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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 13-16

Evaluating the efficacy of 100% trichloroacetic acid needling in the treatment of palmoplantar warts


Department of Skin and VD, Smt. NHL Municipal Medical College, Smt. SCL General Hospital, Ahmedabad, Gujarat, India

Date of Submission25-Jun-2019
Date of Decision04-Mar-2020
Date of Acceptance20-Apr-2020
Date of Web Publication23-Jun-2020

Correspondence Address:
Dr. Pooja Agarwal
Department of Skin and VD, Smt. SCL General Hospital, Smt. NHL Municipal Medical College, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdd.ijdd_38_19

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  Abstract 


Introduction: Warts are benign proliferations of skin and mucosa caused by the human papillomavirus (HPV). Palmoplantar warts are caused any HPV types 1, 2, 4, 27, 57 and occurs mostly in children and young adults. Among the treatment modalities, trichloroacetic acid (TCA) application along with needling after sufficient penetration causes coagulation of proteins of the infected cells of skin and causes necrosis. Aim: To study the efficacy of 100%TCA needling in the treatment of palmoplantar warts. Study Design: Longitudinal study carried out at a tertiary care center in Gujarat. Materials and Methods: Patients having palmoplantar warts between the age group of 4-50 years over a period of 8 months were included in the study as per our inclusion and exclusion criteria. 100% TCA application followed by needling using an insulin syringe was done once per week after informed consent. The necrosed skin was pared on each follow-up and the procedure was repeated till complete clearance of warts. Results: The total number of patients were 60 out of which 6 patients were irregular in follow up. In 4 patients, the treatment modality was changed after 6 weeks because of lack or response. 50 patients had complete clearance of warts. The minimum and maximum duration for complete clearance of warts were 3 weeks and 8 weeks respectively. Limitation: It gives varying results in different individuals and average duration in clearance of wart is comparatively slower as compared to some other methods. Conclusion: TCA needling is an effective treatment modality for palmoplantar warts.

Keywords: Children, trichloroacetic acid needling, warts


How to cite this article:
Bodar P, Agarwal P, Saikia S, Dalal T, Jagati A. Evaluating the efficacy of 100% trichloroacetic acid needling in the treatment of palmoplantar warts. Indian J Drugs Dermatol 2020;6:13-6

How to cite this URL:
Bodar P, Agarwal P, Saikia S, Dalal T, Jagati A. Evaluating the efficacy of 100% trichloroacetic acid needling in the treatment of palmoplantar warts. Indian J Drugs Dermatol [serial online] 2020 [cited 2020 Oct 28];6:13-6. Available from: https://www.ijdd.in/text.asp?2020/6/1/13/287431




  Introduction Top


Warts or verrucae are benign proliferations of the skin or mucosa that are caused by infection with human papillomavirus (HPV).[1] HPV is a double-stranded DNA virus, and to date, over 118 types of HPV have been identified.[2] Warts are spread by direct or indirect contact. For infection to occur, the HPV virus particle needs to come into contact with a stem cell in the basal layer of the epidermis. Thus, impairment of the epithelial barrier function, by trauma (including mild abrasions), maceration, or both, greatly predisposes to inoculation of the virus and is generally assumed to be required for infection at least in fully keratinized skin. Higher incidence of palmar warts in certain occupations, such as handlers of meat and poultry and plantar warts in people using common swimming pools and showers, validates this theory.

The time of acquisition of the infection can seldom be ascertained. Palmoplantar warts are mainly caused by HPV-2, but can also be caused by HPV-1, 4, 27, and 57.[3] The incidence increases during the school years to reach a peak in adolescence and early adulthood, then declines rapidly through the twenties and more gradually thereafter. Currently, available treatment modalities for warts include topical agents, such as salicylic acid (12%–26%) with lactic acid paint, podophyllotoxin, trichloroacetic acid (TCA), 5-fluorouracil, photodynamic therapy, and surgical modalities such as cryosurgery, electrosurgery, laser ablation, and surgical excision. Oral drugs such as levamisole, cimetidine, zinc sulfate, and local immunotherapeutic agents, including imiquimod, contact sensitizers, intralesional interferons, have also been used.[4] Treatment of warts is often difficult, and most of the commonly available treatments are destructive leading to trauma and scarring. Modalities such as electrocautery and cryotherapy are painful and are often difficult to use in children. TCA is a topical destructive agent and causes coagulation of cellular proteins leading to cell death. It is effective in treating common, cervical, genital, and anal warts in the concentrations of 70%–80% and has response rates comparable to cryotherapy.[5],[6] The advantage is the complete lack of systemic toxicity, less pain, and earlier healing time. However, a few local side effects such as pain, burning, hyperpigmentation, and rarely, a scar formation may occur. This study was undertaken to study the effectiveness of 100% TCA application followed by needling in the treatment of palmoplantar warts.


