Letters to the Editor

Statement About Risks of Acupuncture Is Misleading

TO THE EDITOR: I am troubled by the following comment that was made by Dr. Morelli and colleagues: "Although acupuncture has been promoted as a safe therapy, significant infections have occurred, including human immunodeficiency virus and hepatitis, as a result of the use of unsterilized needles."¹ This is a poorly researched comment that inaccurately states the level of risk in acupuncture.

Practitioners of acupuncture in the United States take courses on clean needling technique. Acupuncture needles are gas sterilized to over 300°F and are individually packaged for single use. Both the National Acupuncture Certification Board and state regulatory boards oversee safety issues.

Although there have been a few case reports of human immunodeficiency virus and hepatitis infection, a review² of nine prospective studies of the safety of acupuncture found no reported cases of disease transmission.² According to the same reference that Dr. Morelli and colleagues¹ cite, the 1997 National Institutes of Health Consensus Statement³ on acupuncture notes that the documented occurrence of adverse events with acupuncture is extremely low.

The comment by the authors¹ is made without stating the specific risk level and exaggerates the risk involved in acupuncture. In reality, acupuncture probably helps relieve pain more than the other modalities discussed.

DEXTER S. LEVY, M.D., L.AC.
8966 W. Bowles Ave., Unit L
Littleton, CO 80123

REFERENCES

1. Morelli V, Naquin C, Weaver V. Alternative therapies for traditional disease states: osteoarthritis. Am Fam Physician 2003;67:339-44.
2. Ernst E, White AR. Prospective studies of the safety of acupuncture: a systematic review. Am J Med 2001;110:481-5.
3. Berman BM, Swyers JP, Ezzo J. The evidence for acupuncture as a treatment for rheumatologic conditions. Rheum Dis Clin North Am 2000;26:103-15.

IN REPLY: We agree with Dr. Levy's concerns. As he mentioned, the risks of acupuncture are extremely low. The intention in our article¹ was only to point out that there have been case reports of transmission of human immunodeficiency virus (HIV) and hepatitis from acupuncture needles. We decided to mention HIV because of the severity of the disease and to mention hepatitis because acupuncture was cited in the late 1980s to have been the cause of at least two office-source outbreaks.^2,3 We chose not to mention the much rarer cases of cardiac tamponade,⁴ pneumothorax, and endocarditis.⁵

Again, it is never our intention to present slanted or biased information or to steer patients away from therapies that could be helpful in treating debilitating symptoms. However, acupuncture, like other therapies mentioned in the article, has not been shown to alter the natural course of the disease in any way. And, at the same time, it would be irresponsible not to point out potential risks to patients.

VINCENT MORELLI, M.D.
Louisiana State Health Sciences Center
200 W. Esplanade Ave., Ste. 412
Kenner, LA 70065

REFERENCES

1. Morelli V, Naquin C, Weaver V. Alternative therapies for traditional disease states: osteoarthritis. Am Fam Physician 2003;67:339-44.
2. Kent GP, Brondum J, Keenlyside RA, LaFazia LM, Scott HD. A large outbreak of acupuncture-associated hepatitis B. Am J Epidemiol 1988;127:591-8.
3. Slater PE, Ben-Ishai P, Leventhal A, Zahger D, Bashary A, Moses A, et al. An acupuncture-associated outbreak of hepatitis B in Jerusalem. Eur J Epidemiol 1988;4:322-5.
4. Kirchgatterer A, Schwarz CD, Holler E, Punzengruber C, Hartl P, Eber B. Cardiac tamponade following acupuncture. Chest 2000;117:1510-1.
5. Norheim AJ. Adverse effects of acupuncture: a study of the literature for the years 1981-1994. J Altern Complement Med 1996;2:291-7.

Physicians Need More Evidence on Treatments of Warts

TO THE EDITOR: The recent article, "Molluscum Contagiosum and Warts,"¹ is a praiseworthy attempt to update family physicians on the current treatment options for this commonly encountered problem. However, this paper does not guide physicians on which treatment to choose based on good evidence.

It should be made clear that the methodologic quality of research on various local treatments is mediocre at best. According to the updated systematic review^2,3 on local treatments for cutaneous warts in healthy people, there is only good evidence for the therapeutic efficacy and safety of simple topical salicylic acid. Little evidence exists for the efficacy of the other choices of treatment that were mentioned in the article.¹ We, as physicians, have no convincing evidence that cryotherapy is any more effective than simple topical treatments.

