A 12-year-old male came to clinic for retreatment of his plantar warts. He had been treated with cryotherapy and salicylic acid 3 months previously. The mother said that she thought they had healed, but 2 days ago she noticed that they had returned. The boy had no pain and said that he thought it was okay as long as they didn’t hurt. The past medical history was non-contributory.
The pertinent physical exam showed a healthy male with growth parameters in the 10-25%. On his ball of his right foot he had a 5-6 mm lesion and on the great toe had a 4-5 mm lesion. Both had a verrucous pattern with pinpoint hemorrhages. The bottom of the lesions could be palpated. The diagnosis of recurrent plantar warts was made. Cryotherapy was used again, with an appointment for re-freezing in 2-3 weeks. During the interval, salicylic acid use daily was advised. The physician also told the mother that if this treatment didn’t work, that he would refer the patient to dermatology for intralesional candida antigen immunotherapy.
Veruccae plantaris or plantar warts are caused by Human papillomavirus which causes benign epidermal tumors that often have a cauliflower pattern on the foot that may be elevated or flush with the surrounding skin. Lesions may resemble caluses but the normal footprint pattern is disrupted. The lesions often have pinpoint hemorrhages that appear as black dots. In an immunocompetent individual, the lesions usually have spontaneous resolution within 2 years but the infection may spread to create additional lesions. The lesions may also cause pain or discomfort because of their size or location.
Plantar warts are often difficult to treat. Treatments include keratolytics (e.g. salicylic acid or tricholoacetamic acid), cryotherapy with liquid nitrogen, electrodesiccation, or direct surgical removal. Suffocation by duct tape and plastic have also been used. Immunotherapy with candida, mumps or trichophytin antigens have been used more recently. These are felt to induce a local and distant immunoresponse that destroys the lesions.
Overall intralesional candida antigen therapy appears to be effective.
A retrospective chart review in 2008 found:
- For warts – of 55 patients with followup, 48 (87%) had complete resolution after an average of 3.5 monthly injections and another 3 (5.5%) patients had partial clearing after an average of 3 injections.
- For molluscum contagiosum (caused by a pox virus) – of 25 patients with followup, 14 (56%) had complete resolution after an average of 3 monthly injections and another 7 (28%) had partial clearing after an average of 4 injections.
This study had a large dropout rate though (for warts 67% and for molluscum 47%).
In another small study of 18 patients, 11 completed the study and 9 (82%) had complete resolution and 1 (9%)had partial resolution, with a median of 4 every 3-week injections. Also, 6 of 9 patients (67%) with additional warts at distant locations had resolution of those warts.
Questions for Further Discussion
1. What is the cost of intralesional treatment with Candida antigen?
2. How effective is mumps or trichophytin antigen intralesional treatment of plantar warts?
3. How is intralesional candida antigen given?
4. How are plantar warts spread?
- Symptom/Presentation: Papulosquamous Lesions
- Age: School Ager
To Learn More
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Maronn M, Salm C, Lyon V, Galbraith S. One-year experience with candida antigen immunotherapy for warts and molluscum. Pediatr Dermatol. 2008 Mar-Apr;25(2):189-92.
Kim KH, Horn TD, Pharis J, Kincannon J, Jones R, O’Bryan K, Myers J, Nakagawa M. Phase 1 clinical trial of intralesional injection of Candida antigen for the treatment of warts. Arch Dermatol. 2010 Dec;146(12):1431-3
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital