Short course of imiquimod as good as podophyllotoxin in anogenital warts on keratinized sites: IJDVL study
Short course imiquimod shows similar efficacy to podophyllotoxin in anogenital warts on keratinized sites: IJDVL study.
Anogenital warts are one of the most common sexually transmitted infections. Treatment modalities for anogenital warts are divided into provider‑administered and patient‑applied. Imiquimod and podophyllotoxin are the most commonly used patient‑applied treatments for anogenital warts. Studies comparing head‑to‑head treatment modalities for anogenital warts are sparse. Recently a study comparing imiquimod and podophyllotoxin for treatment of anogenital warts was published in the Indian Journal of Dermatology, Venereology and Leprology.
1This was a retrospective cohort study of patients ≥ 18 years clinically diagnosed with first episode of anogenital warts who were treated with either a short, 8‑week course of imiquimod or the standard 4‑week course of podophyllotoxin between January 2012 and December 2016.
Exclusion criteria
Patients who were receiving any treatment for anogenital warts before presentation
Presence of either intra‑anal/intravaginal warts or warts of the urethral meatus
Presence of giant condylomata (Buschke–Lowenstein tumors)
Presence of only one wart or wart area larger than 6 cm2
Pregnancy
Anatomical sites of anogenital warts were divided into two groups-
Keratinized sites- sites covered by dry, keratinized skin, such as pubic area, penile shaft, scrotum, groin, and the outer surface of labia majora of the vulva
Partially keratinized" sites- sites covered by moist, partially keratinized skin, such as perianal area, perineum, preputial cavity, inner surface of labia majora, and labia minora of the vulva
Imiquimod was applied three times weekly. Podophyllotoxin was applied each week twice daily for 3 consecutive days, followed by 4 days of rest. Podophyllotoxin 0.5% solution was prescribed for lesions on "keratinized" sites and podophyllotoxin 0.15% cream was prescribed for lesions on "partially keratinized" sites, in agreement with the recent European guidelines.
Results
The study included 347 patients.In patients with lesions on dry, keratinized anatomical sites, the complete clearance rates were 7.6% for imiquimod and 27.9% for podophyllotoxin (P < 0.001) and for >50% reduction in wart area (54.3% for imiquimod and 76.0% for podophyllotoxin, respectively, P - 0.001), both being statistically significant.
In patients with lesions on moist, partially keratinized sites, no difference between the treatments was revealed.
On multivariate analysis significant predictors of > 50% reduction in wart area were location of lesions [odds ratio (OR) (95% confidence interval (CI)): 3.6 (1.84–7.08), P = 0.0002] for "partially keratinized" versus "keratinized" sites and treatment used [OR (95% CI): 1.79 (1.08–2.97), P = 0.024] for podophyllotoxin versus imiquimod.
In univariate analysis, lesions on "partially keratinized" sites and female patients were statistically significantly associated with a >50% reduction in wart area. It was also found that patients with lesions on "keratinized" sites which are more commonly "difficult‑to‑treat" lesions, were mostly men and had been treated more frequently with podophyllotoxin, compared with imiquimod.
In conclusion the study showed that the lesions' location plays a central role on response to patient‑applied treatments for anogenital warts. A standard 4 week course of podophyllotoxin was more effective than an 8‑week course of imiquimod only for lesions on keratinized sites so either podophyllotoxin or the standard "up to 16 weeks" imiquimod regime should be preferred for these sites. For lesions on "partially keratinized" sites, an 8‑week course of imiquimod was equally effective to the standard 4‑week course of podophyllotoxin
Source-
1.Nicolaidou E, Kanelleas A, Nikolakopoulos S, Bezrodnii G, Nearchou E, Gerodimou M, et al. A short, 8-week course of imiquimod 5% cream versus podophyllotoxin in the treatment of anogenital warts: A retrospective comparative cohort study. Indian J Dermatol Venereol Leprol 2021;87:666-70.
2. Lacey CJ, Woodhall SC, Wikstrom A, Ross J. 2012 European guideline for the management of anogenital warts. J Eur Acad Dermatol Venereol 2013;27:e263‑70.
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