and apoptotic keratinocytes. Histopathologically Bowen's disease was suspected, but was discounted after clinicopathological correlation was obtained and showed absence of epidermal atypia or disorganization. This case demonstrates the histological resemblance of podophyllin reaction to Bowen's disease. Differentiation of self-inflicted from organic skin disease may be difficult, especially where histopathological findings are confounded by cutaneous application of toxins.

[Clinical and benign aspects of human papillomavirus-associated lesions]. / Aspects cliniques bénins de l'infection à papillomavirus humains.

Human papillomaviruses (HPV) are found in most human epithelia and some tumors. Most HPV strains associated with cutaneous lesions belong to three types, named alpha, beta and gamma. Although the causal link between genital human papillomavirus infection and cervical neoplasia is well established, the role of beta-HPV in non melanoma skin cancers is unclear. HPV mainly causes benign cutaneous lesions on the hands and soles. Genital HPV infection is the most common sexually transmitted infection. It is generally asymptomatic. The genitals can be infected by two low-risk HPV types (6 and 11), which are responsible for benign anogenital warts (condylomata acuminata). The implications of anogenital warts in children are highly controversial as regards sexual abuse. Treatments (chemical, physical or immunological) are lengthy, expensive, inconvenient and often painful. Recurrence is frequent because of HPV persistence in perilesional skin.

Combined treatment of anogenital HPV infection with cryodestruction, podophyllin 25% and post-ablation immunomodulation with sinecatechins 15% ointment - a retrospective analysis.

External genital warts, caused by human papillomavirus, have a significant clinical, epidemiological, and financial impact, including the risk for malignant transformation. Treatment modalities include: (a) destructive (ablative); (b) cytotoxic (proapoptotic) and (c) immunomodulatory, with success and recurrence rates varying from 23% to 94% and from 4.1% to 77%, respectively. Most studies evaluated only single modality therapy, with few reports examining a combined approach for external genital warts management. The introduction of sinecatechins ointment in recent years has resulted in very low recurrence rates of 4.1-10.6%, despite lower initial clearance rates than ablative methods. We present a retrospective review of 27 patients who underwent combined therapy for external genital warts by using one or two sessions of cryodestruction combined with 25% podophyllin as the cytotoxic agent, and post-ablation immunomodulation with topical sinecatechins 15% ointment. This approach resulted in an excellent initial clearance rate of 96.3% with a recurrence rate of 7.4% after a total period of six months of follow-up. We suggest the importance of the combined approach in external genital warts management including post-ablative immunomodulation to augment the immune response and combat the residual latent infection. We hope to encourage trials examining the combined approach to the treatment of external genital warts.

How and when to treat molluscum contagiosum and warts in children.

Warts and molluscum contagiosum are common skin diseases in children and are usually self-limiting. The decision of whether to treat children with molluscum or warts should be individualized to the patient and his or her family. Considerations include how symptomatic the lesions are, the extent and duration of disease, the ability of the child and the parents to tolerate and comply with treatment recommendations, and any underlying medical conditions (Table, see page 219). Recurrences of molluscum contagiosum and especially warts are common, and realistic expectations regarding the potential for treatment failure and recurrence should be discussed with the child and his or her family prior to initiating any therapy. As pediatric practitioners, we all remain acutely aware of our patients' physical and psychological development and the potential for any intervention to influence this development. Although various treatment modalities now exist for the treatment of these viral diseases, any intervention should be balanced against these considerations.

Giant anal condyloma (giant condyloma acuminatum of anus) after allogeneic bone marrow transplantation associated with human papillomavirus: a case report.

