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Received: 29 July 2020    Revised: 21 August 2020    Accepted: 3 September 2020

DOI: 10.1111/jocd.13718

ORIGINAL CONTRIBUTION

Evaluation of intralesional Candida antigen in diabetic patients

with multiple warts

Ayman Marei MD, PhD1,2 | Rania Alakad MD2,3  | Reham M. Wahid MD4

1
Microbiology and Immunology Department,
Faculty of Medicine, Zagazig University,
Zagazig, Egypt
2
Interventional Research Lab, Interventional
Immunology and Allergy Center, Zagazig,
Egypt
3
Dermatology, Venereology and Andrology
Department, Faculty of Medicine, Zagazig
University, Zagazig, Egypt
4
Physiology Department, Faculty of
Medicine, Zagazig University, Zagazig, Egypt
Correspondence
Rania Alakad, Dermatology, Venereology
and Andrology Department, Zagazig
University, Zagazig, Egypt.
Email: Raniaelakad620@gmail.com
Abstract
Background: Treatment of warts in diabetic patients with ablative modalities poses
a significant risk owing to increased possibility of secondary infection, slow healing,
and recurrence. Intralesional immunotherapy has gained popularity in the treatment
of warts due to its proven efficacy and good tolerability compared with destructive
methods.
Aim: To evaluate the intralesional Candida antigen injection for the treatment of mul-
tiple warts in diabetic patients.
Patients/Methods: Fifty diabetic patients with multiple genital/nongenital warts
were divided into two groups. The first group (30 patients) received intralesional
Candida antigen, and the second group (20 patients) had intralesional saline as con-
trol. The treatments were injected into the largest wart every 2 weeks until complete
clearance of warts or for a maximum of five sessions.
Results: Complete clearance of warts was observed in 80% of the diabetic patients
in the Candida antigen group compared with 15% in the control group (P  < .001).
Side effects to Candida antigen included pain during injection in all patients, flu-like
symptoms, and localized reaction at the injection site in few patients.
Conclusion: Intralesional Candida antigen injection can be a promising effective and
safe therapeutic option for the treatment of warts in diabetic patients.

KEYWORDS
Candida antigen, diabetes, intralesional immunotherapy, treatment, warts

1 |  I NTRO D U C TI O N virus (HPV) infections.3 However, a causal relationship between DM

The prevalence of diabetes mellitus (DM) is rapidly growing world-
wide. This rise is largely related to an increase in type 2 DM.1 The
prevalence of type 2 DM in Egypt was almost tripled over the last 2
decades, possibly due to increased risk factors such as obesity, lack
2
of physical activity, and unhealthy dietary habits.
Diabetes mellitus has been considered an immunocompromised
state with significant impact on the morbidity and mortality. The
prevalence of infections in general and cutaneous infections in par-
ticular is increased in diabetic patients including human papilloma
and the incidence or severity of HPV infections is not identified.1
The treatment of warts in diabetic patients is difficult as conven-
tional destructive modalities may be associated with increased risk
of ulceration, infection, and delayed wound healing, especially in pa-
tients with poor glycemic control.4
Immunotherapy using intralesional antigens and vaccines, for
example, Candida antigen; measles, mumps, and rubella (MMR); and
purified protein derivatives (PPD), has documented efficacy in the
treatment of different types of warts.5 It induces the production
of Th1 cytokines, which activate cytotoxic and natural killer cells

