Introduction

Verrucae are one of the most common cutaneous viral infections caused by human papillomavirus (types 1,2,4,7 and 57) (Ljubojevic & Skerlev, 2014). They are benign tumours which commonly involve the skin and epithelial tissues (Drake et al., 1995). Treatment of warts is painful though many modalities are available; which include keratolytic (salicylic acid 10 to 26% with lactic acid) (Sterling et al., 2014), cantharidin (Bunney, Nolan, & Williams, 1976; Miller & Brodell, 1996) electrosurgery (Kuykendall-Ivy & Johnson, 2003) and cryotherapy (Burge, Colver, & Lester, 1996), and the cons are amplified with multiple and recalcitrant warts. The ideal aim of treatment is removing the wart without recurrence, to avoid mutilating procedures and to help the body's immune system to deal with the infection better, producing lifelong immunity against the viral infection (Sterling, Handfield-Jones, & Hudson, 2001). Immunotherapy is defined as a type of biological therapy that uses substances to stimulate or suppress the immune system to help the body fight cancer, infection, and other diseases. In our study, we were looking to induce or enhance immunity against the virus. With this as the background, we surveyed to determine the efficacy of intralesional PPD for the treatment of cutaneous warts. PPD or tuberculin stimulates the cell-mediated immunity nonspecifically by activating Th1 cells, NK cells, and cytokine production; production of IL-12 as a process boosts the cell‑mediated immunity and contributes to the mechanism of action (Saoji, Lade, Gadegone, & Bhat, 2016). It was injected intralesionally at a dose of 0.1ml into each lesional site at two-week intervals until complete clearance of lesions or for a maximum of six sittings.

Materials and Methods

Trial design

Randomised open study on the efficacy of intralesional PPD in the treatment of multiple warts with the approval of the ethical committee.

Study population

Twenty patients attending the dermatology OPD who were clinically diagnosed with verruca Vulgaris are included in the study as per the following inclusion & exclusion criteria.

Inclusion criteria

Patients selected are those attending the Department of Dermatology, Venereology & Leprosy at Saveetha Medical College & Hospital who gave consent for the study.

Patients having multiple warts (verruca Vulgaris) (> 1).

Male and female patients of age group 18 to 61 years having warts (>1).

Exclusion criteria

Those who did not give consent for the study.

Pregnant females and lactating mothers.

Children under 18 years.

Immunosuppressed individuals.

Patients having any chronic systemic illness.

Genital and perianal warts.

Ulcerated or inflamed warts.

Patients with hypersensitivity to antigens.

Methodology

Twenty patients with clinically diagnosed verruca Vulgaris were included in the study. Patients were selected according to inclusion and exclusion criteria. Written informed consent was taken before they participated in the study. Detailed history including name, age, sex, address, contact number, marital status, occupation, history of medication was noted. Patients were thoroughly examined, and the size, location of all the lesions documented on the first visit. All the patients were advised not to take any treatment other than the medication prescribed in our study.

The individuals were injected with an intralesional PPD (Tuberculin Diluted) of 0.1ml on lesional sites with an insulin syringe once in every two weeks till there was complete clearance or for a maximum of six injections (3 months).

The response parameters of the wart on each visit were noted every fortnight. On each follow-up, patients were examined for evidence of partial or complete regression of their lesions by noting down the size of the wart, the appearance of any new lesions, any adverse effects and to ensure that the patients are not using any other treatment. Photographic documentation was done before the procedure and then periodically up to the end of treatment Figure 6; Figure 5; Figure 4; Figure 3; Figure 2; Figure 1.

Results were assessed at the end of three months. The primary outcome measure was the complete disappearance of all the lesions without residual scarring. Complete disappearance occurs when the thickening, hyperkeratosis is no more evident, and the normal skin markings return.

The results were assessed as

• Marked response

Responders who showed greater than 75% outcome.

2. Moderate response

Partial responders who showed 25 to 75% outcome.

3. No response

Those who showed less than 25% outcome. Non-responders were treated with alternate treatment modalities.

Results and Discussion

Twenty patients who attended the Dermatology OPD at Saveetha Medical College and were clinically diagnosed with verruca Vulgaris and gave written informed consent were enrolled in this study. All 20 patients completed the study.

The mean age in our study group was 25.45, with a majority of the patients of the male gender (60%)

In our group, the most predominant type of wart were common warts (55%) followed by periungual warts (15%).

The efficacy of Inj PPD in our study was 80% (Table 1), and this is similar to other previous studies such as that done by Milante RR, Venida‐Tablizo A and King‐Ismael D (Milante, Venida‐Tablizo, & King‐Ismael, 2019) (79%) and S. Wananukul et al (Wananukul, Chatproedprai, & Kittiratsacha, 2010)(67%).

All patients in our study experienced pain during the administration of the injections but had no complications (Table 2).

Conclusions

There are various modalities which had been tried for the treatment of warts, one of which is intralesional immunotherapy. In our study, we used intralesional immunotherapy with Inj PPD, and the results obtained showed its efficacy as well as other comparative advantages which include; its ease of administration, less time consuming, cost-effectiveness, minimal local tissue injury and no complications.