INTRODUCTION: Condyloma acuminatum are caused by human papillomavirus. Giant condyloma acuminatum is a locally invasive, destructive, and large sized mass. Risk factors for the development of giant condyloma acuminatum include an immunodeficient state, such as human immunodeficiency virus infection, post-organ transplantation, or post-allogeneic bone marrow transplantation. However, reports of giant condyloma after bone marrow transplantation are extremely rare (0.3 to 1.3%). The standard treatment for giant condyloma acuminatum is recommended as wide surgical resection due to its high rate of success and low rate of recurrence. CASE PRESENTATION: A 31-year-old Korean man presented to our hospital with anal discomfort for more than one month due to a protruding mass. He had a history of BCR-ABL-positive acute lymphoblastic leukemia and had undergone an allogenic stem cell transplantation. Gross findings revealed a large perianal cauliflower-like mass over 7cm in size with invasion of the anal orifice. He was diagnosed with giant anal condyloma occurring after an allogeneic bone marrow transplantation. However, we achieved successful treatment using a combination of topical podophyllin and cryotherapy and transanal surgical excision, followed by bleomycin irrigation. CONCLUSIONS: We report an extremely rare case of giant condyloma acuminatum of anus due to human papillomavirus type six in a patient with acute lymphoblastic leukemia following an allogeneic bone marrow transplantation. The tumor was successfully treated with a combination of topical podophyllin and cryotherapy and transanal surgical excision, followed by bleomycin irrigation.

The bone marrow in systemic podophyllin toxicity.

The effects of systemic Podophyllin toxicity on the bone marrow are a manifestation of this agent's potent antimitotic activity. Our patient experienced a transient aregenerative anemia with leukopenia and thrombocytopenia. The bone marrow was hypocellular with cytoplasmic vacuolation of myeloid precursors and increased numbers of mitotic figures. Megakaryocytes were normal in number and morphology. Hematologic resolution followed discontinuance of topical therapy.

Podophyllin poisoning. Systemic toxicity following cutaneous application.

The toxicity of topically applied podophyllin in a 16-year-old girl is presented. Coma requiring respiratory support and major neurologic complications as well as hematologic and hepatic toxicity was observed. Therapy with a new modality, charcoal hemoperfusion, resulted in resolution of the acute toxicity, leaving a peripheral neuropathy which had not completely resolved after 4 months. The pharmacology and suggested treatment measures for the toxicity of this rarely reported agent are reviewed.

Patterns of treatment and resource utilization in the treatment of external genital warts in England and Wales.

Our objective was to identify patterns of treatment and resources used in achieving complete clearance of external genital warts (EGWs) A retrospective case note review was carried out at six genitourinary medicine (GUM) clinics in the UK. Case notes from 2366 patients presenting with EGWs were reviewed and 1200 patients with complete episodes of care were identified. Analysis showed that staff-applied therapy dominated treatment practice but there was considerable diversity in treatment modalities across study sites. The average number of visits was 5.71 visits for males: 6.25 visits for females but a substantial minority of patients attended significantly in excess of these averages. Approximately two-thirds of patients failed to achieve complete clearance of warts with their initial therapy. There is little consistency in treatment patterns of care for EGWs across the sites studied. Initial therapy choices are largely ineffective, requiring changes in treatment modality and multiple clinic visits. Increased utilization of patient-applied therapies might result in increased cost effectiveness.

Treatment of HIV-related hairy leukoplakia with podophyllum resin 25% solution.

Ten HIV-infected patients who had bilateral hairy leukoplakia on the tongue were treated with topical podophyllum resin 25% solution. Only one side of the bilateral lesion was treated and the other side served as the control and was not treated. The lesions on both the treatment and control sides were evaluated at day 2, 7, and 30 by an investigator who had not been involved in the initial treatment and had no knowledge of which side had been treated. Therefore the treatment side is compared with the control side in a single-subject design, single-blind control setting. The lesions were judged by the degree of resolution and assigned a number of 0 to 4 with 4 indicating the highest degree of resolution and 0 indicating no resolution or worsening of the condition. The results were analyzed by Student's t test. Significant resolution of hairy leukoplakia was noted on the treatment side compared with the control side at the 2-, 7-, and 30-day levels; the 2-day results were the most significant. Furthermore, the patients reported minimal side effects, which included burning sensation, bad or altered taste, and pain, that were of mild intensity and short duration. The side effects were reported to occur immediately after the topical application. Patient tolerance and acceptance were found to be very favorable. No systemic side effect was reported. We conclude that single topical application of podophyllum resin 25% solution is efficacious in producing significant short-term resolution of HIV-related oral hairy leukoplakia. We also conclude that it is a safe topical regimen with minimal side effects.