Topical hydrogen peroxide solution 40%in the treatment of genital warts

doi:10.21203/rs.3.rs-2728203/v1

Background; The visible result of a human papillomavirus (HPV) infection caused by one or more of the roughly 100 known strains is genital warts. The most prevalent STD in the world is HPV, and infections with it are strongly linked to major morbidity and death. Numerous malignancies and lesions of the mucosa and epithelium are caused by HPV. Women under the age of 25 are most typically affected by HPV infections,

Aim and objectives; to evaluate the efficacy and safety of topical hydrogen peroxide solution 40% in treatment of genital warts,

Subjects and methods; this study was a randomized controlled trial that was conducted on 52 patients attending the Dermatology outpatient clinic at Damietta Faculty of Medicine, Al-Azhar University. The selected subjects were divided into 26 patients treated with topical H₂O₂ as Hydrogen peroxide group and 26 patients treated with saline as control group.

Result; There is statistically significant positive correlation between Size of wart after ttt and number of wart after ttt. There is statistically significant reduction in the number of warts with decrease its number after ttt. However, there is no statistically significant correlation between the size and number of warts after ttt with other clinical variables,

Conclusion; One possible course of therapy for genital warts may be hydrogen peroxide solution, particularly the 40% concentration. As a novel topical therapy for genital warts, it is very efficient, secure, affordable, and simple to apply,

human papillomavirus (HPV)

sexually transmitted disease (STD)

The visible result of a human papillomavirus (HPV) infection caused by one or more of the roughly 100 known strains is genital warts. The most prevalent STD in the world is HPV, and infections with it are strongly linked to major morbidity and death. Numerous malignancies and lesions of the mucosa and epithelium are caused by HPV. Women under the age of 25 are most typically affected by HPV infections. [1].

HPV types 6 and 11, which are seldom linked to aggressive squamous cell carcinoma of the external genitalia, often produce visible genital warts. Squamous intraepithelial neoplasia is linked to HPV types 16, 18, 31, 33, and 35, which have been detected in genital warts. Types 16 and 18 are most strongly linked to malignant potential [2].

The high-risk variant of HPV needs a trigger, such as smoking, a folate deficit, exposure to UV radiation, immunosuppression, and/or pregnancy, in order to cause cancers. [3].

Prior to reaching the prodromal stage, which is when clinical manifestations are seen, the HPV incubation period may last anywhere between 3 weeks and 8 months. [4].

Visual examination is required to detect genital warts, which may be papillomatous plaques or flat lesions with one or more types and a rise in size or number. Genital warts may be any hue, from flesh to white, pink, or brown. Females' cervix, vagina, vulva, urethral meatus, and perianal area, and males' scrotum, penis shaft, corona, beneath the foreskin, and perianal region, are where they may be found. [5].

Additionally, it was discovered that idoxuridine, polyhexamethylene biguanide, cidofovir, and SB206 were all similarly efficient. When patients who withdrew from the research are taken into account, both therapies were equal in terms of wart recurrence and severe adverse effects. The scientists came to the conclusion that all investigated therapies were efficient, well tolerated, and that each had distinct benefits and drawbacks. [6].

Chemically, hydrogen peroxide (HP) has the formula H2O2. In several metabolic activities, it is produced in the human body as a transient byproduct. It belongs to the class of reactive oxygen species (ROS) and has broad-spectrum antiviral, antibacterial, antifungal, and anti-yeasts action. Molluscum contagiosum (MC) was effectively treated topically with HP in the past. [7]

One of the ROS is hydrogen peroxide, and apoptosis and membrane lipid peroxidation are assumed to be the mediators of this ROS' antiviral activity against HPV. According to some theories, when a virus appears in a cell's cytoplasm, xanthine oxidase and intracellular NADPH-oxidase start producing superoxide and hydrogen peroxide. [8].

Our research is the first to investigate the use of topical 40% hydrogen peroxide solution in treating genital warts, to the best of our knowledge.

