Journal of Clinical and Aesthetic Dermatology

MAY 2018

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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18 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY May 2018 • Volume 11 • Number 5 O R I G I N A L R E S E A R C H was seen in 70 percent of palmoplantar warts and 68 percent of common warts (Table 4). Good response was observed in 16.6 percent of total warts, with moderate response in 8.3 percent. Figure 4 shows moderate response in a case of plantar warts after five injections. Response in distant and recalcitrant warts was also observed (Table 5). Adverse effects were evaluated at every visit, then at six weeks and 16 weeks after the last injection. In the MMR group, 90 percent of the patients reported pain while receiving the injection, and in the control group, 88 percent patients reported pain during injection. Additionally, six percent patients in the MMR group reported rhinitis and headache (flu-like symptoms), which were relieved using paracetamol and antihistaminics. Erythema and edema after injection were observed in only four percent of the MMR group and zero in the control group (Table 6). Recurrence was observed in two (2.7%) patients who received MMR injections and three (6%) patients in the control group at 16 weeks after the last injection. DISCUSSION In our practice, the prevalence of cutaneous warts has been increasing. Frequent relapses and resistance to treatment have become challenging problems for dermatologists. Despite the availability of multiple therapeutic options for the treatment of warts, recurrence and resistance to treatment are still commonly seen. 8 Lately, the role of the immune system has been widely studied in patients with cutaneous warts. Spontaneous resolution of warts has led to exploration of the role of the immune system theory. 9,10 As per the literature, there is increase in Th1 cytokines along with the infiltration of T cells (e.g., CD4+,CD8+) around the wart, which is responsible for its spontaneous regression. 11 Keeping in mind this cell-mediated mechanism, various immunotherapeutic options have been used, including oral zinc sulphate, levamisole, cimetidine, and topical contact sensitizers (e.g., dinitrochlorobenzene, diphencyprone, squaric acid dibutyl ester, and imiquimod). 12 Despite the immunomodulatory role of these agents, however, the results obtained generally are not significantly satisfactory. Recently, the use of injectable immunotherapy using antigens such as MMR has gained popularity. Better results with A B B A TABLE 4. Observed response according to the type of warts in MMR injection group (N=72) RESPONSE GRADING PALMO-PLANTAR WARTS (n=31) VERRUCA VULGARIS (n=32) VERRUCA PLANA (n=9) TOTAL (n=72) Complete response, n (%) 22 (70.9) 22 (68.7) 5 (55.5) 49 (68.0) Good response, n (%) 6 (19.0) 4 (12.5) 2 (22.2) 12 (16.6) Moderate response, n (%) 2 (6.4) 4 (12.5) 0 (0.0) 6 (8.3) Mild/no response, n (%) 1 (3.2) 2 (6.2) 2 (22.2) 5 (6.9) n: number FIGURE 3. A case of good response seen over the dorsum of the foot—A) before treatment and B) after the fifth injection. FIGURE 4. Moderate response in plantar warts—A) before treatment and B) after fifth injection

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