Case and Research Letters
Mumps, Measles, and Rubella Vaccine for the Treatment of a Recalcitrant Subungual Wart
Vacuna triple vírica como tratamiento de verruga subungueal recalcitrante
C. Morales-Raya
, L. Maroñas-Jiménez, R. Aragón-Miguel, C. Postigo-Llorente
Corresponding author
Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, Spain
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Morales-Raya, L. Maroñas-Jiménez, R. Aragón-Miguel, C. Postigo-Llorente" "autores" => array:4 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Morales-Raya" "email" => array:1 [ 0 => "carlosmoralesraya@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Maroñas-Jiménez" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Aragón-Miguel" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Postigo-Llorente" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Vacuna triple vírica como tratamiento de verruga subungueal recalcitrante" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1012 "Ancho" => 2333 "Tamanyo" => 491982 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Subungual wart prior to treatment. B, After 7 treatment cycles.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Common warts are viral infections caused by the human papillomavirus. They can occasionally represent a therapeutic challenge, particularly at certain sites such as the subungual or periungual regions and on the soles of the feet. Although there is an extensive therapeutic arsenal for the treatment of these warts, resistance to treatment is common at these sites.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 45-year-old man, with no past medical history of interest, was seen for a subungual wart that had been present on the first digit of the right hand for 2 years, causing nail dystrophy, with pain and limitation for performing domestic and occupational tasks that required use of the finger-thumb pincer grip (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Numerous treatments, summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, had been attempted, including in combination, but had been unsuccessful. After performing biopsy to rule out verrucous carcinoma, it was decided to start immunotherapy treatment with the trivalent mumps, measles, and rubella (MMR) vaccine by local injection. Injections of 0.3<span class="elsevierStyleHsp" style=""></span>ml (each vial contains 0.5<span class="elsevierStyleHsp" style=""></span>ml) were performed at 2-week intervals. No previous immunization was required as the patient had received MMR vaccine in childhood. After 5 sessions, inflammatory changes were observed in the area, with the appearance of edema and erythema, and after the seventh session the wart disappeared completely (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). No adverse effects were observed, except for moderate pain during the injection, and there has been no recurrence after more than a year of follow-up.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The treatment of common warts at certain sites, such as the subungual region, can be frustrating. A wide range of therapies with different mechanisms of action have been tried, most commonly involving destructive methods or immunotherapy.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Immunotherapy techniques include contact allergens, such as diphencyprone and dinitrochlorobenzene, and immunomodulators, which can be topical, such as imiquimod, or oral, such as cimetidine and zinc sulfate.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> In addition, ever more trials of intralesional immunotherapy are being performed, with antigens such as candidin and the tuberculosis antigen, and with vaccines such as the mumps or MMR vaccines.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Although the mechanism of action remains unclear, this therapy is thought to induce a Th1-cell–mediated immune response. Cytokines released in the response include interleukin-2 and γ-interferon, which are released in much higher concentrations at the site of injection, focusing the local immune response in that area and favoring elimination of the human papillomavirus.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Local trauma may contribute to intensification of the response. Furthermore, the immunomodulatory effect may act not only locally, but also at a distance, as it is not uncommon to see the disappearance of warts at distant sites.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> For this immune response to develop, the patient must already have been exposed to one or more of these antigens, either by previous vaccination in accordance with the vaccination calendar, or by direct contact with the virus in the past.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> When patients have not been immunized, an initial dose of subcutaneous vaccine is recommended. The complete response rate varies between 27% and 81%, with each patient requiring a mean of 3.6 cycles at 2-week intervals.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> The most common adverse effects include pseudoinfluenza symptoms and pain at the site of injection; no serious adverse effects have been observed.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Advantages of intralesional over traditional topical immunotherapy include its cost, the availability of antigens, and possible effects at a distance from the injection site.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The vaccine can be obtained from the hospital pharmacy or directly from a high-street pharmacy with a medical prescription. The cost of a vial of vaccine is of approximately 15 euros, which may be subsidized by the health service provider.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion, the availability, cost-effectiveness, and absence of serious adverse effects of intralesional immunotherapy with the trivalent vaccine make it a useful option for the management of warts refractory to other treatments.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Morales-Raya C, Maroñas-Jiménez L, Aragón-Miguel R, Postigo-Llorente C. Mumps, Measles, and Rubella Vaccine for the Treatment of a Recalcitrant Subungual Wart. Actas Dermosifiliogr. 2017;108:966–968.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1012 "Ancho" => 2333 "Tamanyo" => 491982 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Subungual wart prior to treatment. B, After 7 treatment cycles.