TREATMENT OF WARTS BY IMMUNOTHERAPY USING PURIFIED PROTEIN DERIVATIVE Affiliation

Results A total of 52 pa ents,29 males and 23 females, were enrolled in the study and among them 28 pa ents had verruca vulgaris,12 pa ents had verruca plantaris, 9 pa ents had periungual wart and 3 pa ents had verruca plana. Total clearance of warts was seen in 78.8%(41) of pa ents, however 21.2% (11) pa ent did not respond to the therapy. Most of the pa ents tolerated the therapy well and few of them had mild side effects like erythema, pain and oedema at the site of injec on.


INTRODUCTION
Infec on of kera nocytes by human papilloma virus (HPVs) causes warts in human beings.Because these viruses have tropism for epithelial cells they manifest clinically as 1 mucocutaneous lesions.Due to their long period of latency in the host cells they are prone to recurrences causing both benign and malignant lesions.Cutaneous warts are the most common manifesta on among the benign lesions 2 caused by these viruses.Though it is a common self limi ng dermatological condi on, however in some cases they may be persistent and may increase in size and number.A lot of standard modali es are available at present for the treatment of warts and most of them u lize local destruc on of virally infected ssues.The locally destruc ve methods available at present are chemical or electric cauteriza on, electrofulgura on, carbon dioxide laser or cryotherapy.Though the results of these treatments are sa sfactory, these modali es are associated with frequent recurrences along with significant scarring and dyspigmenta on.Development of cell mediated immune response to the virus is an essen al component for clearance of wart and it has shown spontaneous regression of warts.In search for the op mal treatment of warts injec on of various immunotherapeu c agents intralesionally have gained

METHODOLOGY
This open labelled study was conducted in the Department of Dermatology, Venereology and Leprology, Birat Medical college Teaching Hospital, Biratnagar, Nepal from July 1 to December 30, 2017.Pa ent visi ng the outpa ent department of Dermatology who presented with wart anywhere in the body were included in the study.Permission for the study was taken from the ins tu on.
A total of 52 pa ents with different cutaneous viral warts were recruited for the study.All these pa ents were diagnosed with cutaneous warts and were either untreated or were off the treatment for past 1 month.Pa ents with ac ve infec on or systemic illnesses, those on immunosuppressive drugs, pregnant women and pa ent not giving consent were not included in the study.Wri en and informed consent was taken from each pa ent before star ng the treatment and they were fully explained about the disease, including nature course and also about the procedure they were about to undergo, follow up and prognosis.A detailed history and examina on was also carried out to determine the number of lesions, types of wart, size and if there was any other associated co-morbid condi on.A er the pa ent had met all pre requisite 2.5 TU of PPD was injected into each wart un l the lesions got blanched.In cases where pa ents had numerous lesions the maximum dose of PPD was limited to 25 TU in a single session.Injec ons were given with similar single use disposable insulin syringes with bevel facing upward and syringe held parallel to the cutaneous surface.All the pa ents were advised for a total of five sessions each at an interval of 2 weeks.The pa ents were advised for strict follow up even if they were cleared of the lesions earlier than the 10 weeks period.No further injec ons were given if the lesions cleared earlier.
Examina on and evalua on of the pa ent in terms of regression of lesions was done at every visit.Meanwhile the pa ents were not allowed to use any other topical or systemic medica on in concurrence with the undergoing therapy.All the pa ents were asked about the recurrence of lesions a er a period of 6 months via telephone.

Response to the therapy was scored as
Responder: Includes pa ents with complete clearance of lesions Non Responder: Includes pa ents with par al or no response to the treatment RESULT A total of 52 pa ents mee ng the inclusion criteria for the study were enrolled in the study.Among the pa ents included, 29 were males and 23 were females aged between 11 years to 65 years of age.The dura on of the exis ng lesions ranged from 4 months to 48 months.There were different clinical variants of cutaneous warts and among the pa ents maximum number of pa ents (28) presented with verruca vulgaris, 12 pa ents had verruca plantaris, 9 pa ents had periungual wart and 3 pa ents had verruca plana.The number of lesions ranged from 2 to more than 10.Among the treated pa ents 78.8 % of pa ents had complete resolu on of lesions a er 5 sessions whereas 21.2 % pa ents did not show response to the treatment as shown in (Table 1).PPD was well tolerated by all the pa ents except for few mild side effects.Around 10 pa ents had mild erythema and oedema at the site of injec on which subsided on it's own in about a weeks me,2 pa ents complained of pain at the site of injec on requiring mild analgesic like NSAIDs and 1 pa ent developed low grade fever that required an pyre c (Paracetamol).None of the pa ent complained of scarring or pigmentary changes at the site that were resolved of warts and there was no recurrence in any of the pa ents a er a follow up of 6 months.the lesion a er it's regression.The role of immunity has been well proven by the fact that there is increased incidence of warts in immunocompromised subjects and spontaneous clearance of lesions with the enhanced 7 immunity.The protec ve func on of cell mediated immunity against fungal viral and mycobacterial infec on is a well known fact and hence fungal, viral, mycobacterial an gens along with vaccines have been in use for s mula on of cell 8,9 mediated immunity.Since prevalence of tuberculosis is on a higher side in Nepal we choose to use PPD as immunos mulant because of ease in inducing a posi ve cell mediated immune response to PPD and also because of its easy availability.
The effec veness for clearance of wart by PPD is due to nonspecific s mula on of cell mediated immunity through ac va on of Th1 cytokines, natural killer cells and cytotoxic 10 T cells.In a few studies it has been shown that there is significantly Increased rate of clearance of warts with PPD injec on when compared with injec on of normal saline

