Verrucae, current treatment regimes

Report
VERRUCAE, CURRENT
TREATMENT REGIMES
KERWIN TALBOT
OUTLINE
• BIOLOGY OF WARTS
• EPIDEMIOLOGY
• DIFFERENTIAL DIAGNOSIS
• TREATMENT FACTORS
• TREATMENTS

BRIEF SUMMARY OF THE LARGE VARIETY OF
TREATMENTS

IN-DEPTH EXAMINATION OF THE HIGHER EVIDENCE
BASED TREATMENTS
• DISCUSSION
• CONCLUSION
BIOLOGY OF WARTS
• CUTANEOUS VIRAL WARTS, CAUSED BY THE HUMAN
PAPILLOMA VIRUS
• (HPV)
• DNA VIRUSES, WHICH INFECT EPITHELIAL CELLS
• MINOR ABRASIONS AND INFECTIONS FREQUENTLY SERVE
AS CONDUITS
FOR HPV
• REMAIN DORMANT WITHOUT VISIBLE DISEASE
• THE MOST COMMON INFECTIONS ARE WITH HPV TYPE 1,2,
4, 37 AND 57 ON THE HANDS AND FEET.
EPIDEMIOLOGY
OVERALL PREVALENCE OF WARTS OF 32.8/1000 IN THE 15 TO
74 YEARS AGE RANGE.
• YOUNGER GENERATION- HIGHER PREVALENCE
VIRAL ACTIVITY LIKELY DEPENDS ON:
• IMMUNE STATUS
• RESPONSE OF THE INFECTED INDIVIDUAL
SEROCONVERSION AFTER NATURAL INFECTION IS :
• RELATIVELY SLOW
• VIRAL LOAD
• PERSISTENT INFECTION
• RECURRENCE AFTER CLINICAL CURE IS OFTEN DUE TO LATENT
VIRUS VERSUS REINFECTION
DIFFERENTIAL DIAGNOSIS
WARTS ARE IDENTIFIED BY: A CHANGE IN THE REGULAR
PAPILLARY SKIN LINES WITH INDEPENDENT VASCULAR
SOURCES.
HPV CAN MASQUERADE AS:
• A SEBORRHEIC KERATOSIS,
• CALLUS,
• CORN,
• EPIDERMAL NEVUS,
• MOLLUSCUM CONTAGIOSUM OR SQUAMOUS CELL
CARCINOMA.
IS IT IMPORTANT TO KEEP THESE IN MIND- IF UNSURE
HISTOLOGICAL EXAMINATION MAY NEED TO BE PERFORMED.
INDICATIONS FOR WART
TREATMENT
• DEVELOPED BY THE AMERCIAN ACADEMY OF
DERMATOLOGY
1) THE PATIENT’S DESIRE FOR THERAPY,
2) SYMPTOMS OF PAIN, BLEEDING, ITCHING OR BURNING,
3) DISABLING OR DISFIGURING LESIONS,
4) LARGE NUMBERS OR LARGE SIZES OF LESIONS,
5) THE PATIENT’S DESIRE TO PREVENT THE SPREAD OF WARTS
TO UNBLEMISHED SKIN OF SELF OR OTHERS, AND
6) AN IMMUNOCOMPROMISED CONDITION.
TREATMENT FACTORS
WHEN CHOOSING A TREATMENT
• AGE
• SITE OF INFECTION,
• SIZE,
•
NUMBER AND TYPES,
•
IMMUNOLOGICAL STATUS,
•
TREATMENT AVAILABILITY,
• COST,
• PATIENT’S DESIRE FOR THERAPY,
• ABILITY TO ADHERE,
• PAIN TOLERANCE.
