Comparative analysis of different treatment modalities for management of cutaneous warts: A systematic review and network meta-analysis.

BACKGROUND

Cutaneous warts are exophytic, benign proliferative lesions caused by human papillomavirus infection of basal keratinocytes. Many intralesional immunomodulatory agents are used by dermatologists these days including Bacillus Calmette-Guerin vaccine, measles-mumps-rubella vaccine, purified protein derivative (PPD), Candida extract, vitamin D3, interferon alpha, zinc sulphate, and hepatitis B vaccine. Intralesional acyclovir is considered a novel intralesional therapy for warts as it directly destroys the viral cells. The objectives of this study are to provide the latest comparison among different intralesional therapies and to specifically compare acyclovir with PPD.

METHODS

A comprehensive search strategy was implemented to identify relevant randomized controlled trials, and those with single-arm studies were excluded. After this, 5 studies were finally included in the review. Statistical analysis was done using a frequentist random-effects model. Dichotomous outcomes were analyzed using odds ratio and 95% confidence interval with statistical significance set as P-value < .05. All analyses were performed using R version 4.4.1.The study involved a total of 295 patients with sample size ranging from 30 being the least number of participants and 97 being the highest number of participants in a single study.

RESULTS

Use of saline had the highest probability of being the best treatment for achieving a complete response (probability to be the best 96%, P-score = .96) and partial response (98% probability, P-score = .98) when compared with other modalities. The forest plot shows no statistically significant differences among the treatment arms except for saline (P < .01) for no response as compared with PPD. Blister formation was found to be higher on the use of cryotherapy (P = .03) and Mycobacterium w vaccine (P = .02).

CONCLUSION

This network's meta-analysis concludes the superiority of intralesional saline in achieving response to treatment when compared with other modalities such as cryotherapy and vaccines. A higher risk of adverse events was noted on use of vaccines. Future research is needed to strengthen these findings.

Copyright © 2026 the Author(s). Published by Wolters Kluwer Health, Inc.