  Materials and Methods Top


This was a prospective study conducted over a period of 10 months from March 2018 to December 2018 in the department of dermatology of a tertiary care center in Gujarat. A total of 60 patients having palmoplantar warts in the age group of 4–50 years were included in the study at their first visit. The patients unwilling to follow-up regularly, pregnant and lactating women, immunosuppressed individuals, and patients who had received any other treatment for warts in the month prior were excluded from the study. After taking written informed consent, the patient's detailed history and clinical examination were noted. Baseline characteristics of the wart including site, size, and number were evaluated at the start of the study and subsequently at weekly intervals till complete clearance of the lesions. Photographic documentation was done at the beginning and every follow-up visit. Patients who had complete clearance of lesions were followed up for further 3 months to note any recurrence. On first visit application of 100% TCA followed by needling with an insulin syringe on each palmoplantar wart was done. Needling was done to up to the appearance of pinpoint bleeding points. No paring was done at the first visit. This was repeated weekly, and only the necrosed tissue was pared on follow-up without inducing any bleeding points. This procedure was repeated until complete clearance of warts. No other drugs like immune supplements were given.


  Results Top


A total of 60 patients were enrolled in the study. Six of them were lost to follow-up at different stages, and 54 patients were available for evaluation. There was complete clearance of warts in 50 (92.6%) patients [Figure 1], [Figure 2], [Figure 3]. The treatment modality was changed after 6 weeks in 4 (7.4%) patients due to lack of response. Of 54 patients, 32 (59.3%) were males and 22 (40.7%) were females.
Figure 1: Complete clearance of palmar warts at 5 weeks

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Figure 2: Complete clearance of palmar warts at 6 weeks

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Figure 3: Complete clearance of plantar warts at 7 weeks

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Most of the patients belonged to the age group of <20 years, accounting for 53.7% of cases followed by 20–40 years, which accounted for 31.5% of cases. The youngest patient was 4 years, and the oldest patient was 50 years (mean age: 20.8 years).

The majority of patients (48%) were students by occupation.

Plantar warts accounted for 25 (46.3%) cases, palmar warts accounted for 19 (33.9%) cases, and both palmar and plantar warts were seen in 10 (18.5%) cases.

Thirty-five (64.8%) patients had <5 warts, 17 (31.5%) patients had 5–10 warts, and only 2 (3.7%) had ≥10 warts. The patients who had <5 warts (n = 35) had complete clearance in a mean duration of 4.3 weeks, the patients who had 5–10 warts (n = 17) had complete clearance in a mean duration of 4.9 weeks, and two patients who had ≥10 warts had complete clearance in a mean duration of 8 weeks. Thus, we observed that the mean duration needed for complete clearance of warts increased with increase in number of warts at the baseline. Most of the patients (61%) had the disease duration of 3–6 months, 37% had warts for <3 months, and the remaining had warts for ≥6 months. The mean disease duration was 3.2 months.

The minimum duration for complete clearance of warts was 3 weeks, and the maximum duration was 8 weeks (mean duration for complete clearance – 4.6 weeks).

Side effects noticed included burning sensation on application of TCA which lasted only for the duration of the procedure. Postinflammatory hyperpigmentation after healing was also noted in two patients. No other postprocedural complications were noted.

Fifty patients who had complete clearance of warts were followed up for further 3 months, and no recurrence was observed in any of the patients.


  Discussion Top


A multitude of therapies is available for the treatment of common warts, with varying degrees of success ranging from the old-age destructive treatment to cryotherapy and the newly emerging therapies such as pulsed dye laser, intralesional immunotherapy, and autoinoculation therapy.[5],[7],[8] One of the most important shortcomings of most of these methods is that many of them are not 100% successful.

