Reply to: “Comment on ‘Intralesional versus intramuscular bivalent human papillomavirus vaccine in the treatment of recalcitrant common warts’”

Abstract

To the Editor: We read the comments by Taheri and Mansoori on our article “Intralesional Versus Intramuscular Bivalent Human Papillomavirus Vaccine in the Treatment of Recalcitrant Common Warts.”1Nofal A. Marei A. Ibrahim A.M. Nofal E. Nabil M. Intralesional versus intramuscular bivalent human papillomavirus vaccine in the treatment of recalcitrant common warts.J Am Acad Dermatol. 2020; 82: 94-100Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Many of the issues they raised were stressed by the reviewers and editors and so were discussed in our article. For example, the method of randomization, the absence of a control group, the difference in the dosing schedules, and the short follow-up period were all discussed in our article in the last 2 paragraphs of the discussion section. In addition, many of the concerns enumerated by Taheri and Mansoori were reviewed in the article, such as their concern about the dropouts (all patients completed the study), the settings and locations of the study (mentioned in the affiliations), the partial response (response to treatment was evaluated according to the method described by Nofal et al 2017 as already mentioned in the article1Nofal A. Marei A. Ibrahim A.M. Nofal E. Nabil M. Intralesional versus intramuscular bivalent human papillomavirus vaccine in the treatment of recalcitrant common warts.J Am Acad Dermatol. 2020; 82: 94-100Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar), the method of intralesional vaccine injection (intralesional injection of any modality is a well-established technique for clinical dermatologists), and the start of the follow-up period (after completion of treatment because it was done to detect any recurrence). Many researchers have reported that spontaneous resolution of warts occurs in a considerable portion (60%-65%) of patients within 1 to 2 years, after which the warts become highly recalcitrant to treatment by different modalities, including the most aggressive therapies.2Lipke M.M. An armamentarium of wart treatments.Clin Med Res. 2006; 4: 273-293Crossref PubMed Scopus (178) Google Scholar,3Nofal A. Nofal E. Yosef A. Nofal H. Treatment of recalcitrant warts with intralesional measles, mumps, and rubella vaccine: a promising approach.Int J Dermatol. 2015; 54: 667-671Crossref PubMed Scopus (44) Google Scholar Because our patients had recalcitrant warts of more than 2 years' duration that showed no response to at least 2 treatment modalities, it is unlikely that the complete resolution shown in our study after intralesional or intramuscular injection of bivalent human papillomavirus vaccine was spontaneous. Finally, if we go with the assumption mentioned by Taheri and Mansoori that warts are a “self-limiting disease,” the results would be that no studies would be performed and no modality could be proven useful for the treatment of warts. Comment on: “Intralesional versus intramuscular bivalent human papillomavirus vaccine in the treatment of recalcitrant common warts”Journal of the American Academy of DermatologyVol. 82Issue 3PreviewTo the Editor: Nofal and colleagues1 published the results of an interesting pilot study comparing intralesional versus intramuscular bivalent human papillomavirus vaccine in the treatment of recalcitrant common warts. In this clinical trial, 22 patients were injected with intramuscular vaccine at 0, 1, and 6 months or until complete clearance of warts, and 22 patients were intralesionally injected with the vaccine into the largest wart at 2-week intervals until complete clearance or for a maximum of 6 sessions. Full-Text PDF