Cryotherapy Versus Podophyllin in the Treatment of Genital Warts

Abstract: 572 patients with solitary or multiple genital warts attending the Department of Genitourinary Medicine at the Royal Victoria Hospital, Bournemouth, U.K. between lanuary 1981 and December 1981 were allocated to either pedophilic or cryotherapy for the treatment of their warts. Of 350 patients successfully treated for their warts and returned for a follow-up examination 6 weeks or more after completing their treatment, 206 (139 men and 67 women) were treated with pedophilic, and 144 (86 men and 58 women) with cry therapy. One hundred five (51 %) of those treated with pedophilic and 114 (79%) treated with cryotherapy were free of warts at their follow-up examination. Patients treated with podophyllin required a mean of 6,7 SD 3.5 treatments over a mean of 4.7 SD 2.4 weeks, whereas those receiving cryotherapy required a mean of 2.6 SD 2.0 applications over a mean of 2.3 SD 1.2 weeks.     

Treatment of external genital warts: a randomised clinical trial comparing podophyllin, cryotherapy, and electrodesiccation.

Four hundred and fifty patients were enrolled into a randomised clinical trial in a public sexually transmitted diseases clinic to evaluate the efficacy of podophyllin, cryotherapy, and electrodesiccation for treatment of external genital warts. Complete clearance of warts was observed in 41%, 79%, and 94% of patients who received up to six weekly treatments of podophyllin, cryotherapy, and electrodesiccation, respectively. Relapses occurred in 25% of all patients, yielding 3 month clearance rates of 17%, 55%, and 71% for podophyllin, cryotherapy, and electrodesiccation, respectively. Wart volume and duration did not influence treatment outcome. Response to therapy was greater in women than in men, and did not differ by treatment modality. Electrodesiccation and cryotherapy were more effective than podophyllin for the treatment of external genital warts, but none of these three treatments were highly successful.     

Autohaemotherapy for genital,anal and perianal warts

68 men and 16 women with venereal warts, who had previously been treated with podophyllin, cryotherapy, electrocautery, and surgical incision, were treated with autohaemotherapy. The patients were selected at random from patients at the Sexually Transmitted Diseases Department of the Government Rajaji Hospital, Madurai, India, from July 1987-December 1988. Autohaemotherapy is an old nonspecific treatment for chronic diseases such as inflammatory dermatoses. It involves drawing 5-10 ml venous blood from the antecubital vein and injecting it immediately into the gluteal region. Treatments were repeated weekly 3-10 times in these patients. 36.9% were completely cured, with recurrence in 2. 75% of the women, including 3 pregnant women, responded, but only 28% of the men improved. None of the women with warts on the cervix or inner thighs improved, but all women with warts on the vagina or urinary meatus were cured.     

THE COST OF TREATING GENITAL WARTS

Background. Genital warts is a common sexually transmitted disease treated by a variety of medical specialists. Standard therapies offer symptomatic relief but cannot ensure lasting remission. Using the clinical literature, claims databases, and a panel of experienced practitioners, the relative efficacy, cost, and cost effectiveness of five common treatments for genital warts were assessed in this study. Methods. We reviewed the clinical literature for the following genital wart therapies: podofilox, podophyllin, trichloroacetic acid, cryotherapy, and laser therapy, focusing on their relative efficacy. Physicians experienced in treating genital warts defined standard treatment protocols for men and women patients with moderate wart burdens. Using national claims data and protocols developed by physicians, we derived three economic models based on provider charges, third-party payments, and a resource-based relative value scale, respectively. Results. The literature review demonstrated highly variable success and recurrence rates among treatment methods and failed to show that one treatment provides consistently superior efficacy. In the economic models, treating women generally proved more costly than treating men per episode of care. This was due to the need for more extensive follow-up visits in the treatment of women. Total costs were highest for cryotherapy and lowest for a patient-applied therapy that reduced the need for follow-up visits. Conclusions. Clinicians should consider both clinical and cost issues when choosing the appropriate treatment for patients with genital warts.     