DISCUSSION
Cutaneous warts are caused by infec on of kera nocytes by human papilloma virus and is one of the frequently encountered disease in dermatology OPD.As for thus signifying the fact that clearance of wart is due to immunity s mula on rather than due to effect of injec on There is no linear correla on between skin reac on and tuberculin dose and maximum dose of PPD used has been 13 documented to be 88 TU ll date.In our study we used a maximum dose of 20 TU in one pa ent who developed flu like symptoms that was easily managed with NSAIDs.There is no standard protocol regarding the dose, interval between injec ons, number of sessions and different studies show varia on in these things as shown in table 4. However as we know that the me for indura on to heal in montuex test takes around 7-12 days we decided to keep the interval of 2 weeks between the subsequent injec ons.Table 4 shows in brief the response rate of different an gens used for eradica on of warts.Our study shows that 78.8 % of pa ents were cleared of warts in 5 sessions which is quite significant.This study along with several other studies shows that whenever intra-lesional injec ons were given at mul ple sites and in mul ple sessions there was greater chance of faster and effec ve clearance of 8,10,11,14 warts.Tuberculin jelly as a topical immunotherapy has also been used in this context but a very lower response rate 57 % and hence it is more appropriate that the route of 15 administra on be intralesional for be er results .
The pa ents in our study tolerated PPD injec on very well except for few developing very mild side effects like pain, erythema and oedema at injec on site and none of the pa ent had recurrence a er a period of 6 months.

CONCLUSION
Though at present a variety of op ons of therapy are available for the treatment of cutaneous warts, all of them acts in the principal of destruc on of local ssue which may lead to significant scarring.In this era where pa ents are very much concerned about the cosme c appearance these destruc ve methods may not be appropriate and hence an alterna ve therapy to avoid those consequences is required.As suggested by our study immunotherapy using intralesional injec on of PPD may serve as a good alterna ve for the treatment of warts without any significant side effects even in pregnant woman and pediatric age group.Also cheaper cost and easy availability of PPD makes it a very good treatment op on.

RECOMMENDATIONS
Further similar larger scale compara ve studies are required to further validate the efficacy of intralesional PPD injec ons for the treatment of cutaneous warts.

LIMITATIONS OF THE STUDY
The limita on of our study was a small sample size and absence of control group.Also could not perform montoux test in all the subjects because of technical problems and hence we could not find the correla on between montoux posi vity and clearance rate of warts.

3 popularity
in the recent past.A variable response has been observed with the use of An gens such as the measles, mumps, and rubella (MMR) vaccine; Candida albicans; Bacillus Calme e-Guérin (BCG), and Mycobacterium 4 indicus pranii injected intralesionally.This study aims at evalua ng the efficacy and safety of intralesional Purified protein deriva ve, ubiquitously used, standardized, easily available, safe and inexpensive an gen, in the treatment of cutaneous warts.

8 , 11 alone.
It has also been proved that PPD injec on not only s mulates the local immunity but also causes ac vated T Choudhary D et al cells to circulate all over the body and helps in clearance of 10 the distant non injected warts as well.Use of PPD has been proven to be safe among the children and pregnant women as well because of the fact that PPD does not contain any viable organisms.A study done by Essa et al has shown a high success rate for clearance of ano-genital warts without any significant side effects in 10 pregnant women with use of PPD.Hypersensi vity is a 12 very rare occurrence that can take place in 1/million case.

Table 1 :
Frequency of respondersFrequency Percentage

Table 2 :
Frequency of responders

Table 3 :
Clearance rates in various types of warts

Table 3 :
Response rate according to number of sessions

Table 4 :
Response rates to various an gens and vaccines