Intralesional bivalent and quadrivalent human papillomavirus vaccines didn't significantly enhance the response of multiple anogenital warts when co-administered with intralesional Candida antigen immunotherapy. A randomized controlled trial

Abstract

Treatment of anogenital warts (AGWs) is challenging. Candida antigen immunotherapy has been proven to be a safe and relatively effective therapeutic modality; nevertheless, some patients may experience a partial or no response. Combining Candida antigen with other immunotherapies has been proposed to improve the cure rate. Immunotherapy with human papillomavirus (HPV) vaccines has been tried with conflicting outcomes. This study aimed to assess the efficacy and safety of intralesional Candida antigen, either alone or in combination with intralesional bivalent or quadrivalent HPV vaccines, for treating multiple AGWs. Eighty patients with multiple AGWs were included and randomly assigned to four equal groups: group A treated with intralesional Candida antigen only; group B treated with intralesional bivalent HPV vaccine (Cervarix) and Candida; group C treated with intralesional quadrivalent HPV vaccine (Gardasil) and Candida; and group D (control) treated with intralesional saline. Complete clearance of lesions was detected in 40%, 20%, and 60% of patients in Candida monotherapy, Cervarix/Candida, and Gardasil/Candida groups, respectively, whereas 40%, 60%, and 20% of patients in the three groups, respectively, showed partial response. Only 10% of the control group had a partial response. Therapeutic outcomes were significantly better in the three treatment groups compared to the control group, with no statistically significant difference between the Candida monotherapy group and the combination groups, but the response was significantly better in the Gardasil/Candida group than in the Cervarix/Candida group. No statistically significant difference was found between the studied groups regarding the development of side effects. Moreover, no recurrence was detected in any of the groups throughout the 3-month follow-up period. Based on our results, combining intralesional HPV vaccines with Candida antigen immunotherapy may have no significant benefit for treating multiple AGWs. Candida antigen may be recommended as a relatively effective and inexpensive therapeutic modality. The combination of Gardasil and Candida was also effective but very expensive. The results of the Cervarix/Candida combination were unsatisfactory. This clinical trial was registered and approved prospectively by the ethical review board at Faculty of Medicine, Zagazig University.

Keywords: Anogenital warts; Bivalent HPV vaccine; Candida antigen; Immunotherapy; Quadrivalent HPV vaccine; Treatment.

Fig. 1

Patients’ flow chart illustrating the sequence of the study according to CONSORT guidelines for reporting randomized controlled trials. AGWs, Anogenital warts

Fig. 2

a Genital warts before treatment with intralesional Candida antigen immunotherapy b Complete clearance of lesions after two sessions (at 4 weeks)

Fig. 3

a Genital warts before treatment with alternating intralesional injections of Candida antigen and the quadrivalent human papillomavirus vaccine (Gardasil) b Complete clearance of lesions after five sessions (at 5 weeks)

Fig. 4

Clinical outcomes of intralesional Candida antigen either alone or in combination with intralesional bivalent (Cervarix) or quadrivalent (Gardasil) human papillomavirus (HPV) vaccines in the treatment of anogenital warts (AGWs). CR complete response, NR no response, PR partial response, SE side effects