The purpose of the study was to evaluate the effectiveness and safety of topical 40% hydrogen peroxide solution for treating genital warts.

This was a randomized controlled trial. All participants were selected from patients attending the Dermatology outpatient clinic at Damietta Faculty of Medicine, Al-Azhar University. Used drug is FDA approved. Allocation was randomized. Randomization type: Simple randomisation (Sealed Envelope) was applied to the present study.

A study professional inserted 52 opaque envelopes containing white sheets of paper with 26 assignments for "Group 1" (H2O2) and 26 assignments for "Group 2" (placebo) before any participant visits. The envelopes were mixed up and sorted at random into a pre-enrollment allocation of files with sequential numbers. Each eligible volunteer who agreed to participate in the research was given a file with a sequential number that included the hidden group assignment.

After receiving everyone's permission at the initial clinic session, the package holding the group assignment was then unsealed and made public. A study assistant who was not aware of the random assignment carried out all evaluations.

- Double-blinded study (blinding of patients, treating physicians).

Inclusion criteria: Patients with genital warts, aged above 18 years old, both sexes

Exclusion criteria: Age less than 18 years old, pregnancy and lactation and receiving other wart care or vitamin supplementation in the previous 3 months.

Study Methods: All patients were subjected toComplete historytaking:

Personal history: Name, age, six.

Asking patient if he experience any of the following symptoms? vaginal swellings that are little, flesh-colored, brown, or pink a form like a cauliflower brought on by several warts close together, itching or pain in the vaginal region, and bleeding during sexual activity

Sexual historyincluding asking patient about?: having several unprotected partners, having another STD, having unprotected sex with multiple partners having sexual relations with a person whose sexual past is unknown, starting one's sexual life off young. a weakened immune system brought on by conditions like HIV or medications used after an organ donation, a sexual relationship if he had comparable signs and HPV vaccination

Medical history: -Including asking about other conditions he had been treated for, and all medications, vitamins or other supplements he had been taken, including doses.

Family history of having sexually transmitted disease

General examination: Examinevital signs as: blood pressure, respiration rate, body temperature, and pulse rate

Physical Examination: Examining genital warts that are visible and develop on the cervix, vagina, or anus in women. They might be extremely tiny or seem like big clusters. They might be white or reddish in hue. Examining genital warts in males who may have them on their penis, scrotum, or around their anus. Genital warts may also appear on the lips, mouth, tongue, and neck in both men and women. A mild acetic acid solution (vinegar solution) may be applied to the skin by the doctor to distinguish between normal and abnormal tissue. The doctor may perform an acetowhite test to make the warts more apparent. all patients should get a dental check to rule out sexually transmitted infections.

Diagnosis

A non-invasive, in vivo diagnostic method known as dermatoscopy has been shown to be particularly useful in assessing pigmented skin lesions. When used to assess non-pigmented skin lesions, it may identify certain features that are invisible to the unaided eye.

Colposcopy is a procedure used to find warts that are invisible to the naked eye. It aids the physician in locating abnormal parts of the cervix, enabling sample biopsies to be taken.

Pap tests: Regular pelvic examinations and Pap tests are crucial for women because they may help identify vaginal and cervical abnormalities brought on by genital warts or the early stages of cervical cancer. An instrument called a speculum is used by the doctor during a Pap test to hold open the vagina and see the cervix. A long-handled tool is then used to collect a tiny sample of cells from the cervix. A microscope is used to check the cells for anomalies.

HPV test: These cancer-causing HPV strains may be detected in cervical cells collected during a Pap test. Generally, only women over the age of 30 are eligible for testing. Because HPV often disappears in younger women without treatments, it is less helpful to them.

Digital photographs were taken at baseline, and at each follow‐up visit and after treatment. Figure (1, 2, 3, 4)

Special tests:

HIV Antibody test: This examination searches the patient's blood or oral fluid for HIV antibodies. After exposure, it might take 23 to 90 days for antibody testing to identify HIV.

