Cryotherapy of hand warts--a questionnaire survey of 'consumers'

A randomized comparative evaluation of clinical and home application to investigate the effectiveness of silver nitrate (AgNO3 ) (95%) for the treatment of verruca pedis

OBJECTIVE

To investigate the clinical effectiveness of silver nitrate (95%) for the treatment of verruca pedis comparing professional and self-application treatments.

METHODS

A single-centre, two-armed randomized evaluation was conducted at a University podiatry clinic. A total of 113 participants (101 analysed) with verruca pedis were included. Participants were randomized to either a clinical group, where silver nitrate was applied by a healthcare professional or a home group, where silver nitrate was self-applied. The main outcome measure was post-treatment pain, controlling for pre-treatment pain, and resolution of the verruca. Secondary outcome measures were participant satisfaction, partial reduction in the verruca and ease of use of the product.

KEY FINDINGS

The study showed no significant difference between home treatment and clinically applied treatment for the treatment of verruca pedis in either primary outcome; however, a substantive difference in resolution between groups was recorded, with 34.0% full resolution and 26.4% partial resolution in the clinical treatment group, and 18.8% full resolution and 37.5% partial resolution in the home treatment group. Participants widely reported general ease of use of the product. All participants reported a reduction in pain as a result of the intervention.

CONCLUSION

Silver nitrate has been shown to be a safe and effective treatment for verruca pedis, with equal success rates when compared between home and clinical applications.

Intralesional Mycobacterium w Vaccine Versus Cryotherapy in Treatment of Refractory Extragenital Warts

Background:

Initial reports of immunotherapy using intralesional Mycobacterium w (Mw) vaccine have documented its useful role in treatment of genital and extragenital warts.

Objectives:

To compare the efficacy and safety of intralesional Mw vaccine versus cryotherapy in the treatment of refractory extragenital warts.

Methods:

This was a prospective, randomized, comparative study of 66 patients. The outcome was assessed in terms of complete clearance of warts and change in Dermatology Life Quality Index (DLQI) score.

Results:

Complete clearance of treated warts was seen in 66.7% (20/30) and 65.5% (19/29) of patients in the Mw and cryotherapy groups, respectively ( P = .769). Clearance of distant warts was significantly ( P = .004) high in the Mw group. Improvement in DLQI was greater in the Mw group. Both treatment modalities were well tolerated, and no major side effects occurred.

Conclusions:

Mw vaccine and cryotherapy are equally efficacious in treatment of refractory extragenital warts. Mw vaccine has an added advantage of clearance of distant warts.

Topical treatments for cutaneous warts

BACKGROUND

Viral warts are a common skin condition, which can range in severity from a minor nuisance that resolve spontaneously to a troublesome, chronic condition. Many different topical treatments are available.

OBJECTIVES

To evaluate the efficacy of local treatments for cutaneous non-genital warts in healthy, immunocompetent adults and children.

SEARCH METHODS

We updated our searches of the following databases to May 2011: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, MEDLINE (from 2005), EMBASE (from 2010), AMED (from 1985), LILACS (from 1982), and CINAHL (from 1981). We searched reference lists of articles and online trials registries for ongoing trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of topical treatments for cutaneous non-genital warts.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials and extracted data; a third author resolved any disagreements.

MAIN RESULTS

We included 85 trials involving a total of 8815 randomised participants (26 new studies were included in this update). There was a wide range of different treatments and a variety of trial designs. Many of the studies were judged to be at high risk of bias in one or more areas of trial design.Trials of salicylic acid (SA) versus placebo showed that the former significantly increased the chance of clearance of warts at all sites (RR (risk ratio) 1.56, 95% CI (confidence interval) 1.20 to 2.03). Subgroup analysis for different sites, hands (RR 2.67, 95% CI 1.43 to 5.01) and feet (RR 1.29, 95% CI 1.07 to 1.55), suggested it might be more effective for hands than feet.A meta-analysis of cryotherapy versus placebo for warts at all sites favoured neither intervention nor control (RR 1.45, 95% CI 0.65 to 3.23). Subgroup analysis for different sites, hands (RR 2.63, 95% CI 0.43 to 15.94) and feet (RR 0.90, 95% CI 0.26 to 3.07), again suggested better outcomes for hands than feet. One trial showed cryotherapy to be better than both placebo and SA, but only for hand warts.There was no significant difference in cure rates between cryotherapy at 2-, 3-, and 4-weekly intervals.Aggressive cryotherapy appeared more effective than gentle cryotherapy (RR 1.90, 95% CI 1.15 to 3.15), but with increased adverse effects.Meta-analysis did not demonstrate a significant difference in effectiveness between cryotherapy and SA at all sites (RR 1.23, 95% CI 0.88 to 1.71) or in subgroup analyses for hands and feet.Two trials with 328 participants showed that SA and cryotherapy combined appeared more effective than SA alone (RR 1.24, 95% CI 1.07 to 1.43).The benefit of intralesional bleomycin remains uncertain as the evidence was inconsistent. The most informative trial with 31 participants showed no significant difference in cure rate between bleomycin and saline injections (RR 1.28, 95% CI 0.92 to 1.78).Dinitrochlorobenzene was more than twice as effective as placebo in 2 trials with 80 participants (RR 2.12, 95% CI 1.38 to 3.26).Two trials of clear duct tape with 193 participants demonstrated no advantage over placebo (RR 1.43, 95% CI 0.51 to 4.05).We could not combine data from trials of the following treatments: intralesional 5-fluorouracil, topical zinc, silver nitrate (which demonstrated possible beneficial effects), topical 5-fluorouracil, pulsed dye laser, photodynamic therapy, 80% phenol, 5% imiquimod cream, intralesional antigen, and topical alpha-lactalbumin-oleic acid (which showed no advantage over placebo).We did not identify any RCTs that evaluated surgery (curettage, excision), formaldehyde, podophyllotoxin, cantharidin, diphencyprone, or squaric acid dibutylester.

AUTHORS' CONCLUSIONS

Data from two new trials comparing SA and cryotherapy have allowed a better appraisal of their effectiveness. The evidence remains more consistent for SA, but only shows a modest therapeutic effect. Overall, trials comparing cryotherapy with placebo showed no significant difference in effectiveness, but the same was also true for trials comparing cryotherapy with SA. Only one trial showed cryotherapy to be better than both SA and placebo, and this was only for hand warts. Adverse effects, such as pain, blistering, and scarring, were not consistently reported but are probably more common with cryotherapy.None of the other reviewed treatments appeared safer or more effective than SA and cryotherapy. Two trials of clear duct tape demonstrated no advantage over placebo. Dinitrochlorobenzene (and possibly other similar contact sensitisers) may be useful for the treatment of refractory warts.

Does immunotherapy of viral warts provide beneficial effects when it is combined with conventional therapy?

Background

Cryotherapy has been accepted as the mainstay in treating periunugal and palmoplantar warts. The major drawback of cryotherapy is the requirement of several unbearably painful treatment sessions.

Objective

This study aims to assess the efficacy of immunotherapy in viral wart treatment, as an adjunctive method to cryotherapy.

Methods

Retrospective chart review was performed on 124 patients visiting the hospital from January to December 2009 for the treatment of periungual and plantar warts. We analyzed the number of cryotherapy sessions necessary for treating warts and assessed the clinical benefits from the addition of other treatment modalities, by adjusting the various confounding factors.

Results

Of the 124 investigated patients, immunotherapy with diphenylcyclopropenone (DPCP) was performed in 14 patients (11%), together with cryotherapy. After adjusting the factors related to the therapeutic difficulties of wart, the average number of cryotherapy sessions for the immunotherapy-combined group was significantly lower (3.58±1.25) than that for the cryotherapy only group (5.10±0.44) (p=0.026). However, there were no differences in the number of treatment sessions of cryotherapy when topical 5-FU/salicylic acid agents were added to the treatment.

Conclusion

Immunotherapy may be a successful adjuvant to cryotherapy in reducing the number of agonizing cryotherapy sessions.

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

BACKGROUND

Viral warts are a common infectious disease and liquid nitrogen cryotherapy is one of the most common methods for treatment of these warts. Hand-foot viral warts frequently recur and reduce quality of life as well.

OBJECTIVE

To find the ideal treatment interval between cryotherapy sessions that can influence not only the cure rate but also the recurrence rate for hand-foot viral warts.

METHODS

A retrospective study was designed to compare a 2 week interval and a 3 week interval between cryotherapy sessions on hand-foot viral warts with respect to cure rate, recurrence rate, treatment number, duration of treatment, mean time to recurrence and adverse events.

