**5. Virucidal therapy**

### **5.1 Glutaraldehyde**

Glutaraldehyde is a tissue fixative that polymerises keratin. Its effectiveness lies in desiccation of surface virions and resultant reduction of antigenic load [105]. However the mechanism of action of glutaraldehyde against warts has not been clarified precisely. Glutaraldehyde therapy (GA) for warts was first introduced in 1971 [106]. Therapeutic responses with glutaraldehyde in periungual, palmar and plantar warts were 80, 60 and 68.5%, respectively [107]. When GA is buffered by suitable alkalinating agents to a pH of 7.5–8.5, the solution becomes antimicrobially active [108]. The concentration of glutaraldehyde is another consideration for use. Though 2 w/v% is the minimum for antimicrobial activity [108], undiluted high concentration of 25% solution appeared to work faster on warts of all kinds [107]. The benefits of using glutaraldehyde as first-line treatment for warts, especially resistant ones, are the same as those of cryotherapy [107].

**41**

*Human Papillomavirus Infection: Management and Treatment*

**5.3 Acyclovir, valacyclovir and other antiretroviral drugs**

flagellate hyperpigmentation [125] are reported after.

Formalin (formaldehyde) is a virucidal agent and has strong disinfectant properties and exerts its effects by causing damage to the upper layers of epidermal cells that contain the virus, thus destroying viruses [28, 109]. Formalin application was effective in 83.3% of patients, but complete disappearance of warts was seen in 11.1% [110]. The most common side effects of formalin include redness, irritation

Oral antivirals are not a regular treatment modality, but isolated case report about improvement in wart lesion after oral treatment with acyclovir [112], valacyclovir are there. Plantar wart is cleared completely with 1 gm valacyclovir for 60 days [113]. Improvements of wart with intravenous cidofovir in one HIV seropositive patient with complete clearance are available [114]. Nearly total clearance of multiple viral wart with didanosine, stavudine and efavirenz triple antiretroviral therapy in a 34-year-old male homosexual patient was seen, accompanied by a significant improvement in immune status [115]. The observations are not powerful

Bleomycin is a chemotherapeutic agent which has an antitumor, antibacterial and antiviral activity which may be related to its ability to bind with deoxyribonucleic acid (DNA), causing bleomycin strand scission and elimination of pyrimidine and purine bases [116]. It selectively affects squamous cell and reticuloendothelial tissue [117]. Bleomycin is not thought to bind directly to HPV [10]. Bleomycin causes acute tissue necrosis that may stimulate an immune response, as evidenced by the fact that it is less effective as a wart treatment in immunosuppressed renal transplant patients [118–121]. Adverse effects include injection pain and burning, erythema, swelling and pain within 24–72 h after injection before a black thrombotic eschar forms. Local complications after periungual injections are nail loss [122] or dystrophy [123]. Reynaud's phenomenon in treated fingers, local pigmentation [124] or urticaria [122], even

In a systemic review [126], comparing intralesional bleomycin with placebo, the studies have given conflicting results. Intralesional bleomycin was compared with saline or sesame oil; duration was 6 weeks to 3 months. The RCTs in the review favour I/L Bleomycin, and only one study opined placebo to be more effective. The result of wart clearance was between 18 and 94%, but the study showed clearance rate to be 94%, which was not significantly different from the result (73%) achieved by placebo injections of saline. Concentration of 0.5% bleomycin is more effective than concentration of 0.25% or 1% bleomycin. Pain was experienced by most patients, irrespective of doses. In a study of comparison between intralesional Bleomycin and cryotherapy, 0.1% concentration of bleomycin was used [127]. Greater efficacy in clearing warts was shown with intralesional bleomycin than in cryotherapy. The clearance rates of warts for intralesional bleomycin therapy found were 97%, and in 94.9% of patients, all warts treated with bleomycin were cleared. There was significantly less number of treatment sessions, with a mean of 1.38 in

case of bleomycin treatment than the cryotherapy where the mean is 3.08.

enough to assume causality (instead of a simple casual or placebo effect).

*DOI: http://dx.doi.org/10.5772/intechopen.92397*

**5.2 Formaldehyde**

and dryness of skin [111].

**6. Antimitotic therapy**

**6.1 Bleomycin**

### **5.2 Formaldehyde**

Formalin (formaldehyde) is a virucidal agent and has strong disinfectant properties and exerts its effects by causing damage to the upper layers of epidermal cells that contain the virus, thus destroying viruses [28, 109]. Formalin application was effective in 83.3% of patients, but complete disappearance of warts was seen in 11.1% [110]. The most common side effects of formalin include redness, irritation and dryness of skin [111].