J. Cosmet. Dermatol.. 2020;00:1–6. wileyonlinelibrary.com/journal/jocd© 2020 Wiley Periodicals LLC     1 |

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2       MAREI et al.
to eradicate HPV infection in both the injected and distant warts.6
Intralesional immunotherapy may form a useful substitute for the
treatment of warts in diabetic patients as it can potentially enhance
the immune response and overcome the wound healing complica-
tions of destructive measures. To our knowledge, no previous studies
have examined this modality for the treatment of warts in diabetic
patients. In this clinical study, we aim to evaluate the efficacy and
safety of intralesional Candida antigen injection for the treatment of
diabetic patients with multiple genital/cutaneous warts.
2 |  M E TH O DS
Fifty diabetic patients with the clinical diagnosis of multiple warts
were enrolled into the study after obtaining an informed written
consent. They were randomly divided into two groups: The first
group included 30 patients who received intralesional Candida an-
tigen at a dose of 0.2 mL, and the second group included 20 patients
who received intralesional saline as control. The largest wart was
injected every 2 weeks. The treatment was stopped if no thera-
peutic response was observed after five sessions. Only patients
with well-controlled diabetes (hemoglobin A1C value <7%) were in-
cluded. Exclusion criteria were as follows: children <16 years, preg-
nant and lactating women, patients with other causes of primary or
secondary immunosuppression, and those who received any other
treatment for warts at least 1 month prior to the study.
Clinical photographs were taken before treatment and at each
follow-up visit. Response to treatment was evaluated by the regres-
sion in size of warts. Evaluation of the clinical response was per-
7
formed according to Nofal and Nofal : The response was considered
complete if there was a total resolution of the warts (100%), par-
tial response if the warts regressed by 50%-99%, and no response
if there was <50% decrease in wart size. Adverse effects were re-
ported, and follow-up was done monthly for 6 months to detect any
relapse. The photographs were evaluated objectively by two blinded
dermatologists.
2.1 | Statistical analysis
Analysis of data was done using the statistical package SPSS ver-
sion 23. Data were described in terms of mean ± standard devia-
tion (SD), range, frequencies, and percentages. The chi-square test
and t test were used as appropriate. P values <.05 were consid-
ered statistically significant, and P values <.001 were considered
highly significant.
3 | R E S U LT S
The study included 50 diabetic patients, 19 males (38%), 31 females
(62%), whose age ranged from 39 to 63 years with a mean ±  SD
50.7 ± 4.9 years. All patients had type 2 DM with good glycemic control
(hemoglobin A1C <7% with the highest reported value in the tested
subjects, 6.5%). All the patients had multiple warts but in localized ana-
tomical regions. Genital warts were the most common type, presented
in 20 patients (40%), followed by plantar warts in 13 patients (26%),
common warts in 10 patients (20%), and periungual warts in seven pa-
tients (14%). The number of lesions ranged from 3 to 12, and the du-
ration ranged from 1 to 3 years with a mean ±  SD (2  ± 0.75) years.
History of previous treatment of warts was reported in 46% of patients
in the form of cryotherapy and topical salicylic, imiquimod, and laser
therapy. No statistically significant difference was found between the
two groups regarding the demographic and clinical data (P > .05).
All studied patients completed the study. In the Candida group,
complete clearance of warts was observed in 24 patients (80%)
(Figures 1, 2 and 3). Four patients had partial response (13%), and
two patients showed no response to therapy (7%). In the control
group, three patients had complete resolution of their lesions (15%),
four patients had partial response (20%), and 13 patients showed no
response (65%). A high statistically significant difference was found
between the treatment and the control groups (P < .001). The aver-
age number of sessions needed to achieve complete response was
1-5 with a median of four sessions. The baseline characteristics and
F I G U R E 1   Plantar warts in a diabetic
patient. (A) Before treatment. (B)
Complete clearance of warts after three
sessions of intralesional Candida antigen
injection
MAREI et al.
F I G U R E 2   Periungual warts in a
diabetic patient. (A) Before treatment.
(B) Complete clearance after four
sessions of intralesional Candida antigen
injection
F I G U R E 3   Plantar warts in a diabetic
patient. (A) Before treatment. (B)
Complete clearance of warts after four
sessions of intralesional Candida antigen
injection
clinical response of the studied patients are demonstrated in Table 1.
A statistically significant difference was found between the thera-
peutic responses of different types of warts to Candida antigen in-
jection (P  < .001). The highest clearance rate was observed in the
genital warts followed by plantar, common, and periungual warts,
respectively (Table 2). Adverse effects of Candida antigen injection
included pain during injection in all patients, flu-like symptoms in
eight patients (27%), and localized reaction at the site of injection
in the form of edema and erythema in nine patients (30%). All the
patients who achieved complete response remained free of infection
with no recurrence of warts during the 6-month follow-up period.
4 | D I S CU S S I O N
Warts are cutaneous infections caused by HPV. Many observations
have suggested that wart proliferation is controlled by the immune sys-
7
tem, particularly the cell-mediated immunity. The role of immunity in
warts was evidenced by increased prevalence and persistence of warts
in immunosuppressed populations, while spontaneous regression of the
majority of warts was associated with enhanced cellular immunity.8
|
      3
Diabetic patients tend to suffer from more extensive warts,
require more prolonged time for wart clearance, and have more
recurrence rates compared with nondiabetic patients. This can be
attributed to defective immune responses in diabetic patients.3,9
In diabetes, hyperglycemia strongly affects the skin homeostasis.
It impairs phagocytosis and chemotaxis of several immune cells. In
addition, production of advanced glycation end products in diabetic
patients induces reactive oxygen species formation, which conse-
quently promotes inflammation.10,11 There is also a perception that
the skin and mucosa of diabetic patients are more colonized with
pathogenic microorganisms and therefore can easily get infected.12
According to Farshchian et al,13 viral warts are more frequent in
type 1 compared with type 2 diabetic patients. In our study, all the
patients had type 2 DM, likely due to its high prevalence in our coun-
try. The current prevalence of type 2 DM in Egypt is approximately
15.6% of all adults aged 20-79. 2
A wide range of physical measures have been applied for the
treatment of warts, for example, cryotherapy, electrocautery, cu-
rettage, surgical excision, and ablative lasers.14 These destructive
modalities are designed to remove the visibly infected lesions; how-
ever, nonvisible infected tissues are not targeted leading to high
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4       MAREI et al.

