Pulsed-dye laser versus intralesional Candida albicans

Genital human papilloma virus (HPV) infections are widely prevalent worldwide. Genital warts are associated with a negative impact on the wellbeing of infected men and women as reflected by poorer quality-of-life scores. Moreover, anogenital HPV is the leading cause of cervical cancer, especially with oncogenic highrisk HPV types 16 and 18, in addition to other benign and malignant genital neoplastic lesions (1, 2). HPV types 6 and 11 are lowrisk subtypes that are responsible for 90% of the cases of genital warts and rarely give rise to cervical cancers, but they have been associated with some types of verrucous carcinomas such as oral florid papillomatosis and Buschke–Löwenstein tumor (2, 3). Many different therapeutic options for genital warts currently exist, including imiquimod, podophyllin, interferons (IFNs), cryotherapy, intralesional bleomycin, laser vaporization, electrocautery, and surgical removal. Unfortunately, none of these modalities offer a guarantee of cure, in addition to the common risk of recurrence (4, 5). Flash-lamp pumped pulsed-dye laser (PDL) emits a wavelength from 585 to 595 nm, consistent with the hemoglobin absorption peak, and it is therefore used for the treatment of vascular lesions. It has shown promising results in the treatment of viral warts because it destroys the characteristically dilated superficial dermal capillaries that supply the warts, thereby starving the epidermal cells harboring viral particles, resulting in wart regression. Furthermore, HPV is heat-sensitive, and that makes it vulnerable to the thermal destructive effect of PDL. PDL is thought to be a safe and effective modality for treatment of warts that can be applied to most body areas (6–8). Immunotherapy has been tried for warts with oral immune modulators such as cimetidine and levamisole. Several intralesional immunotherapeutic antigens have also been tried, such as Candida albicans (C. albicans) antigen, tuberculin antigens (including purified protein derivative, Mycobacterium w vaccine, and Bacillus Calmette–Guérin), and Trichophyton in addition to measles, mumps, and rubella (MMR) (9). The first antigen that was tried for immunotherapy of warts was that of C. albicans, and the investigators reported success in the majority of patients treated with this test antigen (9, 10). Intralesional immunotherapy stimulates the host immune system to trigger a delayed-type hypersensitivity response to a multitude of antigens, including the wart tissue. This therapy is associated with the production of a Th1 cytokine milieu and activation of cytotoxic and natural killer (NK) cells to fight HPV infection, not only in the local warts, but also affecting distant warts, unlike traditional wart therapies (11). It should be noted that these distant warts, especially if hidden (intravaginal, cervical, intrauretheral, or intraanal), are a major therapeutic challenge in HPV affecting the genital area. Moreover, some cases of genital warts might be associated with dysplasia or carry the risk of future transformation into intraepithelial carcinomas (12), and it should be noted that Buschke– Löwenstein tumors, with invasive growth, recurrence, and possible malignant transformation, are always preceded by condyloma acuminatum (13). We evaluated the efficacy and safety of PDL versus intralesional C. albicans antigen injection for treatment of genital warts.