RESULTS

A total of 560 patients were enrolled. The overall cure rate was 75.7% and the recurrence rate was 19.6%. The mean time to recurrence was 7.8 months (range 1~26 months). For the 2-week and 3-week groups, cure rates were, respectively, 76.6% (196) and 75.0% (228); recurrence rates were 13.3% (26) and 25.0% (57). The mean time to recurrence was 9.8 months and 6.9 months, respectively. Adverse events were not statistically different.

CONCLUSION

We suggested that 2-week cryotherapy is optimal not only because of the rapid cure but also because of the lower recurrence rate and similar adverse events.

Topical treatments for cutaneous warts

BACKGROUND

Viral warts are common and usually harmless but very troublesome. A very wide range of local treatments are used.

OBJECTIVES

To assess the effects of different local treatments for cutaneous, non-genital warts in healthy people.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (March 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to March 2005), EMBASE (1980 to March 2005) and a number of other biomedical databases. The references of all trials and selected review articles were also searched. In addition, we contacted pharmaceutical companies involved in local treatments for warts and experts in the field

SELECTION CRITERIA

Randomised controlled trials of local treatments for cutaneous non-genital viral warts in immunocompetent (healthy) people.

DATA COLLECTION AND ANALYSIS

Data was extracted and two authors independently selected the trials and assessed methodological quality.

MAIN RESULTS

Sixty trials were identified that fulfilled the criteria for inclusion. The evidence provided by these studies was generally weak due to poor methodology and reporting. In 21 trials with placebo groups that used participants as the unit of analysis, the average cure rate of placebo preparations was 27% (range 0 to 73%) after an average period of 15 weeks (range 4 to 24 weeks). The best available evidence was for simple topical treatments containing salicylic acid, which were clearly better than placebo. Data pooled from five placebo-controlled trials showed a cure rate of 117/160 (73%) compared with 78/162 (48%) in controls, which translates to a risk ratio of 1.60 (95% confidence interval 1.16 to 2.23), using a random effects model. Evidence for the absolute efficacy of cryotherapy was surprisingly lacking. Two trials comparing cryotherapy with salicylic acid and one comparing duct tape with cryotherapy showed no significant difference in efficacy. Evidence for the efficacy of the remaining treatments reviewed was limited.

AUTHORS' CONCLUSIONS

There is a considerable lack of evidence on which to base the rational use of topical treatments for common warts. The reviewed trials are highly variable in method and quality. Cure rates with placebo preparations are variable but nevertheless considerable. There is certainly evidence that simple topical treatments containing salicylic acid have a therapeutic effect. There is less evidence for the efficacy of cryotherapy, but reasonable evidence that it is only of equivalent efficacy to simpler and safer treatments. The benefits and risks of topical dinitrochlorobenzene and 5-fluorouracil, intralesional bleomycin and interferons, photodynamic therapy and other miscellaneous treatments remain to be determined.

Local treatments for cutaneous warts

BACKGROUND

Viral warts caused by the human papilloma virus represent one of the most common diseases of the skin. Any area of skin can be affected although the hands and feet are by far the commonest sites. A very wide range of local treatments are available.

OBJECTIVES

To assess the effects of different local treatments for cutaneous, non-genital warts in healthy people.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (January 2003), the Skin Group trials register (January 2003), MEDLINE (1966 to January 2003), EMBASE (1980 to January 2003) and a number of other key biomedical and health economics databases. In addition the cited references of all trials identified and key review articles were searched. Pharmaceutical companies involved in local treatments for warts and experts in the field were contacted. The most recent searches were carried

SELECTION CRITERIA

Randomised controlled trials of local treatments for cutaneous non-genital viral warts in immunocompetent human hosts were included.

DATA COLLECTION AND ANALYSIS

Study selection and assessment of methodological quality were carried out by two independent reviewers.

