Should You Inject Candida Albicans Into Plantar Warts?

Many colleagues have asked me over the years about the use of injecting Candida albicans for plantar warts. It is something that I started to do after reading about it in Cutis years ago.¹ Recently, the article I co-wrote with my former students was published in the Journal of the American Podiatric Medical Association (JAPMA) so let me give you the highlights.² 

In the article, we performed a retrospective review of 80 patients who were injected with the C. albicans skin test allergen (Nielsen BioSciences), finding that 65 percent had a successful treatment (skin lines returned to lesion).² Those who fell into the failure group either were lost to follow-up or did not meet the criteria of having skin lines return throughout the lesion. When examining the data further, we determined that it took around four visits to clear the lesion (consistent with the previous articles out there), and that patients who had a previous tissue destructive procedure (involving cantharidin, salicylic acid or various lasers) before initiating the Candida regimen were almost three times more likely to clear once they started injection therapy in comparison to those who did not have any previous therapy and began the Candida injection process. This was a new finding that we all found fascinating. 

So what does this mean? It shows that warts most likely need a multimodal approach to resolve. Since we examined that data, I no longer inject C. albicans intradermally into warts that have never had treatment. It is a second or third treatment modality for me depending on the patient situation. Also, I only inject the largest wart when anatomically possible. As it is an intradermal injection, I try to target the places that have some skin mobility to ease the discomfort of injection when the largest wart is just too difficult to inject plantarly. I also never directly inject into the lesser digits as I feel it is not advantageous.

People ask me why I do not inject all of the lesions that may be present. I tell them previous articles have shown that injection into a site on the foot will often clear distant wart sites like the hands or knees.³ I have found this to be the case in my own clinical experience as I have had patients who have reported clearance on the rest of the foot and elsewhere time and time again. 

Physicians also question me about cost. I am currently waiting for a shipment of the skin antigen but the last time I checked the invoice, it was over $100 for a 1 mL vial. I only inject 0.1 to 0.3 mL each visit. If you choose the CPT code for a wart destructive procedure, then you can calculate your cost per patient. If my workplace felt it was not cost-effective, I am sure I would have been asked to try something else long ago.

Overall, the article in JAPMA is a formal introduction to its use in the podiatric world, but future studies should include a proper prospective study with a placebo group and more defined parameters. Just like with any therapy, you have to start somewhere, right? 

References

1. Signore RJ. Candida albicans intralesional injection immunotherapy of warts. Cutis. 2002; 70(3):185-92.

2. Vlahovic T, Spadone S, Dunn SP, et al. Candida albicans immunotherapy for verrucae plantaris. J Am Podiatr Med Assoc. 2015; 105(5):395-400.

3. Clifton MM, Johnson SM, Roberson PK, et al. Immunotherapy for recalcitrant warts in children using intralesional mumps or Candida antigens. Pediatr Dermatol. 2003; 20(3):268-71.