Treatment of anogenital warts. Comparison of trichloracetic acid and podophyllin versus podophyllin alone

Seventy-three patients with anogenital warts were randomly allocated to a double-blind comparison of treatment with trichloracetic acid (50%) and podophyllin (25%) versus podophyllin (25%) alone. There was no significant difference in the resolution of warts in the two treatment groups among patients followed for three months. Of patients free of warts at six weeks, treatment with trichloracetic acid/podophyllin required significantly fewer applications (mean 2.9) compared with podophyllin alone (mean 4.0). Five (17%) patients in the former group reported side effects but none in the latter group.     

Treatment of anogenital warts. Comparison of trichloracetic acid and podophyllin versus podophyllin alone.

Seventy-three patients with anogenital warts were randomly allocated to a double-blind comparison of treatment with trichloracetic acid (50%) and podophyllin (25%) versus podophyllin (25%) alone. There was no significant difference in the resolution of warts in the two treatment groups among patients followed for three months. Of patients free of warts at six weeks, treatment with trichloracetic acid/podophyllin required significantly fewer applications (mean 2.9) compared with podophyllin alone (mean 4.0). Five (17%) patients in the former group reported side effects but none in the latter group.     

Topical 5-fluorouracil has no additional benefit in treating common warts with cryotherapy: a single-centre, double-blind, randomized, placebo-controlled trial

The role of topical 5-fluorouracil (5-FU) in treating common warts is not well defined. We tried to evaluate the efficacy and adverse effects of combination cryotherapy and topical 5% 5-FU ointment in the treatment of common warts. The study was a single-centre, double-blind randomized placebo-controlled trial. In the study, 80 patients with common warts were randomized into two groups and underwent two 10-second freeze/thaw cycles of cryotherapy with liquid nitrogen once every three weeks for a maximum of five treatments. Between treatments, patients applied either topical 5% 5-FU ointment (group A) or placebo aqueous cream (group B) twice daily. The mean +/- SD reduction in wart area was 58.57 +/- 0.06% in group A and 65.29 +/- 0.06% in group B. In total, 19 patients in group A and 24 patients in group B had wart size reduced by 75% or more (P = 0.50), while 12 patients in group A and 17 patients in group B had clearance of their warts (P = 0.245). Logistic regression with age, sex, smoking status, immune status, site, duration and number of warty lesions, history of previous treatment, and treatment group found that only a history of previous treatment and acral lesions were significant adverse predictors of improvement. There was no significant difference in the number of adverse events between the two groups, although there was a trend towards more pain and blistering associated with topical 5-FU. We concluded that topical 5-FU has no added benefit in treating common warts with cryotherapy.     

5-Fluorouracil in the treatment of penile and urethral condylomata acuminata.

5-Fluorouracil (5-FU) cream was compared with podophyllin 25 percent in alcohol for treating genital and urethral condylomata acuminata. The cure rate after four weeks was found to be 6 of 18 patients treated with 5-FU and 10 of 19 treated with podophyllin. By changing the treatment for those not cured, warts regressed after four weeks in four more patients in each group. Patients were followed up for four to nine months; 10 of 27 treated with 5-FU and 14 of 31 treated with podophyllin remained in remission. It is not possible to support earlier reports on the successful treatment of meatal warts using 5-FU cream. More than half of the patients given 5-FU reported side effects after 10 to 14 days' treatment, which in some cases led them to stop using the cream. Twenty-one men considered to be treatment failures or relapses were examined by urethroscopy. No intraurethral condylomata were found but three cases of warts in the fossa navicularis were doscovered; this prompted us to introduce an instrument to examine the urethral meatus and the fossa navicularis.     

Podophyllin 0.5% or 2.0% v podophyllotoxin 0.5% for the self treatment of penile warts: a double blind randomised study.

