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A Novel Modification of the Autoimplantation Therapy for the Treatment of

Multiple, Recurrent and Palmoplantar Warts

Article in Journal of Cutaneous and Aesthetic Surgery · March 2012

DOI: 10.4103/0974-2077.94332 · Source: PubMed

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Nischal Kuchangi Mukunda Swaroop

Adichunchanagiri Institute of Medical Sciences Adichunchanagiri Institute of Medical Sciences
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 ISSN 0974-2077
Journal of Cutaneous and Aesthetic Surgery • Volume 5 • Issue 1 • January-March 2012 • Pages 1-???

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ORIGINAL ARTICLE

A Novel Modification of the Autoimplantation Therapy for the

Treatment of Multiple, Recurrent and Palmoplantar Warts

Background: Ideal treatment for warts should be effective, safe, have less morbidity and provide long-lasting
immunity against human papilloma virus. This can optimally achieved by the stimulation of the immune system
against the virus. The autoimplantation of warts, autowart injection and quadrivalent vaccines have been used for
this purpose. Autoimplanatation is a simple technique where the subcutis deep wart tissue is harvested as a donor
and implanted into the uninvolved skin. However, this led to two wounds, at donor and recipient sites. Aim: The
aim was to evaluate the safety and efficacy of a novel modification of autoimplantation therapy in the treatment
of multiple, recurrent and palmoplantar warts. Subjects and Methods: Thirty-three patients with multiple,
recurrent and palmoplantar warts were enrolled. Instead of taking a bit of the wart tissue, the donor tissue was
harvested by paring the wart. The pared tissue was implanted deep into the subcutis by stab incision done using
the same surgical blade no. 11. The resolution of all warts within 3 months after the procedure was considered
successful. Patients with complete clearance were followed up for 1 month for any recurrence. Results: Out of
35 patients, 27 patients were available for follow-up. A total of 20 (74.1%) patients showed a complete clearance
of warts within 3 months. Partial clearance was seen in 1 patient. Erythematous nodules developed at the site
of implantation in 3 (11.1%) patients. There was relapse in one patient. Conclusion: A modified technique of
autoimplantation of warts employing the pared stratum corneum tissue from the wart is a simple, effective, less
traumatic and rapid procedure in the treatment of multiple, recurrent and palmoplantar warts.

KEYWORDS: Autoimplantation, delayed hypersensitivity, palmoplantar, paring, warts

INTRODUCTION serotypes other than those in vaccine (HPV 6, 11, 16 and

18) also cause warts and hence this modality may not
Warts are mucocutaneous growths (exo- or endophytic)
be effective always.[2] Autoimplantation is a novel, one-
caused by human papilloma virus (HPV). Common
time procedure which treats the warts by stimulating
therapeutic modalities ablate the growth without the an immune response against HPV. As it is an autograft
generation of specific immunity against the wart. This technique, it is more likely that immunity against the
often leads to irritation, pain, recurrence, scars, and same serotype is elicited (in contrast to the HPV vaccine
prolonged morbidity (especially in palmoplantar warts). where immunity is developed only against HPV 6, 11, 16
The stimulation of the immune system by exposing the and 18). This is done by extracting a subcutis deep wart
virus to immune mediators forms an ideal modality of tissue and implanting it into the uninvolved skin.[3,4] This
treatment due to spontaneous regression of the wart leads to wound at two sites and more discomfort and
with long-lasting immunity. A quadrivalent HPV vaccine risks infection. The autowart injection involves multiple
has been reported to cause wart regression.[1] However, sessions of injection of wart suspension.[5] In this study, we
extracted the donor tissue by paring the wart instead of
Access this article online removing a part of the wart under local anaesthesia. This
Quick Response Code: was adopted to reduce the discomfort, risk of infection
Website: and hasten the time taken for performing the procedure.
www.jcasonline.com

SUBJECTS AND METHODS

DOI:
10.4103/0974-2077.94332 This study was conducted in the dermatology outpatient
department of a tertiary care rural hospital. Thirty-five

Nischal K C, Sowmya C S, Swaroop M R, Dhruv Premy Agrawal, Basavaraj H B, Sathyanarayana B D

Department of Dermatology, Adichunchanagiri Institute of Medical Sciences, BG Nagar, Mandya, Karnataka, India
Address for correspondence:
Dr. Nischal K C, Department of Dermatology, Adichunchanagiri Institute of Medical Sciences, BG Nagar, Mandya - 571 448, Karnataka, India. E-mail: [email protected]

