الفهرس 
Introduction
Structure of viral particleOnly 14 pages are availabe for public view
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Abstract
Human papilloma virus causes cutaneous and mucosal warts which manifest in the form of verrucous growths. Out of the various layers of the epidermis, though stratum basale is primarily infected with the virus, stratum spinosum and stratum granulosum bear the brunt of viral replication as they are mature keratinocytes There are a wide range of factors that predispose an individual to develop viral warts. Idiopathic etiologies also do play a role, but the common factors include trauma in the form of nail biting, scratching, using swimming pools, colposcope, fumes generated by laser, electrocautery and cryotherapy. Treatment of warts has proved to be quite distressing from the patient’s and well as dermatologist’s perspective. But point of concern lies in recurrence and incomplete cure after treatment. Dermatologists have tried numerous surgical treatment methods as well, but there again lies the problem of patient compliance and expenditure in refractory cases. Warts were earlier treated by destructive modalities namely cryotherapy, electrocoagulation, topical salicylic acid, topical 5-fluorouracil, laser surgery etc. All of these treatments are essentially painful, time consuming, expensive and recurrence is common.1-6 Therefore immunotherapy seems to be a promising modality in such cases. The role of immunity is documented by the appearance and persistence of warts in immunosuppressed individuals. Immunotherapy has gained relevance and importance in the recent past as a promising treatment modality for typically multiple and recalcitrant warts. Immunotherapy can be used either in the form of topical, intralesional or systemic route. Out of the intralesional modalities, Purified protein derivative finds a significant role. Unfortunately, even with years of medical literature on this subject, high-quality evidence for efficacy is lacking for almost all treatments. Primary treatment modalities for verrucae include ablative therapies, e.g. topical chemical cautery, cryotherapy, electrocautery, excision, bleomycin sulfate injection and laser vaporization, but none gives a guarantee of cure, and recurrence and scarring are common. These destructive modalities are designed to remove visible lesions; nonvisible infected tissues are not targeted. Moreover, in patients with numerous lesions, there is no effect on lesions other than the treated ones, resulting in repeated and long-drawn treatment sessions. Immunotherapy in warts utilizes the ability of the immune system to mount a delayed-type hypersensitivity response to various antigens in wart tissue. It has been found to be associated with the production of Th1 cytokines which activate cytotoxic and natural killer cells to eradicate the HPV infection. This clears not only treated warts but also distant warts, unlike conventional therapies. The aim of this study was to compare the results of combined tuberculin purified protein derivative and cryotherapy to results of tuberculin purified protein derivative or cryotherapy alone in treatment of genital warts. This was a randomized clinical trial was carried out on 45 patients with multiple genital and anal warts. The patients were divided into three groups. group A (15 patients) treated with P.P.D injection, group B (15) patients treated with cryotherapy using liquid nitrogen and group C (15) patients treated with combined P.P.D injection and cryotherapy. The main results of the study revealed that: The age of the patients ranged from 23-40 years with a mean ± SD 31.87 ± 4.87 in group A 31.93 ± 5.24 in group B and 31.60 ± 5.21 in group C. there were non- statistical significant differences between the studied groups as regard sociodemographic characteristics. Disease duration was from 2-6 months in group A with mean 3.67 ± 1.18 and 2-5 months in group B with mean 3.47 ± 0.99 and 2-10 months in group C with mean 5.87 ± 2.33. According to site of warts in group A, 7 patients with penile warts, 4 patients with scrotal warts, and 4 patients with anal warts, in group B, 11 patients with penile warts 4 patients with scrotal warts, in group C, 9 patients with penile warts, 4 patients with scrotal warts and 2 patients with anal warts, with no statistical significant difference. In group (A) 2 patients (13.3%) had complete response to PPD therapy, 8 patients (53.3%) had partial response, and 5 patients (33.3%) no response to treatment. While in group (B) 4 patients (26.7%) had complete response to cryotherapy, 6 patients (40%) partial response and 5 patients (33.3%) no response to treatment in group (c) 7 patients (46.7%) complete response 6 patients (40%) partial response and 2 patients (13.3 %) no response, with no statistical significant difference. In group (A) PPD group recorded side effects included pain during injection in 7 patients (46.7%), flu like symptoms in 3 patients (20%), erythema in 3 patients and no side effect in 4 patients (26.7%).While in group (B) side effects of cryotherapy included pain in 5 patients (33.3%). erosions in 3 patients (20%) and hypopigmentation in 8 patients (53.3%), 5 patients with no side effect (33.3%).In group (C) side effects included pain in 10 patients (66.7%), flu- like symptoms in 1 Patient (6.7%) erythema in 4 patients (26.7%) hypopigmentation in 7 patients (46.7%).In group (A): 2 patients (13.3%) were very satisfied about treatment response, 4 patients (26.7%) were satisfied, 5 patients (33.3%) were slightly satisfied and 4 patients (26.7%) were unsatisfied. In group (B): 5 patients (33.3%) were very satisfied about treatment response, 3 patients (20%) were satisfied, 2 patients (13.3%) were slightly satisfied and 5 patients (33.3%) were unsatisfied. In group (C): 6 patients (40%), were very satisfied 2 patients (13.3%) were satisfied 4 patients (26.7%) slightly satisfied, 3 patients (20%) unsatisfied. (There was no statistically significant difference in patient satisfaction between the three groups), with no statistical significant difference. Age of patients with complete or partial improvement range from 23-40 years with mean 31-97 ± 5.08, Age of patients with no improvement range from 25 – 39 years with mean 31-33 ± 492 with no statistical significant between groups. Patients with complete or partial improvement their disease duration range from (2-9) months with mean 4.21 ±1.93. Patients with no improvement range from (3-10) months with mean 4.67 ± 1.92 with no statistical significant between two groups. Patients with complete or partial improvement with penile warts 23 patients (69.7%) and scrotal warts 8 patients (24.2 %) and anal warts 2 patients (6.1%) while patients with no improvement 4 patients with penile warts (33.3 %) 4 patients with scrotal warts (33.3%) 4 patients with anal warts (33.3 %) with statistical significant difference.