OBJECTIVE: To compare the effectiveness and cost of self treatment of penile warts with a commercial preparation of podophyllotoxin 0.5% (PDX 0.5%) with podophyllin 0.5% and podophyllin 2.0% sourced from Podophyllum emodii. DESIGN: A prospective double blind randomised study. SUBJECTS: 315 patients with penile warts attending two departments of genitourinary medicine. MAIN OUTCOME MEASURES: Absence of warts, cessation of treatment due to severe side effects at 5 weeks. RESULTS: Of the 315 patients, 244 conformed to the protocol. Analysis was on an intention to treat basis. At 5 weeks no significant differences were found in the extent of healing of warts or in side effects for the three treatment groups. The costs of drug treatment (excluding staff time) are at least pounds 10.00 less for podophyllin than podophyllotoxin. A fourfold variation in the active constituents of the podophyllin preparations did not produce appreciably different clinical responses. In a subanalysis no evidence of deterioration in effectiveness of podophyllin over time was demonstrated. CONCLUSIONS: Penile warts in selected cases can be safely treated with 0.5-2.0% podophyllin self applied by the patient at a fraction of the cost of commercially available podophyllotoxin. The shelf life of the podophyllin extracts is at least 3 months. These findings may be especially relevant in countries where resources for health care are limited.     

Cryosurgery of genital warts in cases in which podophyllin treatment failed or was contraindicated.

A total of 56 cases with warts in which podophyllin treatment was either contraindicated or a failure, were treated with nitrous oxide using a Keymed 500 cryosurgical appliance. Forty-three patients who completed treatment were followed-up for three months. Thirty-seven of these had received applications of podophyllin twice weekly for an average period of three months before cryosurgery. The remaining cases in whom podophyllin was considered to be contraindicated included five with vulval warts (two were pregnant, two were bronchial asthmatics taking oral prednisolone, and one was taking oral clomiphene citrate), and a diabetic patients with penile warts. Thirty-two were cured and 11 relapsed. The latter were re-treated at the end of the follow-up period with two freezing cycles of 45 seconds at an interval of 30 minutes. Seven were cured and the remaining four men who failed to respond belonged to the podophyllin-resistant group and included three with metal warts and one homosexual with anogenital warts. Cryosurgery gave a cumulative success rate of 91%. A single freezing cycle was free from complications but a double freezing cycle was often followed by severe local reaction.     

Randomised controlled trial and economic evaluation of podophyllotoxin solution,podophyllotoxin cream,and podophyllin in the treatment of genital warts

OBJECTIVES: To evaluate the efficacy and cost effectiveness of self applied podophyllotoxin 0.5% solution and podophyllotoxin 0.15% cream, compared to clinic applied 25% podophyllin in the treatment of genital warts over 4 weeks. METHODS: We conducted a randomised controlled trial in 358 immunocompetent men and women with genital warts of 3 months' duration or less. RESULTS: In the principal analysis both podophyllotoxin solution (OR 2.93, 95% CI 1.56 to 5.50) and podophyllotoxin cream (OR 1.97, 95% CI 1.04 to 3.70) were associated with significantly increased odds of remission of all warts compared to podophyllin. We performed two further analyses. When subjects defaulting from follow up were assumed to have been cured odds of remission of all warts were also significantly increased both for podophyllotoxin solution (OR 3.04, 95% CI 1.68 to 5.49) and for podophyllotoxin cream (OR 2.46, 95% CI 1.38 to 4.40). When subjects defaulting from follow up were assumed not to have been cured odds of remission of all warts were significantly increased for podophyllotoxin solution (OR 1.92, 95% CI 1.13 to 3.27), but not for podophyllotoxin cream (OR 1.17, 95% CI 0.69 to 2.00). Local side effects were seen in 24% of subjects, and recurrence of warts within 12 weeks of study entry in 43% of all initially cleared subjects, without statistically significant differences between the treatment groups. Direct, indirect, and total costs were similar across the three treatment groups. Podophyllotoxin solution was the most cost effective treatment, followed by podophyllotoxin cream, with podophyllin treatment being the least cost effective. CONCLUSIONS: Self treatment of anogenital warts with podophyllotoxin showed greater efficacy and cost effectiveness than clinic based treatment with podophyllin.     

