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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 2  |  Issue : 2  |  Page : 74-77

Autoimplantation therapy for recalcitrant viral warts


1 Department of Skin, MGM Medical College, Aurangabad, Maharashtra, India
2 Department of Dermatology, KEM Hospital, Pune, Maharashtra, India
3 Consultant Dermatologist, Niramaya Hospital, Pune, Maharashtra, India

Date of Web Publication10-Jul-2018

Correspondence Address:
Dhanashree Santosh Bhide
B-8 Malati Madhav Apartment, 819, Bhandarkar Road, Pune - 411 004, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_12_17

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  Abstract 

Background: Various methods for treatment of warts have been practiced; however, in areas such as the beard area or in patients having multiple lesions, recurrence can be a problem. In such situations, autoimplantation therapy can be a useful adjunct. Aim: The aim of the study was to evaluate the efficacy of autoimplantation of viral wart as a treatment option for extensive and recalcitrant warts. Materials and Methods: Twenty-five consecutive patients who presented with recalcitrant warts in a private clinic in Pune and at MGM Medical College in Aurangabad were included in the study. They were followed up for a period of 1 year and evaluated for clearance of lesions. Results: There was complete clearance in 22 patients, 3 patients failed to show any clinical improvement. Conclusion: Autoimplantation of wart is a promising therapeutic option in extensive and recalcitrant warts where most of the treatment options failed to show satisfactory results. However, there are no predictive parameters for the expected outcome.

Keywords: Autoimplantation of wart, human papillomavirus, viral warts


How to cite this article:
Gulanikar AD, Bhide DS, Pethe SA. Autoimplantation therapy for recalcitrant viral warts. Clin Dermatol Rev 2018;2:74-7

How to cite this URL:
Gulanikar AD, Bhide DS, Pethe SA. Autoimplantation therapy for recalcitrant viral warts. Clin Dermatol Rev [serial online] 2018 [cited 2018 Nov 18];2:74-7. Available from: http://www.cdriadvlkn.org/text.asp?2018/2/2/74/236335


  Introduction Top


Cutaneous warts are commonly seen in dermatology practice with an overall prevalence of 7%–10%. They are most commonly found on the hands and feet but can also be found on the face, eyelids, and torso. The causative agent is human papillomavirus (HPV). There are over hundred identified types of HPV; the most common types of cutaneous warts are Types 1, 2, 3, 4, 7, 10, 27, and 57. Cutaneous warts can present in various forms and sizes. Various clinical manifestations are verruca vulgaris, verruca plana, verruca palmaris and plantaris, and genital warts or condyloma acuminata. Without treatment, cutaneous warts can resolve spontaneously within 1–2 years. In some patients, they persist despite repeated treatments and become recalcitrant. There are no definite guidelines for treating recalcitrant warts, and available options include destruction treatments (e.g., cauterizing techniques such as chemicals, electrocautery, radiofrequency, lasers, and cryocautery), intralesional chemotherapy (e.g., bleomycin and 5-fluorouracil), and intralesional immune therapy. Systemic retinoids, oral zinc, Bacille Calmette–Guérin vaccination, levamisole photodynamic therapy, and topical sensitizers such as dinitrochlorobenzene are some of the other modalities tried in the treatment of warts.[1],[2] There is no consensus on the prevalence and most effective treatment for recalcitrant warts. Widespread and recalcitrant wart lesions cause embarrassment and psychological distress to the patients. It is a therapeutic challenge for the treating dermatologist. Till date, no effective vaccine is available against all the subtypes of this virus. Autoimplantation of viral wart particles in subcutaneous tissue or in the dermis is thought to upregulate cell-mediated immunity leading to clearance of warts. Based on this hypothesis, autoimplantation as a treatment option is proposed for recalcitrant and extensive warts.


  Materials and Methods Top


The study was carried out in KEM Hospital Pune, MGM Medical College, Aurangabad and private clinic in Pune. The total duration was of 2 years. Total clinical clearance of lesion was considered as end point.

Recurrence of viral warts in spite of repeated treatments and extensive nature of the problem were the criteria for autoimplantation. As a general rule, patients showing the reappearance of warts after 4–5 sessions of selected treatment options or failing to improve were grouped in the category of recalcitrant warts.[3]

Inclusion criteria

  • Recalcitrant viral wart as per above definition
  • Patients above 18 years.