26 Journal of Cutaneous and Aesthetic Surgery - Jan-Mar 2012, Volume 5, Issue 1

 Nischal, et al.: Novel modification of the autoimplantation therapy for warts

patients with multiple (more than five warts), recurrent Patients were followed up for one more month after
verruca vulgaris (warts which have recurred after any clearance for any recurrence.
modality of treatment) and palmoplantar warts were
enrolled in the study after an informed consent and RESULTS
ethics committee approval. Pregnant, lactating mothers,
Out of 35 patients, 8 were lost to follow-up and
immunocompromised individuals and those with
27 patients were available for evaluation. Most of the
verruca plana were excluded from study.
study patients were males (16 patients, 59.2%). The
Donor tissue for autograft was harvested by paring a commonest age group affected was that of 20–40 years
verrucous lesion or a palmoplantar wart. The lesion to be (13 patients, 48.1%). Ten patients had multiple lesions,
pared was cleansed with spirit–povidone iodine–spirit to 7 had recurrent and 10 had palmoplantar warts.
achieve asepsis. Paring was done using a sterile surgical
blade no. 11 [Figure 1]. The pared tissue was transferred A total of 20 (74.1%) patients showed the resolution of
onto the sterile surgical gauze. the warts within 3 months [Figures 4 and 5], 5 (18.5%)
patients had no improvement at all [Table 1] and in
Autografting was done either on the non-dominant 1 patient (3.7%; male, 17 years of age) with multiple
flexural forearm or the upper anteromedial thigh. The warts, except one lesion, others had resolved completely.
site for engraftment was cleansed with spirit–povidone One (3.7%) male patient aged 16 years had relapse, with
iodine–spirit and infiltrated with about 0.5 ml of lignocaine a new lesion occurring at a different site. He underwent
with adrenaline (1:200,000). A subcutis deep stab incision autoimplantation of the new wart, which healed over
of about 3–5 mm was made using the same surgical a period of 1 month. One of the patients developed
blade of no. 11 used for paring the wart [Figure 2]. The hypopigmentation at the site of resolution of warts.
pared tissue was introduced deep into the subcutis using
Adson’s forceps or an insulin syringe used for infiltration Three (11.1%) patients developed erythematous tender
[Figure 3]. The margins of the wound were approximated nodules at the site of engraftment, with a purulent
by pressure and a micropore plaster was applied on it. discharge from them in one patient. However, this
Patients were advised not to wet or remove the plaster healed with systemic antibiotics and analgesics with
for 5 days. Patients were put on systemic antibiotics for 5 mild transient hyperpigmentation.
days (tab. amoxycillin 500 mg + clavulanic acid 125 mg,
BID) and if required, analgesics orally. DISCUSSION
Warts are one of the common viral infections of the
Patients were assessed monthly, and resolution of all
mucocutaneous surfaces and often induce papillomatous
warts within 3 months was taken as complete clearance.
growth. The commonest modality of treatment for warts
is ablation using electrocautery, radiofrequency, laser or
Table 1: Summary of characteristics of non-responding
cryogens. These treatments destroy the wart-containing
patients
tissue but may not stimulate the immune system against
Age (years) Sex Type of wart
the pathogen. Hence, for the effective treatment of warts,
35 Female Palmoplantar
13 Female Multiple wart there should be immune stimulation which can lead to
17 Female Palmoplantar long-term immunity against HPV.
19 Female Palmoplantar
31 Female Plantar
Specific immune stimulation against HPV has been

Table 2: Comparison of the present study with previous studies

Author Viac et al.,[6] BJD* Usman et al.[4] Shivakumar et al.[3] Srivastava et al.[5] Present study
Technique adopted Repeated intradermal Autoimplantation of Autoimplantation using a Intramuscular injection Autoimplantation of the
injections of formalin the anogenital wart subcutis deep wart tissue of distilled water pared stratum corneum
inactivated the extracted suspension of tissue from the wart
purified viral antigen crushed wart
Male: female NA All males (n=100) 40:20 37:25 16:11
Commonest age group NA NA 21–30 NA 20–40
(years)
Complete clearance (%) 45.4 44 73.3 66.03 74.1
Partial clearance (%) NA 26 NA 22.64 3.7
Non-responders (%) 54.5 30 26.7 11.32 18.5
Relapse (%) - - - - 3.7
Reaction at the site of NA NA Some cases (number not Nil 3 (11.5%) cases
implantation or injection specified)
NA: Not available. *Only abstract referred

