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Original Article
Treating multiple and recalcitrant wart with autoimplantation technique Swapna Subhash Khatu, Yuvraj Eknath More, Divyank Vankawala, Sai S Pawar, Neeta Rajendra Gokhale, Dipali Chetan Chavan Department of Dermatology, Smt. Kashibai Navale Medical College and Hospital, Pune, Maharashtra, India
ABSTRACT Background: Warts are benign tumors involving skin and mucous membrane that are caused by human papillomavirus (HPV). Several treatment modalities are available for treating multiple warts, but without any significant response or cost-effectiveness. Aims: This study aimed to evaluate the safety and efficacy of autoimplantation therapy in the treatment of recalcitrant and multiple warts. Materials and Methods: A total of 40 patients of multiple warts (more than five warts per patient), palmoplantar warts, recurrent warts, and resistant warts were enrolled in this study. A small piece of warty tissue was introduced in the wound with the help of 26 no. needle. Patients were assessed monthly and resolution after 3 months was considered complete clearance. Result: Out of 40 patients, 21 patients of verruca vulgaris (75%) and 10 patients of palmoplantar warts (83.3%) showed resolution within 3 months, accounting for a total clearance rate of 77.5%. Conclusion: Autoimplantation of wart using the pared stratum corneum of wart is a safe, efficacious, less painful, and in-office procedure for the treatment of multiple, recurrent, and palmoplantar warts. Key words: Autoimplantation, recalcitrant, warts
INTRODUCTION Warts are benign tumors involving skin and mucous membrane caused by human papillomavirus (HPV). Infection of keratinocytes at the basal layer of the epidermis is established through abrasion of the skin surface. Here, the virus remains latent in the cell for 1-8 months. [1] As the epidermal cells differentiate and migrate to the surface, the virus is triggered to undergo replication and maturation until it is shed in the exfoliation of the Address for correspondence: Dr. Swapna Subhash Khatu, Department of Dermatology, Smt. Kashibai Navale Medical College and Hospital, Narhe, Pune - 411 041, Maharashtra, India. E-mail:
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epidermis. The process of viral replication produces proliferation of prickle cells, which alters the character of the epidermis, resulting in the visible warty appearance of the verrucae. In most viral infections, the viral proteins within a cell cause damage to the host cell and stimulate production of cytotoxic T cells, which then seek out and destroy the targeted infected cells. [1] However, unlike many viruses, HPV prevents cell lysis as infection spreads through the shedding of infected epithelial cells from the surface of the skin. In other words, there is no release of viral proteins to the circulating dendritic cells and therefore no antigen presentation to the immune system. [2] This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
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How to cite this article: Khatu SS, More YE, Vankawala D, Pawar SS, Gokhale NR, Chavan DC. Treating multiple and recalcitrant wart with autoimplantation technique. J NTR Univ Health Sci 2017;6:247-50.
10.4103/2277-8632.221528
© 2017 Journal of Dr. NTR University of Health Sciences | Published by Wolters Kluwer - Medknow
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Khatu, et al.: Autoimplantation in warts
The absence or reduction of a cellular response may explain why, in spite of several treatment modalities being available for treating warts, there is no single treatment that is 100% effective.[2] In recalcitrant warts, the treatment modalities available are radiotherapy, cryotherapy, LASER ablation, photodynamic therapy, chemical cauterization, and topical sensitizers such as dinitrochlorobenzene (DNCB), squaric acid dibutyl ester (SADBE), and diphencyprone are reported to be effective. Extensive warts cause not only physical problems but also psychological trauma in patients. Most ablative procedures are inconvenient and may leave behind painful scars; they cannot prevent recurrences. Autoimplantation is a novel, one-time procedure in which warts are treated by stimulating immune response against HPV. We have here evaluated the safety and efficacy of autoimplantation therapy in the treatment of recalcitrant and multiple warts.
Figure 1: Multiple facial warts
MATERIALS AND METHODS This study was conducted in outpatient department of tertiary care hospital. A total of 40 patients of multiple warts (more than five warts per patient), palmoplantar warts, recurrent warts, and resistant warts were enrolled in this study [Figures 1-3].