Exclusion criteria

  • Immunocompromised patients, pregnancy, lactation, immunosuppressed state, intake of immunomodulatory drugs, and organ transplant patients
  • Patients below 18 years
  • Patients with major medical illness in the past 6 months.


Method

Detailed counseling regarding nature of treatment, probable outcome, and the need of the treatment was done. Written consent was taken. Relevant investigations such as complete blood count, blood sugar levels, and venereal disease research laboratory were carried out in the selected patients.

Under all aseptic precautions, 3–4 mm size wart papule was incised with a scalpel blade size 11 or using a radiofrequency machine and was kept in normal saline. A small incision was taken either in gluteal region or the anterior aspect of thigh pocket was created in the dermis, and the harvested wart was introduced in the pocket after crushing. Incision was closed with a 5-0 Prolene to secure the wart particle in the dermis. Tight dressing with micropore was done. The dressing was removed after 7 days, and the sutures were removed if there was no gaping of the wound. Patient was called for follow-up every 15 days for 2 months followed by a monthly follow-up for 12 months.

Statistical analysis

The collected data were entered in an Excel sheet. Qualitative data were represented in the form of frequency and percentage and presented in the form of visual impression like pie diagram [Figure 1].
Figure 1: Distribution of wart

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  Results Top


A total of 25 patients of verruca vulgaris and palmoplantar warts were treated [Figure 2], [Figure 3], [Figure 4] The duration of wart was from 2 to 5 years. Twenty-two of them showed complete clearance within 1–6 months and there was no recurrence after 1 year [Figure 5], [Figure 6], [Figure 7]. Three patients showed no response. There were no side effects reported [Table 1] and [Table 2].
Figure 2: Lesion on the face at the beginning of treatment

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Figure 3: Verrucous lesions on the neck at the start of treatment

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Figure 4: Verrucous lesions on the hand at the beginning of treatment

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Figure 5: Clearance of lesions after 6 months of treatment

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Figure 6: Clearance of lesion on neck after 6 months of treatment

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Figure 7: Clearance of lesions on hand after 6 months of treatment

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Table 1: Age and sex distribution

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Table 2: Clearance of wart

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  Discussion Top


Recalcitrant viral warts are difficult to treat and cause significant psychological stress to the patient. There is no single effective treatment and hence multiple modalities are tried with 60%–70% success rate. Recurrence in recalcitrant warts may be due to selective immunodeficiency or altered immune status in the patient. With autoimplantation therapy, there is a change in immune status of the patient leading to clearance in most of the patients. The aim of the treatment should be to achieve complete clearance of wart and boost the immune system to deal efficiently with the virus and to have long-lasting immunity against HPV which will prevent the recurrence. Shivakumar et al. noted a significant alteration in the immune status. Viral-specific IgM and IgG antibodies and delayed hypersensitivity to virus was increased after autoimplantation therapy.[3],[4],[5],[6]


  Conclusion Top


Autoimplantation therapy is minimally invasive, safe, and an effective treatment in recalcitrant warts. This could be because of alteration in immune status of the patient. Our study showed 88% successes as compared to the study by Shivakumar et al., which showed 73% clearance. Our study was limited by a smaller sample size; there is a need of a larger and a double-blind study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Gibbs S, Harvey I, Sterling J, Stark R. Local treatments for cutaneous warts: Systematic review. BMJ 2002;325:461.  Back to cited text no. 1
    
2.
Sterling JC, Handfield-Jones S, Hudson PM; British Association of Dermatologists. Guidelines for the management of cutaneous warts. Br J Dermatol 2001;144:4-11.  Back to cited text no. 2
    
3.
Srivastava PK, Bajaj AK. Autowart injection therapy for recalcitrant warts. Indian J Dermatol 2010;55:367-9.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Shivakumar V, Okade R, Rajkumar V. Autoimplantation therapy for multiple warts. Indian J Dermatol Venereol Leprol 2009;75:593-5.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Viac J, Thivolet J, Chardonnet Y. Specific immunity in patients suffering from recurring warts before and after repetitive intradermal tests with human papilloma virus. Br J Dermatol 1977;97:365-70.  Back to cited text no. 5
    
6.
Briggaman RA, Wheeler CE Jr. Immunology of human warts. J Am Acad Dermatol 1979;1:297-304.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
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