SUMMARY OF TREATMENTS
Treatment categories
Treatment
Folk and
alternative treatments
• Folklore
• Hypnosis/Suggestive Therapy
• Garlic Extracts
• Duct Tape
Destructive therapy
• Surgical Removal by Curettage or Cautery
• Salicylic Acid
• Cantharidin
• Cryotherapy
•
•
•
•
•
•
•
•
Exothermic Patches
Ultrasound Hyperthermia
Radiofrequency Ablation
Microwave Treatment
Infrared Coagulation
Carbon Dioxide (CO2) Laser
Pulsed Dye Laser
Photodynamic Therapy
SUMMARY OF TREATMENTS
Treatment categories
Treatments
Virucidal Therapy
• Glutaraldehyde
• Formaldehyde
• Formic Acid
• Antiviral Drugs
Antimitotic Therapy
•
•
•
•
Immunotherapy
• Oral Zinc Sulphate
Bleomycin
Retinoids
Podophyllin
Podophyllotoxin
• Contact Sensitizers
• Intralesional Injection of Interferon
• 5-Fluorouracil (5-FU)
Combination Therapies
• 5-FU + Salicylic Acid
• Cryotherapy + Podophyllotoxin
• SA + cryotherapy
TREATMENT SPECIFICS
Treatment
type
Treatment
Cost
Reported
efficacy
Reported
pain
Reoccurrence
Side effects
Alternative
remedies
Destructive
Duct tape
Low
High* 85%
Low
Not reported
None (allergy)
Surgical
High*
Low
High -30%
Scarring
Silver nitrate
Low*
High* 6585%
Mod
43%
Low*
Mod 15%
Salicylic acid
Low*
Mod-high
70%
Low -mod
Low
Clinical burns
Irreversible tissue
staining
Localised burns
Contact
dermatitis
Cryotherapy
Traditional
Mod*
Low-mod
30%
Mod
Low
Aggressive
Mod*
Mod 50%
Mod-high*
Low
Virucidal
therapy
Formalin
Low*
(aqueous
solution)
Immunothera Oral zinc sulphate Low*
py
Combination Salicylic acid and Mod*
therapies
cryotherapy
Blistering and
pain* (44%)
Mod-high
60-67%
Low
Low
Increase risk and
severity (64%)
Sensitivity*
High 87%
Low
Not reported
Minimal
High 50100%
Mod-high
Low
Clinical burns
Blistering
Pain
TREATMENTS
KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendation
Evidence rating
Topical salicylic acid therapy is recommended
A
Cryotherapy is not recommended over salicylic acid for treatment
Aggressive is recommended over traditional
A
Surgical is only recommended over salicylic acid in case by case basis
B
Sliver nitrate is recommend for patients with low pain tolerance and children
and facial areas
B
Formalin has found to be effective, pain less and have minimal side effects
B/C
There is poor evidence to recommend pulsed dye laser therapy
B
TREATMENTS
SALICYLIC ACID (SA)
•
KERATOLYTIC THERAPY
•
OVER-THE-COUNTER- 17% SALICYLIC ACID
•
THERAPEUTIC- UP TO 80% SOLUTION.
ADVANTAGES:
•
CONVENIENCE, MINIMAL EXPENSE, NEGLIGIBLE PAIN AND REASONABLE
EFFECTIVENESS.
DISADVANTAGES:
•
REQUIRE WEEKS TO MONTHS OF TREATMENT, AND THE PATIENT COMPLIANCE
RECOMMENDED METHOD:
• HIGHER CONCENTRATION – BETTER RESULTS WITH 60%,
• OCCLUSIVE DRESSING,
• OFF-LOADING PADDING MINIMISED PAIN IN WEIGHT BEARING AREAS
• 1 WEEK WITH TREATMENT ON, TREAT EVERY 2 WEEKS – BEST RESULTS
SA THERAPY SHOULD REMAIN AS THE RECOMMENDED FIRST-LINE THERAPY
TREATMENTS
CRYOTHERAPY
• AGGRESSIVE CRYOTHERAPY TO BE SIGNIFICANTLY MORE EFFECTIVE
THAN GENTLE/TRADITIONAL.
• CRYOTHERAPY TECHNIQUES CAN VARY
• APPLICATION MODE, - NO DIFFERENCE BETWEEN PEN OR SPRAY
• FREEZE TIMES- AGGRESSIVE OVER TRADITIONAL/ GENTLE
• INTERVALS BETWEEN TREATMENTS- EVERY 2 WEEKS
• DEBRIDEMENT IMPORTANT
ADVANTAGES: EFFECTIVE, EASY, ACCESSIBLE (OVER COUNTER)
DISADVANTAGES: HYPOPIGMENTATION/ HYPERPIGMENTATION,
INFECTION RISK, VASCULAR STATUS
CRYOTHERAPY, RECOMMENDED AS A SECOND-LINE THERAPY OR AS A
COMBINATION TREATMENT.