Figure 2: Multiple facial warts
Pregnant women, lactating mothers, immunocompromised individuals, those with intake of immunomodulatory drugs, patients aged below 12 years, and those aged above 60 years were excluded from study. Informed written consent was obtained from all patients. Donor (wart) tissue was first cleaned with spirit and povidone iodine and then paring was done with number 11 scalpel. Pared tissue was crushed with the help of two glass slides. Autografting was done on the flexor aspect of the nondominant forearm. The area was first cleansed with spirit and povidone iodine and infiltrated with lignocaine. With the help of 18 no needle, full- depth piercing of skin was made up to the subcutis level first and then pocket was created with to and fro movements. Crushed warty material was then introduced in the wound with the help of 26 no. needle while removing 18 no. needle. Pressure was applied with sterile gauze piece and the wound was kept covered with Micropore for the next 3 days. 248
Figure 3: Multiple facial warts
Patients were advised not to wet or remove plaster for 3 days. Patients were assessed monthly, and resolution of the warts after 3 months was considered as complete clearance. Nonresponders and persistence of warts after 3 month were considered as treatment failures.
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Khatu, et al.: Autoimplantation in warts
RESULTS Out of 40 patients (25 males, 15 females) 28 had verruca vulgaris and the remaining 12 had palmoplantar warts. The commonest age group was 20-30 years. A total of 21 patients of verruca vulgaris (75%) and 10 patients of palmoplantar warts (83.3%) showed resolution within 3 months [Figures 4-6], accounting for a total clearance rate of 77.5%. The earliest resolution of warts was observed at the end of the third week. In two patients, an inflammatory nodule developed at the site of autoimplantation during the second week and these patients showed early resolution of warts. Two (5%) of our patients showed partial improvement in that a few lesions were persistent, and seven patients (17.5%) showed no response at all.
Figure 4: Resolution of warts after autoimplantation
DISCUSSION Extensive warts not only cause physical problem but also psychological distress to the patients. An ideal aim for the treatment of warts should be to remove the wart without recurrence, avoid aggressive potentially scarring procedures, and assist the immune system in dealing more effectively with the virus and induce lifelong immunity to HPVs. Specific immune stimulation against HPV has been attempted by autoimplantation of the wart tissue into uninvolved skin by Shivkumar et al.,[3] by injecting crushed wart tissue into muscle by Srivastava et al. [4] and into skin by Nischal et al., [5] and by quadrivalent HPV vaccines. [6,7] Repeated exposures to viral antigens showed the development of cell-mediated immunity and appearance of virus-specific immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies.[8,9] In this study we harvested the donor tissue by paring the wart to obtain stratum corneum tissue containing virus, similar to the study conducted by Nischal et al.;[5] by this method we avoided causing a wound at the donor site and also circumvented the issue of taking unwanted deeper tissue as compared to Shivkumar et al. who extracted a subcutis “deep” part of the wart and implanted it elsewhere,[3] resulting in two wounds. HPV being an epidermal infection, there is no added advantage in extracting donor tissue containing dermis and subcutis. In our study
Figure 5: Resolution of warts after autoimplantation
Figure 6: Resolution of warts after autoimplantation
we implanted warty tissue in uninvolved skin with the help of needle, thus avoiding causing the pain of deep intramuscular injection, which was used for implantation of wart in the study conducted by Srivastava et al.[4]
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Khatu, et al.: Autoimplantation in warts
Most of our patients were males and belonged to the 20-40-year age group, in concurrence with other studies. A complete clearance of warts was observed in 77.5% of cases, slightly greater compared to Nischal et al. (74.1%) [5] and Shivkumar et al. (73.3%),[3] while Usman et al.[10] reported only 44% clearance rate. For palmoplantar warts, 83% of cases showed complete resolution; a similar finding was reported by Shivkumar et al.[3]
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.
We had two patients with multiple warts in whom two lesions persisted at the end of 3 months. This finding was similar to a finding reported by Nischal et al.[5] Partial clearance was not observed by Usman et al. [10] and Shivkumar et al. [3] In our study 17.5% patients were nonresponders, similar to 18.5% cases as observed by Nischal et al. [5]
Financial support and sponsorship Nil.
Reaction at the site of engraftment was observed in the form of erythematous nodule in two of our patients. These lesions healed with oral and topical antibiotics, with postinflammatory hypopigmentation. Shivkumar et al.[3] and Nischal et al. [5] also reported similar reactions at the injection site.
1.
CONCLUSION Autoimplantation of wart using the pared stratum corneum of wart is a safe, efficacious, less painful, and in-office procedure for the treatment of multiple, recurrent, and palmoplantar warts. The limitations of our study were the small sample size and lack of controls to assess spontaneous resolution of warts.
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Conflicts of interest There are no conflicts of interest.
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