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ORIGINAL CONTRIBUTIONS
Year : 1990  |  Volume : 56  |  Issue : 1  |  Page : 22-24

Comparison of podophyllin and trichloroacetic acid for the treatment of genital warts




Correspondence Address:
D Nath


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Source of Support: None, Conflict of Interest: None


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  Abstract 

One hundred patients with genital warts of different morphological types were randomly allocated to a therapeutic trial with 25o/, podophyllin in the tincture of benzoin or 50 trichloroacetic acid (TCA). Ninety five patients were followed up for three months. The warts cleared in 78% and 81% patients after treatment with podophyllin and TCA respectively within 3 months. There was no significant difference in the number of applications needed with each type of treatment. Patients with hyperplastic lesions required lesser number of applications (average 3.5) compared to those with flat or verruca vulgaris type of lesions (average 4.5). Young condylomata (less than 6 months duration) responded better than older lesions. Moist lesions on the glans penis and labia responded better than the dry and keratotic lesions. Local soreness was experienced in 8.5y. cases as a side effect of therapy. Recurrence after initial clearance was seen more commonly with podophyllin application (30% than with trichloroacetic acid (13%).


Keywords: Genital warts, Podophyllin, Trichloroacetic acid, Treatment


How to cite this article:
Nath D, Kumar B, Sharma K V, Kaur I, Gupta R, Malhotra S. Comparison of podophyllin and trichloroacetic acid for the treatment of genital warts. Indian J Dermatol Venereol Leprol 1990;56:22-4

How to cite this URL:
Nath D, Kumar B, Sharma K V, Kaur I, Gupta R, Malhotra S. Comparison of podophyllin and trichloroacetic acid for the treatment of genital warts. Indian J Dermatol Venereol Leprol [serial online] 1990 [cited 2019 Aug 25];56:22-4. Available from: http://www.ijdvl.com/text.asp?1990/56/1/22/3472


The treatment of genital warts is generally acknowledged to be difficult and time consuming. It has a high rate of relapse, the evidence for which is provided by the innumerable types of medical, surgical, immunological and psycho­therapeutic approaches to treatment. These include local applications of podophyllin,[1],[2] trichloroacetic acid,[3],[4] 5 fluoro-uracil,[5] cryo­therapy,s laser therapy,[7] elect rodessication[2] etc. There is very little information on the compara­tive efficacy of podophyllin and TCA for the treatment of genital warts.


  Materials and Methods Top


All patients with ano-genital warts attending the STD clinic between the years 1986-88 who had not received any treatment for warts during the last two months were recruited. The diagnosis in each case was clinical. Sites of warts and their morphology were noted in detail. Warts were divided into five different clinical types viz, hyperplastic when they had a fleshy appearance with surface vegetations, sessile and flat when they had a rough surface, sessile and pigmented type when flat warts had a pig­mented shiny surface, verruca vulgaris type when they resembled common skin warts, and giant warts of Lowenstein and Buschke type.

Patients were assigned at random to either 25% podophyllin in the tincture of benzoin or 50% TCA group except that all pregnant females were allocated to TCA therapy. the patients were advised abstinence or to have only protected sexual intercourse. The medicine was applied at weekly intervals with a swab-stick and it was allowed to dry in air for 2-3 minutes. For intrameatal warts, the patients were advised to micturate before the application of the medicine and then to hold urine for atleast four hours as far as possible. Patients given podophyllin were asked to wash off the medicine with tap water two hours after the application. The treatment was carried out for 12 weeks or till the warts completely disappeared before that period if the warts persisted after 12 weeks, the treatment was changed to another modality. Patients were followed up for a further period of 3 months after cure for any relapse. The X 2 test with Yates correction and students `t' test were used for statistical analysis of the data.


  Results Top


One hundred patients (93 men and 7 women) with a mean age of 25.9 years (range 17-43 years) were included in the trial. All of them had hyperplastic warts except two, who had giant condylomata. Other morphological types of warts viz sessile, pigmented papules and verruca vulgaris type, were seen only in combination with hyperplastic warts. Five patients defaulted. Ninety five patients were followed up for 3 months. Forty seven were treated with 25% podophyllin and 48 with 50% TCA. The two groups of patients were statistically comparable in age range, and the location of warts. The number of patients free of warts at 3 months were similar with both the chemicals (38 with podophyllin and 39 with TCA). Cure of warts after a single application was seen in 13% cases. The mean number of applications required for complete clearance of the lesions was 3 for podophyllin compared to 3.8 for TCA. The difference between the two groups was statisti­cally not significant (p>0.05). Recent condylo­mata (<6 months duration) responded earlier than the older lesions, requiring a mean of 3.4 and 4.1 applications respectively. In patients with less than 5 lesions, the clearance of warts was significantly quicker compared to those with more lesions. Lesions in moist areas (glans, inner prepuce, interlabial) required a mean of 3.4 applications whereas dry and keratotic lesions (shaft of penis, mons pubis) required a mean of 4.3 applications. No signi­ficant difference (p>.05) was found as far as the number of patients responded and the mean number of treatments required to clear warts at the end of 3 months in the 2 treatment groups in the case of hyperplastic warts. For flat and verruca vulgaris type of warts the results could not be analysed statistically because of the small sample size. These types of warts seemed more resistant and required more number of treatments [Table - 1][Table - 2].