HCV Serologic Testing (HCV Ab): Enzyme immunoassays for Hepatitis C Antibody Detection

HBsAg (Hepatitis B surface antigen): These are proteins present on the surface of HBV. Theproteins can be detected in high levels during both an acute or chronic hepatitis B infection.

The VDRL test: It is a screening test for syphilis.

Study groups: Hydrogen peroxide group:26 patients treated with topical H2O2.Hydrogen peroxide, weakly acidic and strong oxidizing agent, is commonly utilized as a surface disinfectant, a cleansing agent for wounds, suppurating ulcers, local infections, and inflammatory conditions since years. It has been utilized to treat a wide range of skin diseases in various concentrations ranging from 1% to 45%. It acts as a disinfectant at lower concentrations and causes denaturation of proteins at higher concentrations so has been used as a peeling agent and as a chemical cautery agent. Solution was applied on genital lesions,

at 2 weeks interval for a total of three sessions under medical supervision. Solutions were applied with the help of wooden tooth pick after applying petrolatum jelly around the lesions to avoid accidental normal tissue injury. Lesions were reviewed every 2 weekly for 6 weeks, then at 4 weekly interval for 8 weeks. The outcomes were summarized based on the size and quantity of the lesions that were reduced.

Control group: 26 patients treated with saline, the same procedures as in Hydrogen peroxide group, but instead of using Hydrogen peroxide we use saline.

Ethical considerations: After explaining the steps of the procedure and any anticipated side effects or potential complications to each patient, a written informed consent will be obtained from them. The study protocol will then be submitted to the Institutional Review Board (IRB) for approval, and the data will be utilized only for scientific purposes and the study participants are free not to participate or leave the statistical analysis research at any time.

Statistical analysis:

Statistical Package for Social Science (IBM Corp., 2017) and Excel (Office Software, 2017) will be utilized to gather, review, code, tabulate, and present the data. Armonk, New York: IBM Corp., IBM SPSS Statistics for Windows, Version 25.0. According to the kind of data acquired for each parameter, the appropriate analysis will be performed, such as an ANOVA for comparing more than two groups, means with post hoc testing, or a Chi-Square test to look at the correlation between two qualitative variables. To compare means across one or more variables based on repeated observations, utilize the Repeated Measures ANOVA method. Statistical significance is defined as a P value <0.05.

Regarding age and sex, there is no statistically substantial variation between the two groups. Table (1)

There is no statistically substantial variation in the number and size of warts after ttt using saline. Table (3)

There is statistically significant decline in the number of warts in patients treated by hydrogen peroxide than those who were treated by saline. Figure 5

There is statistically significant decline in the size of warts in patients treated by hydrogen peroxide than those who were treated by saline. Figure 6

There is statistically significant higher rate of good response to treatment in patients treated by hydrogen peroxide than those who were treated by saline (84.6% vs 7.8%). Table (4)

There is statistically significant positive correlation between Size of wart after ttt and number of wart after ttt. There is statistically significant reduction in the number of warts with decrease its number after ttt. However, there is no statistically significant correlation between the size and number of wart after ttt with other clinical variables. Table (5)

Case 1: A 44 year- old female with genital warts before, after 2 sessions and after treatment with hydrogen peroxide 40% application. Figure 7

Case 2: A 19 year- old female with genital warts before, after 2 sessions and after treatment with hydrogen peroxide 40% application. Figure 8

Case 3: A 26 year- old female with genital warts before, after 2 sessions and after treatment with hydrogen peroxide 40% application. Figure 9

Case 4: A 66 year- old male with genital warts before, after 2 sessions and after treatment with hydrogen peroxide 40% application. Figure 10

Free radicals generated by higher concentration of H2O2 overwhelm the antioxidant property of skin or mucosal membranes and can induce apoptosis or necrosis of the cells. There can be increased absorption or diffusion through damaged skin, so precaution should be taken while applying on eroded surfaces [9].