TREATMENTS
SILVER NITRATE
CAUTERIZING AGENT TO REMOVE TISSUE AND BLOOD
VESSELS.
ANTIMICROBIAL ACTIVITY
METHOD RECOMMENDED
FOR 10% - EVERY OTHER DAY FOR APPROXIMATELY 1-2
MINUTES FOR THREE WEEKS WITH HEAVY DEBRIDEMENT
AS THE CONCENTRATION INCREASES 25%, 50% AND 75%
THE DURATION BETWEEN APPLICATION CAN INCREASE AND
LENGTH OF ADMINISTRATION SHORTEN.
INCREASED RISKS OF SIDE EFFECTS WITH INCREASED
CONCENTRATIONS.
TREATMENTS
POTASSIUM HYDROXIDE
POWERFUL CAUSTIC AGENT
KERATOLYTIC AGENT – MULTIPLE DERMATOLOGICAL USES
METHOD RECOMMENDED:
5% : ONCE NIGHTLY, FOR 4 WEEKS, WEEKLY HEAVY
DEBRIDEMENT.
SIDE EFFECTS:
ITCHING, BURNING SENSATION, ERYTHEMA AND TEMPORARY
DYSPIGMENTATIONS.
5% HAD A 77.6% CURE RATE AFTER 4 WEEKS
10% HAD A 88.9% CURE RATE AFTER 4 WEEKS
RECOMMENDED TO AVOID EYE CONTACT
TREATMENTS
FORMALIN
DISRUPTING THE UPPER LAYERS OF THE EPITHELIAL CELLS
KILLING THE VIRIONS
METHOD RECOMMENDED:
DEBRIDEMENT, DAILY APPLICATION, FILING BEFORE
APPLICATION, OCCLUDE WITH DRESSING.
SOAKS HAVE A HIGHER CURE RATE BUT ALSO INCREASED
REPORTED SENSITIVITY.
RECOMMEND NOT TO INHALE SOLUTION / MASK DURING
APPLICATION AS A PRECAUTION.
MINIMAL SIDE EFFECTS, COST AND PAIN
MODERATE TO HIGH REPORTED CURE RATES – EVIDENCE IS
OLD.
TREATMENTS
USING A TECHNIQUE OF MULTIPLE WART PUNCTURES
WITH A BIFURCATED NEEDLE
• IN STUDIES USED WITH ANOTHER TREATMENT,
• FOUND A HIGHER CLEARANCE RATE USING THIS
TECHNIQUE,
• USED IN CONJUNCTION WITH LA / ANKLE BLOCK,
• CAUSES AN INFLAMMATORY RESPONSE – EVOKES AN
IMMUNE RESPONSE.
TREATMENTS
• THIRD LINE TREATMENTS:
• BLEOMYCIN:
• ADVANTAGES:
• RESERVED FOR RECALCITRANT WARTS,
• DNA AND PROTEIN SYNTHESIS ARE INHIBITED, AND
APOPTOSIS IS TRIGGERED.
• DISADVANTAGES:
• SIGNIFICANT SYSTEMIC DRUG EXPOSURE
• EXPENSIVE AND PAINFUL
• RAYNAUD’S PHENOMENON
DISCUSSION
• ENORMOUS VARIETY OF WART TREATMENT,
• CHOOSING THE BEST WART TREATMENT,
• OVER 6 MONTHS- RECALCITRANT
• REMISSION AND RECURRENCE
• INVASIVE METHODS - PAINFUL AND REQUIRE LONG
RECOVERY
TOPICAL MANAGEMENT- DEPENDENT ON:
•
PATIENT COMPLIANCE
• LONG APPLICATION PERIODS
CONCLUSION
• EVIDENCE TO SUPPORT THE USE OF SA
•
CRYOTHERAPY- SECOND-LINE THERAPY/ ALTERNATIVE
TREATMENT
•
THIRD-LINE TREATMENTS
• TAILORED
• MORE HIGH-QUALITY EVIDENCE
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