Combined intralesional injection of tuberculin purified protein derivative plus cryotherapy versus each alone in the treatment of multiple common warts

Abstract

Different modalities are used for treatment of common warts, but none of them had been proved the best in achieving complete cure. We aim to compare the effect of cryotherapy, intralesional injection of tuberculin purified protein derivative (PPD) and cryotherapy combined with intralesional injection of tuberculin PPD in the treatment of multiple common warts. This study is a randomized clinical trial in which the patients were randomly divided into three groups; group (A) included 25 patients subjected to cryotherapy, group (B) included 25 patients subjected to intralesional injection of tuberculin PPD and group (C) included 25 patients subjected to cryotherapy plus intralesional injection of tuberculin PPD. All the three groups showed a significant clinical improvement (p < 0.001) with statistically significant difference between cryotherapy group (A) and intralesional injection of tuberculin PPD group (B) (p < 0.001) and between cryotherapy group (A) and cryotherapy plus intralesional injection of tuberculin PPD group (C) (p < 0.001). However, there was no statistically significant difference between both intralesional injection of tuberculin PPD group alone (B) and cryotherapy plus intralesional injection of tuberculin PPD group (C) (p = 0.213). In Conclusion the cryotherapy combined with intralesional injection of PPD and intralesional injection of PPD alone are better than cryotherapy alone in treatment of multiple common warts. However, better response could be reached in combination of both cryotherapy and intralesional PPD with less number of sessions.

Systematic Review of Intralesional Therapies for Cutaneous Warts

“…Two studies trialed intralesional PPD in the largest wart compared with cryotherapy for all warts plus intralesional PPD in the largest wart and found no significant difference in response rates. However, both found a shortened time to clearance in the combination group ( Awad et al, 2023 ; Ibrahim et al, 2022 ). A combination of IFN alfa-2b with pulsed dye laser had a statistically significant higher clearance rate than either therapy alone ( Choi et al, 2002 ).…”

“…Wart types most commonly included verruca vulgaris, followed by verruca plantaris and verruca palmaris, and least commonly included verruca plana and periungual warts. Only 4 therapies were trialed in greater than 10 RCTs: these 4 most common therapies were MMR (n = 24), PPD (n = 19), vitamin D (n = 15), and Candida (n = 14) ( Table 3 ) ( Abd-Elazeim et al, 2014 ; Abd El-Magiud et al, 2020 ; Agrawal et al, 2018 ; Ahmed et al, 2020 ; Amin et al, 2021 ; Amirnia et al, 2016 ; Awad et al, 2023 ; Awal and Kaur, 2018 ; Baaniya et al, 2021 ; Bhalala et al, 2021 ; Eldahshan et al, 2022 ; ElGhareeb, 2019 ; El Sayed et al, 2020 ; Elsayed Ghaly et al, 2021 ; Fathy et al, 2019 ; Fawzy et al, 2020 ; Hodeib et al, 2021 ; Ibrahim et al, 2022 , 2020 ; Jain and Marfatia, 2021 ; Jartarkar et al, 2021 ; Kareem et al, 2019 ; Kaur et al, 2021 ; Khozeimeh et al, 2017 ; Khurshid and Pal, 2009 ; Mehta et al, 2021 ; Milante et al, 2019 ; Mohammed et al, 2021 ; Mohta et al, 2022 , 2021 ; Nassar et al, 2022 ; Nofal et al, 2022a , 2022b , 2022c , 2021a , 2021b , 2020b ; Nofal and Nofal, 2010 ; Rageh et al, 2021 ; Rajegowda et al, 2020 ; Rezai et al, 2019 ; Rutnin et al, 2023 ; Shaldoum et al, 2020 ; Wan Ahmad Kammal et al, 2021 ; Zamanian et al, 2014 ; Zainab et al, 2021 ). The most common therapy, MMR, was reported in 807 patients across studies.…”

“…All 4 common therapies had significantly variable treatment regimens, making it difficult to compare across studies. Another 18 therapies were trialed in less than 10 studies and are reported in Table 4 ( Adalatkhah et al, 2007 ; Barkat et al, 2018 ; Choi et al, 2002 ; Dhakar et al, 2016 ; Dhar et al, 2009 ; Ebrahim et al, 2021 ; Eldahshan et al, 2022 ; ElGhareeb, 2019 ; Ghonemy et al, 2020 ; Hodeib et al, 2021 ; Horn et al, 2005 ; Ibrahim et al, 2022 ; Kaur et al, 2021 ; Mohta et al, 2022 ; Muhammad et al, 2019 ; Niimura, 1990 ; Nofal et al, 2022b , 2022c , 2020a , 2020b ; Sarin and Dfwan, 1974 ; Soni et al, 2011 ; Yazdanfar et al, 2008 ).…”

“…Other therapies with greater than 80% response rate include bleomycin in 4 different studies ( Adalatkhah et al, 2007 ; Dhar et al, 2009 ; Hodeib et al, 2021 ; Soni et al, 2011 ), bleomycin with cryotherapy ( Muhammad et al, 2019 ), Candida in 2 additional studies ( Nofal et al, 2021a ; Rageh et al, 2021 ), PPD with cryotherapy ( Ibrahim et al, 2022 ), HPV vaccine ( Nofal et al, 2020a ), IFN alfa-2b with pulsed dye laser ( Choi et al, 2002 ), Mycobacterium indicus pranii (MIP) vaccine ( Kaur et al, 2021 ), MMR in 6 additional studies ( Baaniya et al, 2021 ; Mohammed et al, 2021 ; Mohta et al, 2021 ; Nofal and Nofal, 2010 ; Shaldoum et al, 2020 ), PPD in 1 additional study ( Rutnin et al, 2023 ), and vitamin D3 in 3 additional studies ( Amin et al, 2021 ; Ibrahim et al, 2020 ; Nofal et al, 2021a ).…”

“…Assume this regimen in the discussion unless otherwise noted. PPD at various regimens has 4 studies showing its superiority to cryotherapy or normal saline ( Abd-Elazeim et al, 2014 ; Amirnia et al, 2016 ; Ibrahim et al, 2022 ; Wan Ahmad Kammal et al, 2021 ). The highest rate of complete response, 87%, was achieved using 1 ml of 2.5 TU injected into the largest wart every 2 weeks for up to 6 sessions ( Wan Ahmad Kammal et al, 2021 ).…”