Treatments for human papillomavirus
The human papillomavirus (HPV) is the cause of warts vulgaris and condylomas (anogenital warts). In this section, we will focus on the latter type of human papillomavirus and condyloma therapy.
If you want more information about condylomas you can click here; and if you want to know more about their treatment, click here.
Imiquimod
Traditionally, imiquimod has been used in cream form at a concentration of 5% applied on alternate nights. Currently, studies have been carried out with concentrations of 3.75% applied every night, which have shown an effectiveness of complete remission of lesions of 36.6% of patients at 8 weeks, compared to placebo (14.2%). Although there are no comparative studies with the application of imiquimod at 5% in terms of efficacy, it is known that the adverse effect profile (local skin reactions) is lower with the preparation applied at 3.75% each night. This new dosage makes it possible to shorten the duration of treatment (8 weeks) and improve patient adherence to treatment due to its greater comfort and lower frequency of local side effects. At the moment, this concentration of the drug is not marketed in Spain.
Synatekins (polyphenon E)
Polyphenon is a substance derived from green tea extract, whose most active molecule is epigallocatechin gallate. This inhibits cell replication, the transcription of the human papillomavirus and increases the response of cellular immunity against it. Theoretically, thanks to the combination of these actions, it is able to eliminate clinically affected cells and those with subclinical ( not appreciable) infection. In Spain, a 10% synatequin preparation is marketed daily application every 8 hours for a maximum of 16 weeks. Studies show an efficacy of between 54 and 65% in terms of total disappearance of condylomas, compared to 37% for placebo. Up to 80% of patients experience local adverse effects (redness and itching), which are generally tolerable and manifest themselves from the second or third week of treatment. It seems that the presence of an inflammatory reaction is positively correlated with a better therapeutic response. The main drawback of this therapy is its dosage, which lasts up to 16 weeks and requires 3 daily applications. At the moment there are no comparative studies with imiquimod.
Photodynamic therapy
Photodynamic therapy consists of applying a 5-aminolevulinic acid cream on top of the lesions and then exposing them to a specific light source in the dermatological consultation. As this substance is photosensitive, the cells that contain it are destroyed once they are exposed to the light lamp. The cells that absorb the highest amount of aminolevulinate are those with the fastest metabolic rate, such as those infected by the human papillomavirus. It is proposed as an option for stubborn lesions or in relapses despite having carried out a previous correct treatment, since the economic cost of photodynamic therapy is not low. In comparative studies for the treatment of condylomas, it seems to be an alternative as effective or more effective than theCO2 laser or surgical excision of lesions with a lower rate of relapse once the treatment is completed. Adverse effects include pain, redness and burning sensation. As for the advantages , the high effectiveness and safety, the rapid healing and the excellent aesthetic result of the treatment stand out.
Intralesional immunotherapy
One option for warts vulgaris and condylomas is the intralesional injection of substances that activate the immune response against the human papillomavirus. Since its mechanism is immunogenic, the treatment is not only effective in eliminating the wart where the drug is injected but also acts on all lesions at a distance. The most commonly used substance is candidin (antigen of the Candida fungus), injecting 0.1 – 0.3 mL into the largest wart, every 1-3 weeks, a maximum of 3-5 sessions. Although on a personal level the author of this article has obtained frankly positive results with this therapy, there are no large studies that support greater efficacy compared to other options. The drawbacks include the occasional pain during the injection (seconds) and the possibility of suffering from a temporary flu-like syndrome (cold) due to the immunological reaction caused by the drug, although it is not common. For more information about caandidine, click here.
CONCLUSIONS
· There is no single treatment for condylomas, nor one that has shown clearly superior efficacy to the others.
· The best treatment is the one agreed upon by the patient and dermatologist according to the number of lesions, the location, the preferences of the former and the therapies previously used.
· In the author’s opinion , the recommended work scheme is the physical removal of warts in a first step (podophyllin resin, cryotherapy and/orCO2 laser) and then using a therapeutic option that favors the formation of an immune response against HPV (imiquimod, synatequins).
→ Click here to learn how condylomas are diagnosed and treated.
→ Click here for more information on the diagnosis and treatment of condylomas.
→ Click here for information on laser condyloma removal.
REFERENCES
· Muñoz-Santos C, Pigem R, Alsina M. New treatments for human papillomavirus infection. Actas Dermosifiliogr. 2013 Dec; 104(10):883-9.