Recently, topical hydrogen peroxide 40% solution is approved by FDA for seborrheic keratosis [10].

Therefore, this study aimed to evaluate the effectiveness and safety of topical hydrogen peroxide solution 40% in treatment of genital warts.

This research was a randomized controlled trial that was conducted on 52 patients attending the Dermatology outpatient clinic at Damietta Faculty of Medicine, Al-Azhar University.

The selected subjects were divided into 26 patients treated with topical H₂O₂ as Hydrogen peroxide group and 26 patients treated with saline as control group. HIV antibody test, HCV, HBS, Syphilis screen and oral examination had been done for all patients and no one of them had an oral transmitted sexual disease.

Our research is the first to test topical hydrogen peroxide solution 40% in the management of genital warts, to the best of our knowledge.

In the current thesis, our results showed that, regarding age, sex, and BMI, there were no statistically substantial variations between the two study groups (p > 0.05). in Hydrogen peroxide group the median age was 39.35 ± 12.81 years and the most patients were 69.2% females. Disease duration was statistically significant longer and syphilis infection was statistically significant higher in patients treated by hydrogen peroxide than those who were treated by saline and syphilis infection was statistically substantial greater in patients treated by saline than those who were treated by hydrogen peroxide.

In agreement Kaur et al., [11] sought to assess and contrast the treatment effectiveness and safety of a solution of 40% hydrogen peroxide and a solution of 80% TCA for genital warts. Forty patients of more than 18 years of age with clinically diagnosed genital warts were divided into two groups of 20 each, all the 40 patients completed the study, about 42% of the patients were females and 68% were males.

In the same line, Sanad et al., [12] sought to evaluate various hydrogen peroxide gel concentrations (10% and 20%) as a possible new treatment option for genital warts. According to their findings, there was no statistically substantial variation in the research groups' ages and genders. Additionally, there was no substantial distinction in the length of the sickness (p > 0.05).

In contrast to our results, Khopkar et al. [13] reported higher prevalence among men than women with the highest prevalence in age group 25–29 years.

According to the comparison of response to treatment, in patients treated by Hydrogen peroxide, there was statistically substantial decline in the number and size of warts after ttt using Hydrogen peroxide (p < 0.0001). While, in patients treated by saline there was no statistically substantial variation in the number and size of warts after ttt using saline (p > 0.05).

The current research observed that, there is statistically substantial decline in the number and size of warts in patients treated by hydrogen peroxide than those who were treated by saline.

In accordance to our results Schianchi et al., [14] when they observed an 85.7% reduction in the frequency of lesions in children using 1.8% hydrogen peroxide gel formulations for 3 weeks, they proved the antiviral properties of HP.

Also, along with our findings Sanad et al., [12] Group (A) who utilized 10% H₂O₂ before and after treatment showed a statistically substantial variation in the size of lesions compared to the other groups. In group B, which utilized 20% H2O2 before and after treatment, there was a statistically substantial variation in the size of lesions.

Prior to therapy, the number and size of lesions had a substantial unfavorable influence on treatment outcomes. A research by Mahran et al., [15] showed that the number and size of warts may be utilized as a predictive indicator to predict treatment response.

Kaur et al., [11] showed that, about 30% of the patients in both the groups reported Grade 4 improvement (> 75% reduction in size), 35% versus 25% patients had Grade 3 improvement, 25% versus 20% patients had Grade 2 improvement, and 0 versus 20% had Grade 1 improvement in hydrogen peroxide group versus TCA group, respectively.

When we compared the treatment response of the studied groups we found that, there was statistically significant higher rate of good response to treatment in patients treated by hydrogen peroxide than those who were treated by saline (84.6% vs 7.8%).