Chemical cauterization provides a useful approach in the treatment of warts in patients where pain is a major limiting factor. TCA causes destruction of tissue by causing coagulation of proteins in the cells and thus destroying the cells. It has the added advantage of not being absorbed systemically, and white frosting develops within a few minutes of the application, which indicates the end point. Burning and itching sensations are often accompanied by the application of TCA, whereas ulceration leading to secondary infection and subsequent scarring are the rare side effects of TCA application.[9]

Falknor first explained a direct needling procedure as a treatment modality for warts in the form of inciting physical trauma without use of any chemicals (excluding the use of local anesthesia).[10] His method consisted of anesthetizing the verruca, then thrusting a needle in “dart fashion,” so as to penetrate the full depth of the verruca and exiting through the base of the capsule into the fat to induce a controlled inflammatory response. He claimed only two recurrences of 126 lesions treated with this technique. Subsequent published research using this method has been sparse. Skilton and Mehar published a case series of 14 patients with painful verrucae who were treated with the needling technique wherein they claimed complete resolution in 50% of the cases after an 8-week review.[11] In our study, we have combined the application of 100% TCA with needling method with the intention of combining two different mechanisms with which the palmoplantar warts may be cleared and thereby increase the rate of clearance of warts.

In the study by Nischal et al.,[12] 55% patients were females and 45% were males. In our study, 59.3% were males and 40.7% were females. This slight male preponderance could be due to more outdoor exposures (occupation, sports etc.).

The mean age in that study was 8.32 ± 1.54 years as compared to our study where it was 20.8 years.[12]

In a study done by Pezeshkpoor et al., patients with verruca vulgaris were treated with either 80% TCA (group A) or 35% TCA (group B) once per week until complete clearance of the lesions or for a maximum duration of 6 weeks. The results showed a significant difference in improvement between the two treatment groups, and the improvement was greater with higher concentration of the solution (80% TCA).[6]

Salicylic acid is a keratolytic agent which causes the cells of the epidermis to shed more readily and allows room for new cell growth. Various studies have compared cryotherapy with salicylic acid for the treatment of plantar and hand warts. They showed that cryotherapy is equally effective as salicylic acid in the treatment of warts.[13],[14] However, on reviewing the literature, we were unable to find a study which compared salicylic acid with TCA for palmoplantar warts. Cryotherapy was found to be more effective than 90% TCA for the treatment of common warts in a study done by Abdel et al. However, 90% TCA had lesser complications than cryotherapy.[15] The scenario on the other hand differed when a similar study was done for plantar warts. In a study done by Cengiz et al., in which the effectiveness and safety profile of 40% TCA and cryotherapy were compared for plantar warts, they found that 40% TCA was more effective for clearance of plantar warts with a better safety profile.[16]

The British Association of Dermatologist's guidelines suggests 50%–80% TCA weekly application for 8 weeks for treating hand warts.[17]

Ten percent of KOH has been found to be effective in the treatment of plane warts by Khan et al.[18] However, due to the difference in the HPV type between plane warts and palmoplantar warts, and the lack of a similar study of 10% KOH application done for palmoplantar warts, it would not be fair to compare these two modalities until further studies are established.

In our present study, 92.6% of patients had complete clearance of warts with from 3rd week onward. We also observed that patients having a greater number of warts required increased the duration for complete clearance of warts. The only side effect which we noticed was burning sensation during the procedure itself which lasted only for the duration that the TCA needling was done. No recurrence of warts was seen during the 3-month follow-up period after complete clearance of lesions. To the best of our knowledge, no similar study which evaluates the efficacy of 100% TCA with needling in palmar and plantar warts has been published to date in the literature.


  Conclusion Top


This study has shown that 100% TCA needling is a highly effective and relatively painless procedure for the treatment of palmoplantar warts. This may be used as a primary treatment modality in palmar and plantar warts in children where intralesional injections or electrosurgery are limited due to the pain. Further studies are warranted with a larger sample size.