KAI MING CHOW, M.R.C.P., M.D.
Prince of Wales Hospital
Chinese University of Hong Kong
Ngan Shing St.
Shatin, Hong Kong, China

REFERENCES

1. Stulberg DL, Hutchinson AG. Molluscum contagiosum and warts. Am Fam Physician 2003;67:1233-40.
2. Gibbs S, Harvey I, Sterling J, Stark R. Local treatments for cutaneous warts: systematic review. BMJ 2002;325:461.
3. Gibbs S, Harvey I, Sterling JC, Stark R. Local treatments for cutaneous warts. Cochrane Database Syst Rev 2001;2:CD001781.

Efficacy Rates of Various Treatments for Warts Treatment Efficacy (%) None/placebo 30 (range: 0 to 70) Topical salicylic acid 75 Cryotherapy 30 to 75* Dinitrochlorobenzene 80 Cimetidine (in children) 46 to 75† Cimetidine with levamisole 86 Candida or mumps injection 74 Imiquimod 56 Duct tape 853 *--Extrapolated from Cochrane review1 noting two randomized controlled trials showing equivalence to placebo and two randomized trials showing equivalence to topical salicylic acid. The larger trials of cryotherapy were excluded because of lack of a placebo arm. †--Control arm of cimetidine alone from one trial4 was as effective as topical salicylates or cryotherapy.5

IN REPLY: Dr. Chow's comments astutely refer physicians to availing themselves to the best possible evidence in the care of our patients. First, Dr. Chow requests guidance as to which treatments to choose based on good evidence. Dr. Chow has referred to the same Cochrane Review¹ that Dr. Hutchinson and I refer to in our article,² which reviews the most appropriate studies to offer assistance in the treatment approach to warts. In addition to referencing that work, our article presents several small studies that explore other treatment options that are prevalent in clinical practice, with reference to the nature of the study, its size, and its outcome. The accompanying table summarizes the estimated treatment success rates based on the information presented in the Cochrane review,¹ in our article,² and in a recent article about using duct tape to treat warts.³

Two of Dr. Chow's statements, nearly verbatim from the Cochrane review,¹ are best interpreted together. (1) "There is only good evidence for the therapeutic efficacy and safety of simple topical salicylic acid," and (2) "no convincing evidence that cryotherapy is any more effective than simple topical treatments." Cryotherapy is not more effective, but, if it is equally effective as two of the allowed studies in the Cochrane review¹ indicate, then it should be an acceptable treatment, because many patients prefer a one-time treatment to weeks or months of daily applications.

The Cochrane review¹ included only randomized controlled trials and did not include data from most of the large trials involving cryotherapy, because those trials primarily compared various methods of cryotherapy. It is my understanding that many trials are appropriate studies comparing variations of treatments without imposing a placebo arm, just as we would hope in chemotherapy trials testing new versus established therapies or in trials comparing aspirin and coumadin (Warfarin) for clotting disorders. An analysis of the large trials that compare various forms of cryotherapy with the estimated spontaneous resolution rate of 30 percent from the Cochrane analysis¹ might yield useful information.

Perfect data are not available but based on the best available evidence, cryotherapy appears to be approximately 60 percent effective in the treatment of warts and topical salicylates are approximately 75 percent effective. Data from population studies and control arms of studies show spontaneous resolution to be approximately 30 percent. Physicians will make the decision with their patients as to which treatment or nontreatment will best suit the individual, based on tolerance of the time and work involved in the treatment, and the side effects and efficacy of the treatment.

DANIEL L. STULBERG, M.D.
Utah Valley Family Practice Residency
1134 N. 500 West
Provo, UT 84604

ANNE GALBRAITH HUTCHINSON, M.D.
203 Turnpike St.
North Andover, MA 01845

REFERENCES

1. Gibbs S, Harvey I, Sterling JC, Stark R. Local treatments for cutaneous warts. Cochrane Database Syst Rev 2001;2:CD001781.
2. Stulberg DL, Hutchinson AG. Molluscum contagiosum and warts. Am Fam Physician 2003;67:1233-40.
3. Focht DR III. The efficacy of duct tape vs cryotherapy in the treatment of verruca vulgaris (the common wart). Arch Pediatr Adolesc Med 2002;156:971-4.
4. Bauman C, Francis JS, Vanderhooft S, Sybert VP. Cimetidine therapy for multiple viral warts in children. J Am Acad Dermatol 1996;35:271-2.
5. Rogers CJ, Gibney MD, Siegfried EC, Harrison BR, Glaser DA. Cimetidine therapy for recalcitrant warts in adults: is it any better than placebo? J Am Acad Dermatol 1999;41:123-7. *

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