الفهرس 
Plantar wartsOnly 14 pages are availabe for public view
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Abstract
Both needling and cryotherapy are simple, efficient and inexpensive modalities with excellent safety profile in treatment of multiple plantar warts, yet, combining both modalities yields best results, through combining rapid response of cryotherapy and low recurrence rates through needling.
RECOMMENDATIONS
More studies should be done to evaluate the efficacy and safety of needling technique as an immunotherapeutic modality in treatment of various types of warts, with larger sample sizes of different age groups (both adults and children) and longer follow up time interval.
Further studies could be done combining needling with different lines of treatment other than cryotherapy for plantar warts such as electrocautery or lasers.
SUMMARY
Plantar warts are common benign tumors caused by human papilloma virus (HPV) infection of the epidermal cells with an estimated annual incidence of 14%.
Plantar wart management strategies are met with high degrees of variability in success rates and often fail to adequately manage a recalcitrant wart. Most treatment modalities work by destroying affected tissues, either by a cytotoxic or physical ablative mode of action as lasers, chemical, cryotherapy and electrocautery. However, tissue damage alone may not be enough to produce relevant cytokines to destroy latent viruses in adjacent cells. Also, these methods might be associated with pain, scarring, and high recurrences rates.
Immunotherapy seems to be a promising modality in treatment of warts and the goal of most research is to find a simple, safe, effective and inexpensive immunotherapeutic approach for treatment of warts. Immunotherapeutic approaches as intralesional antigen therapy (purified protein derivative (PPD), candida or mumps) act by enhancing the host cell-mediated immunity to eliminate the virus rather than just clearing the skin lesions to clear treated as well as distant warts.
Needling, a novel therapeutic approach, stimulates the immune system resulting in clearance of even untreated lesions, in several patients. Introduction of human papilloma virus infected keratinocytes into the subcutaneous layer may facilitate a desired immune response.
On the other hand, Cryotherapy, an inexpensive and simple traditional provider administered procedure using liquid nitrogen in a spray or cryoprobe, is frequently used in many countries as a first line of treatment of plantar warts.
We decided in this study to evaluate the efficacy and safety of immunotherapeutic modality (needling) versus locally destructive modality (cryotherapy), as well as combination of both immunotherapeutic modality and locally destructive modality (cryotherapy) in treatment of multiple plantar warts.
Our study included 60 patients aged from 19 to 55 years with planter warts (>2) who haven’t received treatment for the condition within the previous month, divided into 3 groups, 20 patients per group, one group subjected to needling procedure, another group subjected to cryotherapy and the third group subjected to a combination treatment of both needling and cryotherapy.
Follow up of the studied patients was assessed by physician at the 2nd, 4th, 6th and 8th week, as well as at the 12th week (6 weeks after last session). Evaluation was done through clinical and dermoscopic examination to assess treatment response as well as recurrence rate.
Results of our study reported that at the 8th week (end of treatment) results were higher in cryotherapy and combination therapy groups than in needling group. This is due to the rapid good response provided by cryotherapy, furthermore, the duration was not long enough for systemic immune response to occur via needling procedure, which introduces viral antigens to the subcutaneous tissue.
While at the 12th week (follow up) there was a statistical significant difference between the 3 studied groups as regard response to treatment being the highest among combination treatment group, followed by needling group and at last among cryotherapy group. This is due to high recurrence rate among cryotherapy group due to localized effects of cryotherapy through destruction of virally infected cells without induction of a strong immune response. While high response and low recurrence rates were reported in combination therapy and needling groups, this could be due to induction of systemic immune response through stimulation of cell mediated immunity by introducing virally infected cells into the subcutaneous tissue through needling.
Regarding patients’ satisfaction, there was a statstical significant difference between the 3 studied groups as regard patients’ satisfaction (median/range), being higher in cryotherapy and combined treatment groups than in needling group. This is the rapid effect of cryotherapy in warts treatment which shows higher scores in the 8th week. Also, not all patients are satisfied with needling since it is not commonly used as cryotherapy, which makes patients question its efficacy especially when used alone. As it is a painful procedure that has to be performed with local anesthetic which consumes a lot of time.
Regarding reported side effects of our study, patients of needling group experienced pain, mild bleeding and mild infection. While patients of cryotherapy group experienced pain, blistering, infection and high recurrence rates. Patients of the combination treatment group experienced pain, mild bleeding and blistering.
In conclusion, combining cryotherapy (locally destructive method) and needling (immunotherapeutic method) provides promising results as it combines benefits of cryotherapy, being rapid, safe and shows rapid response together with benefits of needling, being an immuno-stimulant that provides effective, long lasting, minimally invasive, low-cost treatment with excellent safety profile and low recurrence rates for treatment of plantar warts.