Intralesional Candida Antigen and Intralesional Bivalent HPV Vaccine Are More Effective Than Cryotherapy in the Treatment of Common Warts Journal of the American Academy of Dermatology

TAKE-HOME MESSAGE

• Patients with multiple common warts were randomized to treatment with intralesional Candida antigen, intralesional bivalent HPV vaccine, cryotherapy, or intralesional saline as a control treatment. The clearance rates were 63.3% in the Candida group and 50% in the HPV group, which was significantly higher than the groups treated with cryotherapy (20%) and the control group (0%). The rate of resolution of distant, non-injected warts was 71.4% in the Candida group versus 41.2% in the HPV group. Side effects included transient edema and flu–like symptoms with Candida antigen, transient erythema and edema with the HPV vaccine, and blistering and dyspigmentation with cryotherapy.

• Immunotherapy with Candida antigen or the HPV vaccine is more effective than cryotherapy in the treatment of multiple common warts.

–  Katherine M. Stiff, MD

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Sandra Marchese Johnson MD, FAAD

This is a really well-written article comparing intralesional Candida skin test antigen with intralesional bivalent HPV vaccine with cryotherapy, using intralesional saline injection as a control. Patients were treated every 2 weeks for up to five treatments. 

My favorite part of the article is the figure at the end. The authors compared the three active treatment arms. Each arm included 30 patients. Of these patients, 63.3% of patients treated with Candida had complete clearance and no recurrence; 50% of patients treated with the HPV vaccine had complete clearance and no recurrence; 20% of patients treated with cryotherapy had complete clearance, but there was recurrence in 1 of the 6 patients with complete response. The authors concluded (and I agree) that immunotherapy is more effective than cryotherapy in the treatment of multiple common warts. There is also improvement of untreated distant warts with immunotherapy. There are none of the disfiguring side effects of blistering or dyspigmentation with immunotherapy that occur with cryotherapy. One can, however, develop local erythema and edema from intralesional immunotherapy as well as occasional flu-like symptoms. 

This article is another of the many published that support immunotherapy for the treatment of HPV infections. The main benefits in my opinion include the systemic immunity, only one wart needs to be treated, and there are no disfiguring side effects. This article is interesting in that the investigators compared intralesional Candida with intralesional HPV vaccine.

Abstract 

Traditional destructive modalities, such as cryotherapy, have been applied over the years to remove tissue infected with the human papilloma virus (HPV). Because they act locally without systemic effect, every wart has to be treated, which might make these modalities inappropriate for patients with multiple lesions.1On the other hand, intralesional immunotherapeutic agents, such as Candida antigen and HPV vaccines, are associated with systemic immune responses that help eradicate HPV in both injected and noninjected warts. Therefore, they can provide an effective alternative to destructive therapy for patients with multiple warts.2,3

Journal of the American Academy of Dermatology

Comparative efficacy of intralesional Candida antigen, intralesional bivalent HPV vaccine, and cryotherapy in the treatment of common warts

J Am Acad Dermatol 2021 Aug 28;[EPub Ahead of Print], A Nassar, R Alakad, R Essam, NM Bakr, A Nofal 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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