Journal of Cutaneous and Aesthetic Surgery - Jan-Mar 2012, Volume 5, Issue 1 27

Nischal, et al.: Novel modification of the autoimplantation therapy for warts

Figure 1: Paring of the wart using surgical blade no. 11 Figure 2: Stab incision done using the same surgical blade
no. 11 used to pare the wart

Figure 3: Introducing the pared tissue deep into the subcutis

using Adson’s forceps
Figure 4: Recurrent wart on the lateral aspect of the right
second toe

quadrivalent HPV vaccines.[1,2] Patients with regression

of warts either spontaneously or following successful
therapy or injection of antigens showed the development
of cell-mediated immunity and appearance of virus-
specific IgM and IgG antibodies.[6,7]

In their study on the autoimplantation technique,

Shivakumar et al. extracted a subcutis deep part of the
wart using a 18 G needle and implanted it into the skin
elsewhere.[3] This resulted in two wounds. Also, HPV is
an epidermal infection and there is no added advantage
with the extracting donor tissue containing dermis and
subcutis. Hence, in this study, we harvested the donor
Figure 5: Complete resolution of the wart after by paring the wart to get the stratum corneum tissue
autoimplantation containing virus. By this method, we avoided wound at
the donor site and also circumvented the issue of taking
tried by autoimplantation of the wart tissue into the the unwanted deeper tissues for engraftment. In contrast
uninvolved skin, [3] injecting the suspension of the to the autowart injection therapy, this is a single sitting
crushed wart into the muscle[5] or skin[6] [Table 2] and by procedure and avoids the risk of injection abscess.

28 Journal of Cutaneous and Aesthetic Surgery - Jan-Mar 2012, Volume 5, Issue 1

 Nischal, et al.: Novel modification of the autoimplantation therapy for warts

Most of our patients were males and belonged to the of only anecdotal reports, partial clearance in one of the
20- to 40-year age group in parlance with other studies. two studies and a limited access in resource-restricted
A complete clearance of warts was observed in 74.1% of countries are the drawbacks of this vaccine.[1,2]
patients [Table 2], greater than that observed by Usman
et al. (44%) or Shivakumar et al. (73.3%). Autowart Limitations of our study include a small sample size,
injections also had lesser clearance than our study. We lack of controls to assess spontaneous resolution of warts
had one patient with multiple warts in whom one of the and lack of serotyping of persistent warts or checking
warts persisted at the end of 3 months. Partial clearance for serospecific HPV antibodies. We also need to study
was not observed by Usman et al. or Shivakumar et al. the cause for the partial clearance or occurrence of new
Non-responders were minimal in the study, using warts in spite of the clearance of all previous warts.
autowart injection, by Srivastava et al. But they had a high
percentage (22.64%) of partial clearance patients. One of CONCLUSION
our patients had clearance of warts after autoimplantation The modified technique of autoimplantation using the
but developed a new lesion at a new site. This observation pared stratum corneum tissue of the wart instead of
has not been reported by other researchers. This probably the subcutis deep wart tissue for autografting is a safe,
could be due to infection by a different serotype of HPV. efficacious, less traumatic and rapid procedure for the
As we were unable to isolate the species of HPV, this treatment of multiple, recurrent and palmoplantar warts.
inference is hypothetical. We did autoimplantation of This technique also scores over the autowart injection
the new wart and it healed in over 1 month. This further method of treatment.
supports the hypothesis. In one patient, warts healed with
transient hypopigmentation. Of the 27 patients, only 2 had REFERENCES
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Hence, the final outcome was much better in our study 16, and 18) in a developmentally delayed, 31-year-old white man. Arch
(74.1%) when compared with other autoimplantation as Dermatol 2010;146:475-7.
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a patient with WILD syndrome following recombinant quadrivalent
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How to cite this article: Nischal KC, Sowmya CS, Swaroop MR, Agrawal
reaction which occurs in the case of a ruptured follicle. DP, Basavaraj HB, Sathyanarayana BD. A novel modification of the
autoimplantation therapy for the treatment of multiple, recurrent and
A quadrivalent HPV vaccine has shown promising palmoplantar warts. J Cutan Aesthet Surg 2012;5:26-9.
results in the treatment of warts. However, the presence Source of Support: Nil. Conflict of Interest: None declared.

Journal of Cutaneous and Aesthetic Surgery - Jan-Mar 2012, Volume 5, Issue 1 29

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