In the same line Mahran et al., [15] used hydrogen peroxide 6% versus 3% versus vehicle in common warts daily for 1 h under occlusion on common warts in a total of 145 patients. Therapeutic results were much better with hydrogen peroxide than with placebo (P = 0.0001), Partial response was seen in 81% (hydrogen peroxide 6%), 26% (hydrogen peroxide 3%), and only 2% (vehicle group) of patients, suggesting hydrogen peroxide can be a safe and cheap modality for common warts.

Our results showed that, Between the excellent response group and the bad response group, there was no statistically substantial variation in age or sex. Additionally, there was no statistically substantial variation in BMI or illness duration between the groups with excellent and poor response. Syphilis infection was higher in poor response than good response patients.

In recent research aimed to determine the therapeutic efficacy and safety of HP 45% in the treatment of common warts Salloum et al., [16] showed that, the response to the treatment at the end of the treatment was complete in 51.2% depending on the location of warts, size of warts, and duration of the disease, without any correlation with age or sex of the patient. Complete response to the treatment was more frequently in patients with duration of disease ≥ 1year (89.4% vs.1.6%, p: 0.01).

In another study done by Schianchi et al., [7] observed that, as regard age and BMI no significant difference had been found between complete, partial and no response groups all p-values were ˃ 0.05.

In the current study, there was statistically substantial positive connection between Size of wart after ttt and number of warts after ttt. There is statistically substantial decrease in the number of warts with decrease its number after ttt. However, there is no statistically substantial correlation between the size and number of warts after ttt with other clinical variables.

Along with our study Sanad et al., [12] noted that, a significant positive correlation between Size and number of wart had been detected, both the size and the number of warts in hydrogen peroxide treatment groups were significantly reduced after six weeks, however in group using a higher concentration of H₂O₂ saw the greatest decrease in size and quantity.

In the same line Stephen et al., [17] evaluate the effectiveness of 45% hydrogen peroxide solution in treatment common warts, they observed that no positive correlation had been detected between number of wart and age or disease duration.

In conclusion, a potential course of therapy for genital warts may be hydrogen peroxide solution, particularly the 40% concentration. As a novel topical therapy for genital warts, it is very efficient, secure, affordable, and simple to apply. To be able to extrapolate these findings into clinical practice, further studies are needed.

Conflicts of Interest: no conflicts of interest

Bhatia N, Lynde C, Vender R (2013) Understanding genital warts: epidemiology, pathogenesis, and burden of disease of human papillomavirus. Journal of cutaneous medicine and surgery. 17(6_suppl):S47-54.
Kodner CM, Nasraty S (2004) Management of genital warts. Am. Fam. Physician, 70 (12): 2335–42.
Bradbury M, Xercavins N, Garcia-Jimenez A (2019) Vaginal intraepithelial neoplasia: clinical presentation, management, and outcomes in relation to HIV infection status. J. Low. Genit. Tract. Dis, 23 (1): 7–12.
Winer RL, Lee SK, Hughes JP (2003) Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students. Am. J. Epidemiol, 157(3): 218–26.
Lopaschuk CC (2013) New approach to managing genital warts. Can. Fam. Physician. 59(7):731–6.
Jung JM, Jung CJ, Lee WJ (2020) Topically applied treatments for external genital warts in nonimmunocompromised patients: a systematic review and network meta-analysis. Br. J. Dermatol. 183(1):24–36.
Schianchi R, Nazzaro G, Veraldi S (2018) Treatment of molluscum contagiosum with hydrogen peroxide, 43(1):66–7.
Skulachev VP (1998) Possible role of reactive oxygen species in antiviral defense.Biochemistry, 63:1438–40.
Murphy EC, Friedman AJ (2019) Hydrogen peroxide and cutaneous 7-biology: translational applications, benefits, and risks. J Am Acad Dermatol, 81(6):1379–86.
Günter K (2018) Hydrogen peroxide. In: Antiseptic Stewardship, 99–130.
Kaur N, Boparai AS (2022) Comparative evaluation of therapeutic efficacy and safety of 40% hydrogen peroxide versus 80% of trichloroacetic acid in genital warts. National Journal of Physiology, Pharmacy and Pharmacology, 12(12):2081.
Sanad EMK, Ibrahim SE, Abdulemam HA (2022) Evaluation of Different Concentrations of Hydrogen Peroxide Gel (10% and 20%) as a Potential New Therapeutic Option of Genital Warts. Benha Journal of Applied Sciences, 7(5):7–13.
Khopkar US, Rajagopalan M, Chauhan AR (2018) Prevalence and burden related to genital warts in India. Viral Immunol, 31(5):346–51.
Burk, Robert D. “Human Papillomavirus Genome Variants.” Virology, 2013; 445(1–2): 232–43.
Mahran AM, Twisy HO, Elghazally (2020) Evaluation of different concentrations of hydrogen peroxide solution (3% and 6%) as a potential new therapeutic option of nongenital warts: A randomized controlled triple-blinded clinical trial. Journal of Cosmetic Dermatology, 19(2):416–22.
Salloum HM, Khaddam J, Alkhair A (2022) Efficacy and safety of topical application of 45% hydrogen peroxide solution in the treatment of common warts, Journal of Medical & Pharmaceutical Sciences, 6(1), 98–105.
Leslie and Stephen W (2022) “Genital Warts.” Diagnostics to Pathogenomics of Sexually Transmitted Infections, 6(1):98–105.‎