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duration \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">50% salicylic acid under occlusive dressing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 wk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Topical 5% 5-fluorouracil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 wk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Topical 5% imiquimod \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 wk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">50% salicylic acid<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>5% 5-fluorouracil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 wk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cryotherapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 cycles at 2-week intervals \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pulsed dye laser \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 cycles at 3-week intervals \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1607297.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Previous Treatments in Our Patient and Their Duration.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nuevos tratamientos en la infección por virus del papiloma humano" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. Muñoz Santos" 1 => "R. Pigem" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ad.2013.03.003" "Revista" => array:6 [ "tituloSerie" => "Actas Dermosifiliogr" "fecha" => "2013" "volumen" => "104" "paginaInicial" => "883" "paginaFinal" => "889" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23706272" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of warts in children: An update" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Gerlero" 1 => "Á. Hernández-Martín" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ad.2016.04.010" "Revista" => array:6 [ "tituloSerie" => "Actas Dermosifiliogr" "fecha" => "2016" "volumen" => "107" "paginaInicial" => "551" "paginaFinal" => "558" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27241712" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efficacy of intralesional immunotherapy for the treatment of warts: A review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.S. Aldahan" 1 => "S. Mlacker" 2 => "V.V. Shah" 3 => "P. Kamath" 4 => "M. Alsaidan" 5 => "S. Samarkandy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/dth.12352" "Revista" => array:6 [ "tituloSerie" => "Dermatol Ther" "fecha" => "2016" "volumen" => "29" "paginaInicial" => "197" "paginaFinal" => "207" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26991521" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of recalcitrant warts with intralesional measles, mumps, and rubella vaccine: A promising approach" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Nofal" 1 => "E. Nofal" 2 => "A. Yosef" 3 => "H. Nofal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/ijd.12480" "Revista" => array:6 [ "tituloSerie" => "Int J Dermatol" "fecha" => "2015" "volumen" => "54" "paginaInicial" => "667" "paginaFinal" => "671" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25070525" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Two-year experience of using the measles, mumps and rubella vaccine as intralesional immunotherapy for warts" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C.H. Na" 1 => "H. Choi" 2 => "S.H. Song" 3 => "M.S. Kim" 4 => "B.S. Shin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/ced.12369" "Revista" => array:6 [ "tituloSerie" => "Clin Exp Dermatol" "fecha" => "2014" "volumen" => "39" "paginaInicial" => "583" "paginaFinal" => "589" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24934912" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010800000010/v1_201711300824/S1578219017303347/v1_201711300824/en/main.assets" "Apartado" => array:4 [ "identificador" => "6157" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case and Research Letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010800000010/v1_201711300824/S1578219017303347/v1_201711300824/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219017303347?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 11 | 22 |
| 2024 October | 95 | 43 | 138 |
| 2024 September | 92 | 25 | 117 |
| 2024 August | 134 | 41 | 175 |
| 2024 July | 105 | 27 | 132 |
| 2024 June | 121 | 25 | 146 |
| 2024 May | 98 | 35 | 133 |
| 2024 April | 94 | 18 | 112 |
| 2024 March | 108 | 23 | 131 |
| 2024 February | 102 | 24 | 126 |
| 2024 January | 118 | 30 | 148 |
| 2023 December | 104 | 19 | 123 |
| 2023 November | 131 | 40 | 171 |
| 2023 October | 147 | 55 | 202 |
| 2023 September | 125 | 35 | 160 |
| 2023 August | 96 | 23 | 119 |
| 2023 July | 103 | 34 | 137 |
| 2023 June | 72 | 23 | 95 |
| 2023 May | 94 | 27 | 121 |
| 2023 April | 82 | 32 | 114 |
| 2023 March | 72 | 33 | 105 |
| 2023 February | 63 | 29 | 92 |
| 2023 January | 62 | 43 | 105 |
| 2022 December | 83 | 50 | 133 |
| 2022 November | 45 | 30 | 75 |
| 2022 October | 39 | 24 | 63 |
| 2022 September | 46 | 46 | 92 |
| 2022 August | 32 | 40 | 72 |
| 2022 July | 35 | 46 | 81 |
| 2022 June | 36 | 34 | 70 |
| 2022 May | 76 | 47 | 123 |
| 2022 April | 111 | 36 | 147 |
| 2022 March | 82 | 48 | 130 |
| 2022 February | 95 | 42 | 137 |
| 2022 January | 79 | 44 | 123 |
| 2021 December | 53 | 40 | 93 |
| 2021 November | 57 | 51 | 108 |
| 2021 October | 78 | 55 | 133 |
| 2021 September | 57 | 43 | 100 |
| 2021 August | 67 | 40 | 107 |
| 2021 July | 37 | 26 | 63 |
| 2021 June | 72 | 32 | 104 |
| 2021 May | 58 | 35 | 93 |
| 2021 April | 110 | 68 | 178 |
| 2021 March | 80 | 28 | 108 |
| 2021 February | 87 | 32 | 119 |
| 2021 January | 41 | 23 | 64 |
| 2020 December | 28 | 15 | 43 |
| 2020 November | 37 | 25 | 62 |
| 2020 October | 22 | 23 | 45 |
| 2020 September | 36 | 12 | 48 |
| 2020 August | 26 | 21 | 47 |
| 2020 July | 42 | 16 | 58 |
| 2020 June | 35 | 28 | 63 |
| 2020 May | 35 | 12 | 47 |
| 2020 April | 25 | 18 | 43 |
| 2020 March | 29 | 21 | 50 |
| 2020 February | 3 | 0 | 3 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 8 | 0 | 8 |
| 2019 August | 2 | 0 | 2 |
| 2019 July | 6 | 0 | 6 |
| 2019 June | 6 | 0 | 6 |
| 2019 May | 4 | 0 | 4 |
| 2019 April | 3 | 0 | 3 |
| 2019 March | 5 | 0 | 5 |
| 2019 February | 1 | 0 | 1 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 4 | 0 | 4 |
| 2018 November | 1 | 0 | 1 |
| 2018 October | 5 | 0 | 5 |
| 2018 September | 2 | 0 | 2 |
| 2018 February | 24 | 5 | 29 |
| 2018 January | 33 | 25 | 58 |
| 2017 December | 132 | 34 | 166 |
| 2017 November | 10 | 13 | 23 |
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