MAIN RESULTS

Fifty two trials were identified which fulfilled the criteria for inclusion in the review. The evidence provided by these studies was generally weak because of poor methodology and reporting. In 17 trials with placebo groups that used participants as the unit of analysis the average cure rate of placebo preparations was 30% (range 0 to 73%) after an average period of 10 weeks (range 4 to 24 weeks). The best available evidence was for simple topical treatments containing salicylic acid, which are clearly better than placebo. Data pooled from six placebo-controlled trials show a cure rate of 144/191 (75%) compared with 89/185 (48%) in controls, odds ratio 3.91 (95% confidence interval 2.40 to 6.36), random effects model. Most of the bigger trials of cryotherapy studied different regimens rather than comparing cryotherapy with other treatments or placebo. Pooled data from two small trials that included cryotherapy and placebo or no treatment, showed no significant difference in cure rates. In two trials comparing cryotherapy with salicylic acid and one comparing duct tape with cryotherapy no significant difference in efficacy was demonstrated. There was no consistent evidence for the effectiveness of intralesional bleomycin. Four studies, using warts rather than individuals as the unit of analysis, had widely varying results which could not be meaningfully pooled. There was some evidence for the efficacy of dinitrochlorobenzene, a potent contact sensitizer. Pooled data from two small studies comparing dinitrochlorobenzene with placebo showed cure rates of 32/40 (80%) and 15/40 (38%) respectively, odds ratio 6.67 (95% confidence interval 2.44 to 18.23), random effects model. Only limited evidence was found for the efficacy of topical 5-fluorouracil, intralesional interferons and photodynamic therapy.Bleomycin, dinitrochlorobenzene, 5-fluorouracil, interferons and photodynamic therapy are potentially hazardous or toxic treatments.

REVIEWER'S CONCLUSIONS

There is a considerable lack of evidence on which to base the rational use of the local treatments for common warts. The reviewed trials are highly variable in method and quality. Cure rates with placebo preparations are variable but nevertheless considerable. There is certainly evidence that simple topical treatments containing salicylic acid have a therapeutic effect. There is less evidence for the efficacy of cryotherapy and some evidence that it is only of equivalent efficacy to simpler, safer treatments. Dinitrochlorobenzene appears to be effective but there were no statistically significant differences when compared with the safer, simpler and cheaper topical treatments containing salicylic acid. The benefits and risks of 5-fluorouracil, bleomycin, interferons and photodynamic therapy remain to be determined.

Photodynamic therapy with 5-aminolaevulinic acid or placebo for recalcitrant foot and hand warts: randomised double-blind trial

BACKGROUND

Photodynamic therapy (PDT) with topical 5-aminolaevulinic acid (ALA) followed by irradiation with incoherent light (ALA-PDT) for recalcitrant warts have had beneficial results. Therefore, we undertook a randomised, parallel, double-blind clinical trial of ALA-PDT versus placeboPDT for recalcitrant foot and hand warts.

METHODS

Recalcitrant foot and hand warts were randomly assigned to six repetitive ALA-PDT or placebo-PDT interventions combined with standard treatment encompassing paring followed by a keratolytic (Verucid). Standardised photographs of each wart were taken before, during (week 7) and after treatment (weeks 14 and 18). The area of each wart compared with entry area was the primary outcome variable, measured from photographs by an evaluator unaware of treatment allocation for intervention. Pain intensity immediately and 24 h after each intervention was assessed by a five-point scale.

FINDINGS

A total of 232 foot and hand warts in 45 patients were entered into the trial: 117 warts were allocated to ALA-PDT and 115 warts to placebo-PDT. In week 14, the median relative reduction in wart area was 98% in the ALA-PDT group (interquartile range 100%, 55%) versus 52% (100%, 0) in the placebo group (p=0.0006). In week 18, the median relative reduction in wart area was 100% in the ALA-PDT group (100%, 57%) versus 71% (100%, 0) in the placebo-PDT arm (p=0.008). Both the number of vanishing warts and the difference in relative wart area of persisting warts at week 14 and 18 were significant (p<0.05) in favour of ALA-PDT. Significantly more ALA-PDT warts were graded at a higher pain intensity after treatment than placebo-PDT warts.

INTERPRETATION

ALA-PDT is superior to placebo-PDT when both wart area and number of vanishing warts are considered.

Treatment of common warts using the infrared coagulator

BACKGROUND

The infrared coagulator (IRC) is an instrument that delivers a narrow beam of noncoherent infrared light to the skin surface.

OBJECTIVE

The purpose of the study was to determine the utility of the infrared coagulator in treating common warts of the hands and feet.

METHODS

Forty-four warts in 21 patients were treated with 1.25-second pulse durations. Thirty-one of the warts were recurrent after previous electrosurgery or cryosurgery. Average follow-up time was 11 months.

RESULTS

Overall, 25 warts (57%) resolved after one treatment, 6 warts (14%) regressed and cleared with additional treatment, and 13 warts (30%) recurred, giving an overall cure rate of 70%. Eleven of the 21 patients (52%) were cleared of all their treated warts.

CONCLUSION

The IRC is a useful therapeutic modality for common warts.