Subcutaneous interferon alpha 2a combined with cryotherapy vs cryotherapy alone in the treatment of primary anogenital warts: a randomised observer blind placebo controlled study.

OBJECTIVE--To compare patient tolerance and treatment efficacy of subcutaneous interferon (IFN) alpha 2a plus cryotherapy versus cryotherapy alone in treatment of primary anogenital (AG) warts. DESIGN--Randomised placebo controlled observer blind study. Statistical analysis was by chi square and Mann Whitney U tests. PATIENTS--60 patients with newly diagnosed AG warts. INTERVENTION--29 and 31 patients were treated with subcutaneous IFN alpha 2a plus cryotherapy or placebo injections plus cryotherapy, respectively. MAIN OUTCOME MEASURES--Clinical presence or absence of AG warts. Patients wart-free at 8 weeks were asked to re-attend at 12 weeks; those with persistent warts at 8 weeks were withdrawn from the study. RESULTS--At 8 weeks 60.7% (17/28 patients) of the IFN group and 67.9% (19/28 patients) of the placebo group were clinically wart-free (not significant); corresponding figures at 12 week review were 29.6% (8/27 patients) and 40% (10/25 patients) respectively (not significant). There was no difference in treatment response between males and females. Recurrence of warts at three month review, in patients cleared of warts at 8 weeks, was seen in 50% (8/16) and 37.5% (6/16) of patients in the IFN and placebo groups respectively (not significant). Multiple warts and the presence of perianal/anal canal warts, either alone or concurrent with warts on the genitalia, at first clinic attendance, were adverse prognostic indicators (p less than 0.001, and p = 0.05 respectively). Cervical human papilloma virus (HPV) infection, exophytic or subclinical, was present in 58.3% and 77.2% of females in the IFN and placebo groups respectively, at trial entry. Although these lesions were not directly treated, colposcopic resolution was seen in 12.5% of affected women, in both treatment groups, by the end of the 7 week treatment period. Systemic side effects were significantly more common in the IFN than in the placebo group, 50% versus 10.7% of patients (p less than 0.01). Severe influenza like symptoms occurred, after the first three injections only, in one patient treated with IFN; all other reported side effects were mild. CONCLUSIONS--Subcutaneous IFN alpha 2a combined with cryotherapy is no more effective than cryotherapy alone in the treatment of primary AG warts. The presence of multiple warts and perianal/anal canal warts are adverse prognostic indicators.     

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

One-hundred and thirty (82%) of 159 patients who had been treated with cryotherapy for warts on the hands replied to a postal questionnaire. Most patients had wanted treatment for cosmetic reasons, although 35% also wanted treatment because of pain. Only 34% had used a wart paint for more than 6 weeks before referral. The long-term results of cryotherapy were poor, although 83% of patients thought they had been cured in the short-term; only 57% of patients were clear of warts after a median of 19 months' follow-up. Seventy-one per cent had defaulted from follow-up. In some cases this may have been encouraged by the dermatologists, but other reasons were pain, cost and perceived failure of treatment. Nearly 90% tolerated cryotherapy well and for 76% this was the preferred method of treatment. Fifty-nine per cent would have preferred to be treated in their local health centre and 85% would have been willing to be treated by a nurse. The results are discussed and we conclude that cryotherapy should be offered as a treatment for hand warts in most general practices.     