Three non-pregnant married females treated with podophyllin required an average of 3 applications for clearance of their warts whereas four pregnant females treated with TCA required an average of 3.8 applications. Recurrence of warts within 3 months of clearance occurred in 14 (30%) and 6 (13%) patients treated with podophyllin and TCA respectively. The overall recurrence rate was 20%.

Local soreness was experienced by 8.5% cases. There was no systemic toxicity.


  Comments Top


Podophyllin, obtained as a resin from the rhizomes of Podophyllum peltatum and Podo­phyllum emodi (the may-apple and mandrake plants) has been the most widely used cytotoxic agent for the treatment of genital warts. It has a colchicine-like action, initiating mitotic activity in the prickle cell layers and arresting cell division in the metaphase. Early reports of the use of podophyllin for the treatment of ano-genital warts were very encouraging, giving a cure rate of 81 % (200 patients) after one application of podophyllin,[10] but subsequent studies have not indicated as high a success rate. Gabriel and Thin[3] observed an overall clearance rate of 32% at 3 months in 60 patients using podophyllin and podophyllin with TCA in two groups of patients. The high clearance rate in the present study could be due to the regular attendance of the patients, application of the medicine by the same observer, possibly early presentation of the disease, and many of them had only a few warts (less than 5 in 40% cases).

Powell[4] recommended trichloroacetic acid as a form of chemical cautery for the treatment of genital warts. It has an instant coagulant and dessicant action leading to necrosis of the super­ficial skin layers. Although systemic absorption is not a problem, the pain on application is a common side effect. In the present study, 25% podophyllin and 50% TCA were equally effective. Hyperplastic warts required less number of appli­cations than the dry and keratotic lesions. It is possible that TCA may be more effective in treating the dry and keratinised lesions due to its better penetrative and coagulant properties.

 
  References Top

1.Simmonds PD : Podophyllin 10% and 25 % in the treatment of anogenital warts. A comparative double blind study, Brit J Vener Dis, 1981; 57 208-209.  Back to cited text no. 1    
2.Von Krogh G : Topical treatment of penile condy­lomata acuminata with 5-FU, podophyllin, podo­phyllotoxin and colchicine : A comparative study, Acta Dermato-Venereol, 1981; 98 (Suppl) : 10-25.  Back to cited text no. 2    
3.Gabriel G and Thin RNT : Treatment of anoge­nital warts, Comparison of trichloroacetic acid and podophyllin versus podophyllin alone, Brit J Vener Dis, 1983; 59 : 124-126.  Back to cited text no. 3    
4.Powell LC : Condyloma accuminatum, Clin Obstet Gynaecol, 1972; 1.5 : 948-964.  Back to cited text no. 4    
5.Drelter SP and Klein LA : The eradication of intraurethral condyloma accuminata with 5 fluorouracil cream, J Urol, 1975; 13 : 195-198.  Back to cited text no. 5    
6.Simmonds PD, Langlet F and Thin RNT : Crvo­therapy versus electrocautery in the treatment of genital warts, Brit J Vener Dis, 1981; 57 : 273-274.  Back to cited text no. 6    
7.Billingham RP and Lewis FG : Laser versus electri­cal cautery in the treatment of condylomata acuruinata of the anus, Surg Gynaecol Obstet, 1982; 155 : 865-867.  Back to cited text no. 7    
8.Robinson JK : Extirpation by electrocautery of massive lesions of condyloma acuminatum in the genito-perineal region, J Dermatol Surg Oncol, 1980; 6 : 733-735.  Back to cited text no. 8    
9.Kinghorn GR : Genital papillomavirus infections treatment, in : Recent Advances in Sexually Trans­mitted Diseases, Number 3, Editors, Oriel JD and Harris JRW : Churchill Livingstone, Edinburgh, 1986; p 147-156.  Back to cited text no. 9    
10.Culp OS and Kaplan 1W : Condylomata acumi­nata, 200 cases treated with podophyllin, Ann Surg, 1944; 120 : 251-256.  Back to cited text no. 10    


    Tables

[Table - 1], [Table - 2]



 

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