recurrence rates.15 Warts in diabetic patients should be treated cau-
tiously with traditional ablative modalities as they carry the risk of
wound healing complications, especially in patients with uncontrolled
hyperglycemia.3 For example, care should be taken when using de-
structive therapy to ablate plantar warts in diabetic patients, for fear
of diabetic foot ulcers. Foot ulcers have always been a challenge
for healthcare professionals when treating diabetic foot infections
particularly if the patient has other deformities.16 The prevalence of
foot ulcers in diabetic patients is reported between 5.3% and 10.5%,
and lifetime risk diabetic foot ulcer is 25%.17 Furthermore, surgical
removal of large warts in diabetic patients represents a high anes-
thetic risk due to associated comorbidities along with the possibility
of slow healing of postsurgical wounds.3
Previous trials that discussed the treatment of warts in diabetic
patients are limited. Yong et al3 described 12 diabetic patients with
genital warts who were treated with physical and chemical ablative

TA B L E 1   Baseline characteristics and clinical response of the studied groups

Candida group Control group

(N = 30) (N = 20) T P

Age (years)
Range 39-63 42-56 −1.5 .12
Mean ± SD 50.7 ± 4.9 52.6 ± 3.7 NS
Duration (years)
Range 1-3 1-2 1.9 .06
Mean ± SD 2 ± 0.75 1.7 ± 0.34 NS

Number of warts X2 P

Range 5-12 3-10 1.6 .2

NS

No % No % X2 P

Gender
Female 18 60 13 65 .72
Male 12 40 7 35 0.127 NS
Previous therapy
Yes 12 40 11 55 1 .29
No 18 60 9 45 NS
Type of warts
Common 6 20 4 20 0.037 .99
Plantar 8 27 5 25 NS
Periungual 4 13 3 15
Genital 12 40 8 40
Therapeutic response
Complete 24 80 3 15 23.3 <.001
Partial (50%-99%) 4 13 4 20 HS
Poor <50% 2 7 13 65
2
Note: T, t test; X , chi-square test; P > .05, nonsignificant (NS); P < .05, significant (S); P < .001, highly significant (HS).

TA B L E 2   Therapeutic response according to the type of warts in the Candida antigen group

Periungual
Common warts Plantar warts warts Genital warts P
Therapeutic response N = 6 N = 8 N = 4 N = 12 X2 value

