Effectiveness of topical and ablative therapies in treatment of anogenital warts: a systematic review and network meta-analysis

Abstract

ObjectiveTo generate estimates of comparative clinical effectiveness for interventions used in the treatment of anogenital warts (AGWs) through the systematic review, appraisal and synthesis of data from randomised controlled trials (RCTs).DesignSystematic review and network meta-analysis of RCTs. Search strategies were developed for MEDLINE, Embase, the Cochrane Library and the Web of Science. For electronic databases, searches were run from inception to March 2018. The systematic review was carried out following the general principles recommended in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.ParticipantsPeople aged ≥16 years with clinically diagnosed AGWs (irrespective of biopsy confirmation).InterventionsTopical and ablative treatments recommended by the British Association for Sexual Health and HIV for the treatment of AGWs, either as monotherapy or in combination versus each other.Outcome measuresComplete clearance of AGWs at the end of treatment and at other scheduled visits, and rate of recurrence.ResultsThirty-seven RCTs met inclusion criteria. Twenty studies were assessed as being at unclear risk of bias, with the remaining studies categorised as high risk of bias. Network meta-analysis indicates that, of the treatment options compared, carbon dioxide laser therapy is the most effective treatment for achieving complete clearance of AGWs at the end of treatment. Of patient-applied topical treatments, podophyllotoxin 0.5% solution was found to be the most effective at achieving complete clearance, and was associated with a statistically significant difference compared with imiquimod 5% cream and polyphenon E 10% ointment (p<0.05). Few data were available on recurrence of AGWs after complete clearance. Of the interventions evaluated, surgical excision was the most effective at minimising risk of recurrence.ConclusionOf the studies assessed, as a collective, the quality of the evidence is low. Few studies are available that evaluate treatment options versus each other.Trial registration numberCRD42013005457

Local Management of Anogenital Warts in Non-Immunocompromised Adults: A Network Meta-Analysis of Randomized Controlled Trials

“…Our results are in line with the NMA of Barton et al [13], which concluded that ablative techniques were superior. However, unlike us, Barton Unlike systematic reviews on AGW management [10,13,97], our NMA examined the efficacy of combination therapies, including ablative therapy ? imiquimod, cryotherapy ?…”

“…Furthermore, RCTs comparing several major treatments for AGWs (cryotherapy [12] vs podophyllotoxin cream or gel, imiquimod vs TCA, CO 2 laser vs surgery or electrosurgery, etc.) are lacking [10,[13][14][15] and may never be performed (because they are costly, time-consuming, less attractive than new treatments, etc.). Reliable evidence on the comparative efficacy of these treatments is nevertheless needed to make informed clinical decisions.…”

“…In this context, network meta-analyses (NMAs) can help compare the relative benefits associated with different types of intervention for the same disease [16,17]. The only NMA on AGWs, which was conducted by Barton et al [13] based on a systematic review up to March 2018, concluded that ablative techniques were superior; it also found podophyllotoxin 0.5% gel to be the most cost-effective topical treatment. However, this NMA did not examine sinecatechins, 5-FU cream, and several RCTs on new treatments [citric acid, intralesional bleomycin, potassium hydroxide (KOH), photodynamic therapy (PDT), etc.…”

Letter to the Editor Regarding ‘A Multicentre, Randomised Clinical Trial to Compare a Topical Nitrizinc® Complex Solution Versus Cryotherapy for the Treatment of Anogenital Warts’

“…A high risk of bias has been identified in RCTs of AGW treatments. This is largely explained by the fact that blinding of participants and care providers is difficult or impossible to achieve in the case of provideradministered treatments [4,5]. Although Pontini et al [1] ensured that the effectiveness of the nitrizinc complex solution and cryotherapy was evaluated by someone other than the physician administering treatment, lack of blinding may have resulted in the physician's lack of conviction in his or her own actions and poor adherence to trial protocol, placebo effects, or early patient withdrawal from the study [6].…”

“…A high risk of bias has been identified in RCTs of AGW treatments. This is largely explained by the fact that blinding of participants and care providers is difficult or impossible to achieve in the case of provider-administered treatments [ 4 , 5 ]. Although Pontini et al .…”