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ORIGINAL ARTICLE
Year : 2017  |  Volume : 6  |  Issue : 4  |  Page : 247-250

Treating multiple and recalcitrant wart with autoimplantation technique


Department of Dermatology, Smt. Kashibai Navale Medical College and Hospital, Pune, Maharashtra, India

Date of Web Publication26-Dec-2017

Correspondence Address:
Dr. Swapna Subhash Khatu
Department of Dermatology, Smt. Kashibai Navale Medical College and Hospital, Narhe, Pune - 411 041, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.221528

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  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.

Keywords: Autoimplantation, recalcitrant, warts


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

How to cite this URL:
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 [serial online] 2017 [cited 2020 Mar 31];6:247-50. Available from: http://www.jdrntruhs.org/text.asp?2017/6/4/247/221528




  Introduction Top


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 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] 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.


  Materials and Methods Top


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 [Figure 1], [Figure 2], [Figure 3].
Figure 1: Multiple facial warts

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Figure 2: Multiple facial warts

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Figure 3: Multiple facial warts

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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. 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.


  Results Top


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 [Figure 4], [Figure 5], [Figure 6], accounting for a total clearance rate of 77.5%.
Figure 4: Resolution of warts after autoimplantation

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Figure 5: Resolution of warts after autoimplantation

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Figure 6: Resolution of warts after autoimplantation

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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.


  Discussion Top


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 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]

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]

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]

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.


  Conclusion Top


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.

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.
Longhurst B, Bristow I. The treatment of verrucae pedis using Falknor's needling method: A review of 46 cases. J Clin Med 2013;2:13-21.  Back to cited text no. 1
[PUBMED]    
2.
Frazer IH. Interaction of human papillomaviruses with the host immune system: A well evolved relationship. Virology 2009;384:410-4.  Back to cited text no. 2
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3.
Shivkumar V, Okade R, Rajkumar V. Autoimplantation therapy for multiple warts. Indian J Dermatol Venereol Leprol 2009;75:593-5.  Back to cited text no. 3
    
4.
Srivastava PK, Bajaj AK. Autowart injection therapy for recalcitrant warts. Indian J Dermatol 2010;55:367-9.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Nischal KC, Sowmya CS, Swaroop MR, Agrawal DP, Basavaraj HB, Sathyanarayana BD. A novel modification of autoimplantation therapy for the treatment of multiple, recurrent and palmoplantar warts. J Cutan Aesthet Surg 2012;5:26-9.  Back to cited text no. 5
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6.
Venugopal SS, Murrell DF. Recalcitrant cutaneous warts treated with recombinant quadrivalent human papillomavirus vaccine (types 6, 11, 16, and 18) in a developmentally delayed, 31-year-old white man. Arch Dermatol 2010;146:475-7.  Back to cited text no. 6
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Kreuter A, Waterboer T, Wieland U. Regression of cutaneous warts in a patient with WILD syndrome following recombinant quadrivalent human papillomavirus vaccination. Arch Dermatol 2010;146:1196-7.  Back to cited text no. 7
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8.
Viac J, Thivolet J, Chardonnet Y. Specific immunityin patients suffering from recurring warts before and after repetitive intradermal test with human papilloma virus. Br J Dermatol 1977;97:365-70.  Back to cited text no. 8
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9.
Briggaman RA, Wheeler CE Jr. Immunology of human warts. J Am Acad Dermatol 1979;1:297-304.  Back to cited text no. 9
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10.
Usman N, Udayshankar K, Subramanian S, Thyagarajan SP. Autoimplantation technique in the treatment of anogenital warts: A clinic-immunological study. Int J STD AIDS 1996;7:55-7.  Back to cited text no. 10
    


    Figures

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



 

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