N % N % N % N % 274.3 <.001
Complete 4 66.7 7 87.5 2 50 11 91.7
Partial (50%-99%) 1 16.7 1 12.5 1 25 1 8.3
Poor (<50%) 1 16.7 0 0 1 25 0 0
2
Note: X , chi-square test; P > .05, nonsignificant (NS); P < .05, significant (S); P < .001, highly significant (HS).
MAREI et al.
therapy, for example, cryotherapy, imiquimod, and podophyllo-
toxin. A long duration was needed for clearance of warts (average
12 weeks), and recurrence of warts occurred in 25% of patients. One
of their described patients had large genital warts that required sur-
gical debulking. Surgical resection was associated with ulceration,
4
wound infection, and delayed healing. Huo et al have reported
clearance of multiple genital warts in three diabetic patients using
local hyperthermia at 44° within 6-9 weeks. They suggested that
local hyperthermia is an effective and safe therapy in diabetic pa-
tients; however, their study was limited by the small sample size.
Intralesional injection of immunotherapeutic agents has been
used to overcome the adverse effects associated with destructive
methods.7 Candida antigen is recently one of the most widely used
agents for the treatment of different types of warts. It is associated
with the production of Th1 cytokines such as IFN-γ and IL-2, which
activate cytotoxic and natural killer cells to eradicate HPV infec-
tion.18 We have previously reported the efficacy of intralesional
Candida antigen in the treatment of multiple warts in immuno-
competent patients with minimal adverse effects.18,19 Injection of
Candida antigen has an estimated clearance rate ranging from 33.3%
to 75.9% of the injected subjects.18
To date, studies that investigate the safety of intralesional im-
munotherapy for the treatment of warts in immunosuppressed pa-
tients are lacking. Wong and Crawford20 have reported clearance
of refractory warts in three out of seven HIV patients using intrale-
sional Candida antigen. They stated that Candida is an effective and
well-tolerated line of therapy in those immunosuppressed patients.
In this study, we tried to evaluate intralesional Candida antigen
in diabetic patients with both genital and cutaneous warts. Twenty-
three (46%) of our patients have previously failed conventional ther-
apy for warts prior to our study. Complete resolution of warts was
achieved in 80% of diabetic patients using intralesional Candida an-
tigen. A high statistically significant difference was found between
the treatment and the saline control groups (P < .001). This clearance
rate was consistent with previous trials investigating intralesional
Candida injection in nondiabetic patients.5,18,19,21 This signifies
that patients with DM could mount an effective immune response
to the injected antigen despite presumed defective immunity. The
immune dysfunction in diabetic patients was previously described
to involve the innate immunity (in the form of impaired chemotaxis
and phagocytosis of diabetic polymorphonuclear cells and macro-
phages) rather than the adaptive immunity.9 This may explain the
good clinical response to Candida antigen in diabetic patients as it
mainly depends on the stimulation of adaptive immune system and
production of Th1 cytokines.
The adverse effects to Candida injection were often noticed
early during treatment (after the first or second session). They
were mild and well tolerated including pain during injection in
all patients, injection site redness and edema in 30% of patients,
and flu-like symptoms in 27% of patients. The pain was tolerated
by all patients without the need for pretreatment anesthesia. The
Candida-associated reactions rapidly cleared with nonsteroidal an-
ti-inflammatory drugs and did not necessitate stoppage of treatment.
|
      5
Wound healing complications, for example, ulceration, scarring, and
secondary infection, were not reported, and no recurrence was
noted through the follow- up period. It is noteworthy that the me-
dian treatment time needed for clearance of warts in our patients
was 8 weeks (four treatment sessions). That was significantly shorter
than the median treatment time reported by Yong et al3 using con-
ventional ablative modalities (12 weeks). Thus, immunotherapy help
shorten the duration of treatment, which can subsequently decrease
the associated morbidity and cost of therapy.
To conclude, intralesional Candida antigen injection can be a
promising therapeutic option for the treatment of warts in diabetic
patients. The treatment was effective in most of the patients, and
wound healing complications were not reported. We recommend it
as a first-line therapy in cases of multiple and refractory warts. This
trial can be a foundation for larger studies in the future to evaluate
variant types of intralesional immunotherapy in diabetic patients.
E T H I C A L A P P R OVA L
The manuscript is original and was not published before in another
journal. We declare no conflict of interest and no funding sources.
DATA AVA I L A B I L I T Y S TAT E M E N T
The authors elect to not share data.
ORCID
Rania Alakad  https://orcid.org/0000-0002-3907-087X
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How to cite this article: Marei A, Alakad R, Wahid RM.
Evaluation of intralesional Candida antigen in diabetic
patients with multiple warts. J. Cosmet.
Dermatol.2020;00:1–6. https://doi.org/10.1111/jocd.13718