Successful treatment of periungual warts using photodynamic therapy: a pilot study

AIM: The aim of this pilot study was an investigation on photodynamic therapy (PDT) whether it is a good alternative for treating periungual and subungual warts of the hands. STUDY DESIGN: Twenty patients (mean age: 30.5 years) with a total of 40 periungual and subungual warts were treated with PDT. A photosensitizer, 20%delta-aminolevulinic acid was applied on the warts. After a mean incubation time of 4.6 h (SD: 1.2), the warts were irradiated with the VersaLight for 5-30 min (15.2 +/- 4.3 min). RESULTS: After a mean of 4.5 treatments a mean clearance of 100% was achieved in 90% of the patients. One patient (5%) showed a clearance of 50% and another showed no improvement. The subungual or periungual location of the wart had no influence on the number of treatments or end result (P > 0.05). There were two recurrences during the mean follow-up period of 5.9 months (SD: 7.6). Besides mainly pain and hyperpigmentation, most treatments had no side-effects. CONCLUSION: PDT can offer a good alternative for treating periungual warts of the hands. Larger studies are indicated.     

Treatment of warts

ABSTRACT: Warts are caused by human papilloma viruses (HPV) and more than 80 types of HPV have been described. Although some HPV types in the anogenital area can lead to dysplasia and cancer, most HPV infections cause histologically benign warts. Clinically, warts produce much morbidity, mainly due to their resistance to most standard therapies. Although the choice of therapy depends partly on the location of the warts, i.e., anogenital vs. non-anogenital, most treatments in the past have been anti-wart but not antiviral. Therefore, removal of the wart was often followed by a recurrence in a few weeks due to sub-clinical or latent HPV infections surrounding the wart. Such non-antiviral therapies included a variety of acids, podophyllin, podophyllotoxin, chemotherapeutic agents, retinoids, topical sensitizers, a spectrum of surgical techniques, and cryotherapy. Two drugs approved for anogenital warts have antiviral and immunomodulatory activity, interferon and imiquimod, although imiquimod is much more convenient to use. While neither of these antiviral agents is approved for non-anogenital warts, they do appear to have efficacy in these warts when used as adjunctive therapy. Experimental therapies for warts are currently under study and include topical cidofovir and both prophylactic and therapeutic HPV vaccines.     

Compared therapeutic efficacy between intralesional bleomycin and cryotherapy for common warts: a randomized clinical trial

In spite of many available studies on bleomycin and cryotherapy in treating warts, little head to head research is done to compare efficacy of these treatments. Our aim was to compare the therapeutic effects of intralesional bleomycin and cryotherapy on common warts of the hands and feet. In this clinical trial 44 patients above 12 years of age referred to the dermatology clinic of Bouali University Hospital were enrolled. The patients were required to have warts on at least two symmetric limbs (hands or feet). The warts located on right and left limbs of each patient were examined and counted. Each patient received both cryotherapy and intralesional bleomycin on his or her warts. The two treatment types were randomly allocated to either right sided or left sided warts. Each patient was evaluated at 2 week intervals and retreated if necessary up to three times. Data were analyzed by SPSS 11 and EPI Info 2002 statistical packages. The mean number of warts was 5.2 on upper limbs and 4.6 on lower limbs. In 86.4 percent of the cases all warts on the limb side treated by intralesional bleomycin were cleared compared with 68.2 % for cryotherapy (P<0.05). Relative risk for the effect of bleomycin compared to cryotherapy in this regard was 1.27 (1相似文献   

Comparison of 40% trichloroacetic acid and cryotherapy for the treatment of plantar warts: A single‐blind,randomized clinical trial

Plantar warts can cause pain near the toes and the sole of the foot and may result in referral for treatment. This study was aimed at comparing 40% trichloroacetic acid (TCA) and cryotherapy (Cryo) for the treatment of plantar warts. This single‐blind, randomized clinical trial was performed on 60 subjects presenting with plantar wart in Sabzevar, Iran in 2018. The first intervention group was treated with 40% TCA in four sessions within 4 weeks. The second intervention group was treated with Cryo using liquid nitrogen in four sessions within 8 weeks. The mean (SD) age of subjects was 20.16 ± 5.96 years and 68.33% (n = 41) were male. Although the resolution rate of warts in the TCA 40% group was greater than the Cryo group, there was no statistical association found between the two groups by adjusting age, sex, and basal time (P = .648). Findings suggest that although 40% TCA was almost as effective as Cryo in the treatment of plantar warts, considering the lower adverse effects of TCA 40% group as compared to the Cryo group, it could be a proper alternative.     

