Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Letter to the Editor - Therapy Letter
2020:86:4;456-458
doi: 10.4103/ijdvl.IJDVL_535_19
PMID: 32415053

“Verrucous vulva”: Meeting therapeutic challenges in massive condyloma acuminata with intralesional immunotherapy

Saurabh Singh
 Associate Professor, Department of Dermatology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Correspondence Address:
Saurabh Singh
Dermatology OPD, Main OPD Block, All India Institute of Medical Sciences, Basni Phase-2nd, Jodhpur - 342 005, Rajasthan
India
Published: 15-May-2020
How to cite this article:
Singh S. “Verrucous vulva”: Meeting therapeutic challenges in massive condyloma acuminata with intralesional immunotherapy. Indian J Dermatol Venereol Leprol 2020;86:456-458
Copyright: (C)2020 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

Mycobacterium indicus pranii vaccine was developed and approved in India as an adjuvant to multidrug treatment of multibacillary leprosy for faster and complete immunological clearance of Mycobacterium leprae. Of late, it had been shown to be of benefit in anogenital warts.[1],[2]

A 57-year-old post-menopausal woman presented with progressive coalescent verrucous papules on the vulva since 1 year. Lesions started as asymptomatic skin-colored papules on the vulva a year back and gradually proceeded to cover most part of the visible genitalia. There was associated pruritus but no discharge. She was married but had no marital or extramarital sexual contact in the past 1 to 1.5 years and denied similar genital lesions in her husband. Her past medical history was unremarkable. Lesions had failed to respond to topical applications including salicylic acid, trichloroacetic acid, and 5-fluorouracil. Examination revealed a bulky labia majora with an uneven lobulated surface which was completely covered with skin-colored to grayish-white confluent verrucous papules and plaques [Figure - 1]a. On separating the labia majora, the verrucous lesions were found to diffusely involve and obliterate the labia minora and the clitoris was almost obscured [Figure - 1]b. Few scattered lesions were present in the perineal and perianal regions. Moderate non-foul smelling whitish discharge was visible at the introitus and per speculum examination showed features suggestive of vaginal candidiasis. Serology for sexually transmitted infections like enzyme-linked immunosorbent assay for human immunodeficiency virus, venereal disease research laboratory test and hepatitis B surface antigen and anti-hepatitis C virus antibodies were negative. Routine blood counts and biochemistry were also within normal limits. A diagnosis of extensive vulval condyloma acuminata with vaginal candidiasis was made. After treating vaginal candidiasis with oral fluconazole and clotrimazole vaginal pessary, the extensive vulval condyloma acuminata were planned for intralesional immunotherapy with Mycobacterial indicus pranii (MIP) vaccine. After a standard sensitizing test dose, 0.1 ml of the vaccine was injected in 2 wart sites in superficial dermis at 2 weekly intervals.[1] Patient achieved about 50–60% remission after 1 injection, 80–90% after 3 injections, and 95–100% after 4th and final injection [Figure - 2]a and [Figure - 2]b. Transient injection site tender nodules were noted on vulva [Figure - 2]b which disappeared spontaneously in next 7 to 10 days. The patient achieved complete remission at 10 weeks after starting therapy. The injection was associated with mild pain but no other adverse effects were noted. Patient reported being lesion free for 2 years after which she was lost to follow-up.

Figure 1:
Figure 2:

The high immunogenicity of MIP vaccine has been found to have wider applications in fields like infectious diseases as well as oncology, the latest being its approval by drug controller general of India in 2013 for the treatment of advanced non-small cell lung cancer along with chemotherapy. The health ministry and Indian Council of Medical Research have recently initiated field trials of MIP vaccine as a prophylactic agent against leprosy. Despite this fact, unfortunately, the vaccine is currently unavailable commercially in India in a multi-dose vial preparation as needed for wart treatment and this is currently the greatest hindrance for further research and therapeutics.

The early studies using MIP vaccine included a sensitizing dose of intradermal injections on both deltoids[2],[3],[4],[5] but a series has shown effective results without the intradermal doses.[6] This vaccine has been widely reported to be beneficial in both extensive anogenital and extra-genital warts.[2],[3],[4] Its published efficacy in series on genital warts ranged from 67% to 88%.[1],[2] A study by Kumar et al. revealed that MIP vaccine fared slightly better than imiquimod in terms of proportion of patients achieving complete remission (67% in MIP group and 59% in imiquimod group), even though the results were not statistically significant. They also noted that although both drugs were able to reduce the viral load of human papilloma virus type 6, only MIP reduced the viral load of HPV-11. The only 2 prior studies using MIP vaccine in genital warts have reported complete remission, in one study in combination with vehicle cream after a mean of 5.66 doses (53.3 weeks)[2] and another study reporting time to remission ranging from 2 to 12 weeks.[1] Thus, the effects of vaccine may be delayed and may continue long after the treatment is over. Although the exact mechanism by which it works in warts is unknown, the evidence suggests that it mounts a strong Th1 cytokine response leading to effective T-cell and macrophage activation probably leading to infection clearance.[7]

The current case is being reported to highlight the rare instance of massive condyloma acuminata resolving completely and rapidly with intralesional MIP vaccine monotherapy. Despite the fact that several vaccines have been used to clear warts, the low cost, early response, and acceptable safety profile of killed MIP vaccine does indicate its suitability as an immunotherapeutic agent for resistant extensive warts. It is hoped that scientific literature will provide the much-needed impetus for the Government of India and pharmaceutical industry to reinitiate the process of making MIP vaccine commercially available for prescription usage.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References
1.
Gupta S, Malhotra AK, Verma KK, Sharma VK. Intralesional immunotherapy with killed Mycobacterium w vaccine for the treatment of ano-genital warts: An open label pilot study. J Eur Acad Dermatol Venereol 2008;22:1089-93.
[Google Scholar]
2.
Kumar P, Dar L, Saldiwal S, Varma S, Datt Upadhyay A, Talwar D, et al. Intralesional injection of Mycobacterium w vaccine vs. imiquimod, 5%, cream in patients with anogenital warts: A randomized clinical trial. JAMA Dermatol 2014;150:1072-8.
[Google Scholar]
3.
Meena JK, Malhotra AK, Mathur DK, Mathur DC. Intralesional immunotherapy with Mycobacterium w vaccine in patients with multiple cutaneous warts: Uncontrolled open study. JAMA Dermatol 2013;149:237-9.
[Google Scholar]
4.
Singh S, Chouhan K, Gupta S. Intralesional immunotherapy with killed Mycobacterium indicus pranii vaccine for the treatment of extensive cutaneous warts. Indian J Dermatol Venereol Leprol 2014;80:509-14.
[Google Scholar]
5.
Khullar G, Narang T, De D, Nahar Saikia U, Dogra S, Handa S. Recalcitrant giant condyloma acuminatum treated successfully with a novel combination of Mycobacterium indicus pranii immunotherapy and acitretin. Int J STD AIDS 2017;28:1155-7.
[Google Scholar]
6.
Garg S, Baveja S. Intralesional immunotherapy for difficult to treat warts with Mycobacterium w vaccine. J Cutan Aesthet Surg 2014;7:203-8.
[Google Scholar]
7.
Aldahan AS, Mlacker S, Shah VV, Kamath P, Alsaidan M, Samarkandy S, et al. Efficacy of intralesional immunotherapy for the treatment of warts: A review of the literature. Dermatol Ther 2016;29:197-207. Sir,
[Google Scholar]

Fulltext Views
3,334

PDF downloads
1,545
Show Sections