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Intralesional Antigen Immunotherapy for Treatment of Periungual Warts
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In this blinded prospective study, 150 patients (aged 6–22 years) with periungual warts were randomized to receive intralesional measles, mumps, rubella (MMR) vaccine; Candida antigen; or purified protein derivative (PPD). Patients were treated at 2-week intervals for a maximum of 5 treatment sessions or until complete resolution. Complete clearance of warts was achieved in 80% of the Candida antigen group, 74% of the MMR group, and 70% of the PPD group. The mean number of sessions needed to treat ranged from 1.88 (Candida) to 4.22 (MMR). Erythema, edema, and flu-like symptoms were experienced by a minority of patients in all three treatment groups. No recurrence was noted following 6 months of follow-up in all treatment groups.
- These data suggest that intralesional antigen immunotherapy with MMR, Candida antigen, or PPD may be efficacious in the treatment of periungual warts with low recurrence potential. Intralesional immunotherapy was well tolerated and did not cause cosmetic disfigurement of the nail.
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
Intralesional immunotherapy using different types of antigens is considered an effective and safe treatment option for different types of warts. However, there are few studies that illustrate the use of these antigens in the treatment of periungual warts as a distinct type of warts.
OBJECTIVE
To evaluate the efficacy and safety of three antigens: measles, mumps, rubella (MMR) vaccine, Candida antigen, and purified protein derivative (PPD) in the treatment of periungual warts.
METHODS
The study included 150 patients who were randomly assigned to 3 groups with 50 patients in each. Each agent was injected intralesionally at a dose of 0.1 mL into the largest wart at 2-week intervals until complete clearance or for a maximum of 5 sessions.
RESULTS
Complete clearance of warts was observed in 70%, 80%, and 74% in PPD, Candida antigen, and MMR vaccine groups, respectively. There was no statistically significant difference regarding the therapeutic response between the 3 studied groups. Adverse effects were transient and insignificant in the 3 groups. No recurrence of the lesions was reported in any of the studied groups.
CONCLUSIONS
Intralesional antigen immunotherapy seems to be an effective therapeutic option for the treatment of periungual warts.
Additional Info
Intralesional Antigen Immunotherapy in the Treatment of Periungual Warts
J Cutan Med Surg 2021 Jan 27;[EPub Ahead of Print], A Nofal, R Alakad, I Fouda, MM FawzyFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Dermatology
“Intralesional Antigen Immunotherapy in the Treatment of Periungual Warts” by Nofal and colleagues is a report on a well-designed, well-executed study. They compare intralesional immunotherapy with Candida, MMR, and PPD for the treatment of periungual warts. As dermatologists, we all know how difficult it is to treat warts under and around the nails as well as to eradicate the virus under the nail plate. These authors designed a Skintastic study and report similar efficacy to other studies for the treatment of warts using immunotherapy, which hovers at about 70%. As expected, compared with other studies, Candida immunotherapy is more robust and therefore will have a higher success rate and a higher adverse event rate as compared with MMR. Complete response with Candida is 80% versus 74% with MMR and 70% with PPD. The rate of local adverse events is 12% with Candida, 6% with MMR, and 8% with PPD. Flu-like symptoms occur in 10% of people treated with Candida, 4% with MMR, and 6% with PPD. No patients had recurrence of warts after 6 months. The authors also were able to demonstrate distant response of untreated warts. Their design is like our paper published in 2001, which is one of the first papers to show the benefits of injecting Candida skin test antigen to treat warts.1 This is another well-done paper to support the use of Candida immunotherapy for the treatment of HPV tumors.
Reference
Dermatology
Intralesional immunotherapy for warts appears here to stay. Optimal antigen dose as well as administration schedule ought to be investigated further, although the response rates documented in this study (which are better than mine) suggest that there is only a little wiggle room. PPD will only be effective in populations with a high incidence of tuberculosis or of immunization with BCG—still, a large portion of the world‘s population. The biggest question in my mind is whether there is an antigenic source better than Candida. Surely, it‘s out there.