Discussion
anaphylaxis, wart, TNF-α, itching, Pain, HPV infection, AGWs
WART, RECURRENCE, ANAPHYLAXIS, HPV INFECTION, DISEASE, WARTS, REGRESSION
The current treatment options for AGWs have variable efficacy, and optimal treatment continues to be required [In the current study, 40% of patients in the Candida monotherapy group had complete clearance of AGWs. Marei et al. [Also, our results were lower than those of Tawfik et al. [The precise mechanism of intralesional Candida antigen immunotherapy is not fully understood. This modality is mostly associated with stimulation of T-helper (Th)-1 cytokine production, such as interferon (IFN)-γ and interleukin (IL)-2, which stimulate natural killer cells and cytotoxic T cells to eradicate HPV infection [To enhance the response rate of intralesional Candida antigen immunotherapy, its combination with other therapeutic modalities, including various immunotherapies, has been investigated [In the present study, the clinical response was significantly better in the three treatment groups compared to the control group. Surprisingly, the Cervarix/Candida group had a lower complete response rate (20%) than the Candida monotherapy group (40%), while the Gardasil/Candida group had a higher complete response rate (60%) than the Candida monotherapy group. However, no statistically significant difference was detected between the Candida monotherapy group and combination groups, but the response was significantly better in the Gardasil/Candida group compared to the Cervarix/Candida group. This could imply that Gardasil is superior to Cervarix as an immunostimulant; yet, it didn't significantly improve the clinical response to Candida immunotherapy. In consistency with our results, Gilson et al. [On the contrary, other studies have reported the efficacy of HPV vaccines, either as monotherapy or in combination with other therapies, for warts. Nofal et al. [Furthermore, Marei et al. [Meanwhile, Choi [Additionally, Protasov et al. [Furthermore, Kumar et al. [Although HPV vaccines are primarily used to prevent HPV infections by inducing the production of antibodies that bind to the virions, their mechanism as immunotherapy for warts has not yet been established. This may be due to their ability to evoke both B-cell and T-cell responses that cross react with other HPV strains, resulting in wart clearance and prevention of their recurrence. They have been shown to induce long-lasting protective immunity by stimulating circulating B memory cells, which release neutralizing antibodies upon subsequent antigenic exposure. Also, they have been shown to up-regulate levels of Th1 cytokines, such as TNF-α and IL-2, as well as pro-inflammatory cytokines, such as IL-1α, IL-1β and IL-6 [In the present study, only 10% of patients in the control group had partial response that may be explained by psychological factors or may reflect the natural course of the disease with possible spontaneous regression [Regarding side effects, anaphylaxis was observed in 2 patients (in the combination groups) upon the last Candida antigen injection and was treated immediately with anti-shock measures. Pain and itching at the injection site were also detected. There was no statistically significant difference between the studied groups. Similar side effects were reported in previous studies [During the 3-month follow-up period, no recurrence was detected among patients with complete or partial response. Similarly, other studies have reported no recurrence in patients who had received Candida antigen [