Table (1): Comparison of age and sex of the studied groups

		Hydrogen peroxide		Saline		Independent t-test
		N=26		N=26
		Mean	SD	Mean	SD	t	p-value
Age (years)		39.35	12.81	43.19	13.05	-1.072	0.289
		N	%	N	%	Chi square test
						X²	P-value
Sex	Male	8	30.8%	7	26.9%	0.094	0.760
	Female	18	69.2%	19	73.1%

Table (2): Comparison of response to treatment in patients treated by Hydrogen peroxide

	Number of warts		Size of warts
	N=26		N=26
	Mean	SD	Mean	SD
Before ttt	18.42	10.67	4.42	1.27
First session	14.81	9.39	4.58	1.17
Second session	11.35	7.76	3.50	1.03
Third session	5.77	3.71	2.19	0.75
Fourth session	0.27	0.67	0.19	0.49
f	24.488		89.074
ANOVA	<0.0001		<0.0001

There is statistically significant decline in the number and size of warts after ttt using Hydrogen peroxide. Table (2)

Table (3): Comparison of response to treatment in patients treated by saline

	Number of warts		Size of warts
	N=26		N=26
	Mean	SD	Mean	SD
Before ttt	20.61	8.75	5.03	1.45
First session	19.88	8.12	4.19	1.36
Second session	18.58	6.64	4.27	1.31
Third session	18.85	5.25	4.27	1.31
Fourth session	19.61	5.77	4.27	1.31
f	0.402		1.752
ANOVA	0.807		0.143

Table (4): Comparison of treatment response of the studied groups

	Hydrogen peroxide		Saline		Chi square test
	N=26		N=26
	N	%	N	%	X²	P-value
Good response	22	84.6%	2	7.8%	30.952	<0.0001
Poor response	4	15.4%	24	92.2%

Table (5): the correlation between Size and number of wart after ttt and other clinical variables

	Size of wart after ttt		No. of wart after ttt
	r	P-value	r	P-value
Age	-0.054	0.702	-0.202	0.151
BMI	-0.103	0.468	-0.006	0.969
Disease duration	-0.033	0.817	0.075	0.596
Number of wart before ttt	0.180	0.200	0.264	0.059
Size of wart before ttt	0.204	0.146	0.158	0.264
Number of wart after ttt	0.713**	<0.0001

No competing interests reported.

Topical hydrogen peroxide solution 40%in the treatment of genital warts

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Abstract

Figures

Introduction

Patients And Methods

Results

Discussion

Conclusion

Declarations

References

Tables

Additional Declarations

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