Limitations

A control group with Falknor's needling method alone could have been taken to compare the efficacies of the two methods. Furthermore, it gives varying results in different individuals, and the average duration in the clearance of wart is comparatively slower as compared to some other methods.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lowy DR, Androphy EJ. Warts. In: Freedberg IM, Eisen AZ, Wolf K, Austen KF, Goldsmith LA, Katz SI, editors. Fitzpatrick's Dermatology in General Medicine. Vol. 4, 6th ed. New York: McGraw-Hill; 2003. p. 2119-30.  Back to cited text no. 1
    
2.
de Villiers EM, Fauquet C, Broker TR, Bernard HU, zur Hausen H. Classification of papillomaviruses. Virology 2004;324:17-27.  Back to cited text no. 2
    
3.
Sterling JC. Virus infections. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 8th ed. Massachuesttes: Blackwell Science; 2010. p. 33.1-33.78.  Back to cited text no. 3
    
4.
Dasher DA, Burkhart CN, Morrell DS. Immunotherapy for childhood warts. Pediatr Ann 2009;38:373-9.  Back to cited text no. 4
    
5.
Godley MJ, Bradbeer CS, Gellan M, Thin RN. Cryotherapy compared with trichloroacetic acid in treating genital warts. Genitourin Med 1987;63:390-2.  Back to cited text no. 5
    
6.
Pezeshkpoor F, Banihashemi M, Yazdanpanah MJ, Yousefzadeh H, Sharghi M, Hoseinzadeh H. Comparative study of topical 80% trichloroacetic acid with 35% trichloroacetic acid in the treatment of the common wart. J Drugs Dermatol 2012;11:e66-9.  Back to cited text no. 6
    
7.
Sharquie KE, Al-Rawi JR, Al-Nuaimy AA, Radhy SH. Bacille Calmette-Guerin immunotherapy of viral warts. Saudi Med J 2008;29:589-93.  Back to cited text no. 7
    
8.
Lal NR, Sil A, Gayen T, Bandyopadhyay D, Das NK. Safety and effectiveness of autoinoculation therapy in cutaneous warts: A double—blind, randomized, placebo-controlled study. Indian J Dermatol Venereol Leprol 2014;80:515-20.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Damstra RJ, van Vloten WA. Cryotherapy in the treatment of condylomata acuminata: A controlled study of 64 patients. J Dermatol Surg Oncol 1991;17:273-6.  Back to cited text no. 9
    
10.
Falknor GW. Needling – A new technique in verruca therapy. A case report. J Am Podiatry Assoc 1969;59:51-2.  Back to cited text no. 10
    
11.
Skilton B., Mehar Z. Needling: A treatment option for recalcitrant verrucae pedis. Podiatry Now 2011;14:21-5.  Back to cited text no. 11
    
12.
Nischal KC, Sowmya CS, Swaroop MR, Agrawal DP, Basavaraj HB, Sathyanarayana BD. A novel modification of the autoimplantation therapy for the treatment of multiple, recurrent and palmoplantar warts. J Cutan Aesthet Surg 2012;5:26-9.  Back to cited text no. 12
  [Full text]  
13.
Bunney MH, Nolan MW, Williams DA. An assessment of methods of treating viral warts by comparative treatment trials based on a standard design. Br J Dermatol 1976;94:667-79.  Back to cited text no. 13
    
14.
Steele K, Irwin WG. Liquid nitrogen and salicylic/lactic acid paint in the treatment of cutaneous warts in general practice. J R Coll Gen Pract 1988;38:256-8.  Back to cited text no. 14
    
15.
Abdel Meguid AM, Abdel Motaleb AA, Abdel Sadek AMI. Cryotherapy vs trichloroacetic acid 90% in treatment of common warts. J Cosmet Dermatol 2019;18:608-13.  Back to cited text no. 15
    
16.
Cengiz FP, Emiroglu N, Su O, Onsun N. Effectiveness and safety profile of 40% trichloroacetic acid and cryotherapy for plantar warts. J Dermatol 2016;43:1059-61.  Back to cited text no. 16
    
17.
Sterling JC, Handfield-Jones S, Hudson PM, British Association of Dermatologists. Guidelines for the management of cutaneous warts. Br J Dermatol 2001;144:4-11.  Back to cited text no. 17
    
18.
Khan S, Zeeshan HM, Mushtaq F. Efficacy of 10% KOH in palmoplantar warts. Pak J Med Health Sci 2017;11:553-5.  Back to cited text no. 18
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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