الفهرس 
Cutaneous WartsOnly 14 pages are availabe for public view
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Abstract
Warts are caused by Human Papilloma Virus (HPV), a double stranded DNA virus. Warts have a variety of clinical manifestations depending on the viral type and site and are usually treated by a wide variety of methods including cryotherapy, surgical excision, podophyllin, bleomycin and various lasers. Each mode of therapy has its own complications and failure rates.
The treatment of patients with multiple, recalcitrant or recurrent verrucae continues to be a formidable task for both primary care physicians and dermatologists. Previous mentioned methods are not always successful and may be associated with adverse events. Even when existing warts are successfully eradicated, patients may develop new warts in other areas.
Immunotherapeutic modalities were introduced to try to overcome the problem of recalcitrant or multiple warts starting from topical immunotherapeutic modalities e.g. DNCB, DCP, SADBE to intralesional injection of candida, mumps, tuberculin or trichophyton.
Candida antigen is a potent immunogen through the production of cell-mediated immunity. Furthermore, candida exposure is ubiquitous although there are rare patients with innate inability to respond to candida antigen. Previous studies reported the regression of warts at sites distant to the originally injected warts.
Photodynamic therapy involves the combination of a photosensitizer and light in the presence of oxygen during which free radicals destroying the tissue are generated. ALA is a natural precursor of protoporphyrin IX (PPIX) in the biosynthesis of hemoglobin. It can be given either systemically or locally. In cases of warts, it is applied topically and left for 4 to 8 hours to achieve the optimal level of PPIX in the tissues followed by exposure to light in the range of 400-800nm.
TNF-α is one of the key cytokines in immunology-based studies as it is a very potent endogenous mediator of immune and inflammatory functions. It is predominantely produced by activated macrophages in addition to other cells in response to various stimuli such as bacterial toxins and inflammation.
TNF-α is also essential for an effective DTH response as it induces chemokine production from macrophages and endothelial cells and also up-regulates adhesion molecules on vascular endothelial cells resulting in cellular influx of further inflammatory cells.
We performed our study on 70 patients with recalcitrant plantar warts ± warts at other sites after having stopped all treatments for at least 1 month. The patients were divided into 2 groups, the first group containing 30 patients divided as follows: 20 patients injected with candida antigen and their controls consisting of 10 patients who received saline injection. The second group containing 40 patients who were further divided into: 20 patients receiving photodynamic therapy and 2 control groups, 10 patients had blunt scraping only and 10 received IPL sessions only. A 3ml venous blood sample was taken from all patients and controls before and 24 hours after the previous modes of therapy for measuring TNF-α by ELISA technique.
Our aim was to compare the effect of candida antigen injection versus PDT on plantar warts as regards morbidity, cost and clinical response and to investigate the role of TNF-α in the pathogenesis of wart response after both modes of therapy.
As regards cure rates, they were highest in the candida group patients reaching 75% achieving complete cure in addition to 10% having achieved partial cure. Resolution of distant warts occurred in all patients with multiple warts whose injected wart responded, which was much appreciated by the patients added to the absence of notable side effects. In contrast, PDT resulted in 60% cure rate of treated warts only, was time consuming to the patients. Adverse effects were also of no significance, but no effect on distant warts was seen.
TNF-α levels measured 24 hours after various modes of therapy showed close relation to local tissue inflammation and destruction and to systemic side effects occurring after candida antigen injection, but weak relation to the response to therapy as it increased also in patients who had blunt scraping of their warts. PDt was also associated with a significant increase in TNF level which might prove the immunological role of this mode of therapy. However, serial evaluation of TNF levels is mandatory to accurately depict actual role in distant wart resolution.