Verrucas

Most people will experience infection with human papilloma virus (HPV) at some point in their life. Diagnosis, based on clinical examination, is usually straight forward. Treatment can, however, be challenging. Indications for treatment include pain, interference with function, cosmetic embarrassment, and risk of malignancy. Clearance rates are highest in young, healthy individuals with short duration of infection. Treatment may be with destructive agents (keratolytics, cryotherapy, curettage and cautery, laser, photodynamic therapy), with antimitotic agents (podophyllin, bleomycin, retinoids), with immune stimulants (topical sensitizers, cimetidine), or with topical virucidal agents [formaldehyde (formalin), glutaral (gluteraldehyde)]. As yet, there is no single totally effective treatment for viral warts. Some patients may choose to leave their warts untreated until spontaneous resolution. In those who seek intervention, simple, well tolerated therapies should be chosen initially in preference to more complicated, potentially harmful agents. It is likely that future research will be directed to developing an antiviral agent specific for HPV which would be safe, effective and not prohibitively expensive.     

Silver duct tape occlusion in treatment of plantar warts in adults: Is it effective?

Duct tape occlusive therapy may represent a convenient alternative to the standard wart therapies. The objective of the current study is to assess the therapeutic effect of duct tape occlusion in comparison to cryotherapy in treatment of plantar warts in adults, in a prospective comparative randomized non‐inferiority design. A total of 100 patients presenting with plantar warts were divided into two equal groups. First group was treated with silver duct tape occlusion for up to 8 weeks or disappearance of warts, whichever occurred first. Second group was treated with cryotherapy every 2 to 3 weeks for a maximum of four sessions or disappearance of warts. There was a statistically significant lower rate of complete resolution in duct tape than cryotherapy group (20% vs 58%, P = .0001, respectively). Degree of response to treatment in the duct tape and cryotherapy groups was not correlated to patients' age (P = .361 and .334, respectively) or disease duration (P = .266 and .285, respectively), while there was a statistically significant inverse relationship between the number (P = .0032 and .001, respectively) and diameter of warts (P = .013 and .003, respectively) and the degree of response in the two studied groups. Cryotherapy has higher efficacy than duct tape in the treatment of plantar warts in adults; however, duct tape may represent a practical and convenient alternative to cryotherapy in certain circumstances.     

CARBON DIOXIDE LASER TREATMENT OF PERIUNGUAL AND SUBUNGUAL VIRAL WARTS

This is a retrospective study of the cure rates of forty patients with subungual and periungual viral warts treated with carbon dioxide laser vapourisation (total of 69 lesions). 70.6% (48/68) lesions had failed treatment with cryotherapy and/or electrocautery treatment previously. 20/68 were treated with CO2 laser vapourisation as a first line treatment. The overall cure rate over 10 months follow-up period was 57.4% (39/68). Most recurrences (24/25) occurred within the first 3 months of vapourisation. The carbon dioxide laser vapourisation cure rate for warts in which previous cryotherapy and/or electrocautery had failed was 47.9% whereas those treated with carbon dioxide laser vapourisation as a first line treatment had a cure rate of 80% (p = 0.043). Subungual warts responded slightly better with a cure rate of 64.7% compared with periungual warts (54.9%) (n.s.). The carbon dioxide laser vapourisation cure rate for recurrent subungual and periungual warts (which failed previous carbon dioxide laser vapourisation) was 73.3% (11/15). Our findings appeared to indicate that periungual and subungual warts can be eradicated by CO2 laser vapourisation. Recurrent warts can be effectively eradicated by further vapourisation. Recalcitrant periungual and subungual warts which have previously failed to respond to cryotherapy and/or electrocautery can be effectively eradicated with CO2 laser vapourisation.