Letter to the Editor
Genital Warts, Lymphangioma, and Treatment with Imiquimod
Verrugas genitales, linfangioma y tratamiento con imiquimod
L. Padilla-España
, J.B. Repiso-Jiménez, J.F. Millán-Cayetano
Corresponding author
Servicio de Dermatología, Hospital Costa del Sol, Marbella, Spain
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Padilla-España, J.B. Repiso-Jiménez, J.F. Millán-Cayetano" "autores" => array:3 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Padilla-España" "email" => array:1 [ 0 => "laura.padilla.espana@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.B." "apellidos" => "Repiso-Jiménez" ] 2 => array:2 [ "nombre" => "J.F." "apellidos" => "Millán-Cayetano" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Costa del Sol, Marbella, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Verrugas genitales, linfangioma y tratamiento con imiquimod" ] ] "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" => 678 "Ancho" => 900 "Tamanyo" => 86744 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical appearance of vulvar lesions following surgery and electrocoagulation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">After carefully reading the letter to the editor, “Genital Warts, Lymphangioma, and Treatment with Imiquimod”, by Monteagudo et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> concerning our recently published case report, we would like to respond with several clarifications.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was an adult woman who presented with multiple papular lesions, some pedunculated, in the vulvar region, which had first appeared some years earlier. She reported that she had been assessed 5 years earlier for similar lesions, which were diagnosed as genital warts (condyloma acuminata) and treated with imiquimod cream 5% applied 3 times a week for less than 16 weeks, with apparent complete resolution of the lesions and no local side effects of note. However, since this information was reported to us by the patient when we first recorded her medical history, we do not have the results of any histologic study or molecular diagnostic tests with genotyping of the human papillomavirus that would allow us to confirm the diagnosis definitively.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On physical examination, the lesions, which were located on the anterior vulvar fourchette and the labia majora, were observed to be highly monomorphic and composed of multiple papular elements forming a cobblestone pattern. We also observed an increase in the volume of the mons pubis and slight edema of the soft tissue. The patient reported that the edema had been present for a long time and was not related to the application of the imiquimod cream.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Given the complexity of the differential diagnosis, one of the wart-like lesions was biopsied and imaging studies were carried out; the results facilitated a diagnosis of acquired circumscribed vulvar lymphangioma.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In this case, the treatment option chosen was surgical excision of the larger lesions and curretage and electrodesiccation of the smaller lesions, with a good clinical and cosmetic outcome (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient has remained asymptomatic, but is being followed up regularly with cycles of cryotherapy to treat small papular elements that continue to appear.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">With respect to the hypothesis suggested by Monteagudo et al. regarding the possible etiologic and pathogenic role of imiquimod in lymphedema, and consequently in the appearance of vulvar lymphangiomas, we consider that it is more likely that the lesions presented by this patient 5 years earlier were also vulvar lymphangiomas and that they responded partially to imiquimod, as described in other cases reported in the literature.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">As has been reported previously, imiquimod can act as an angiogenesis inhibitor through the induction of endothelia cell apoptosis and the inhibition of interleukins and other proangiogenic factors.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> There have been reports of its usefulness, with variable response, in the management of vascular lesions of different types: infantile hemangiomas,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> lymphangioendotheliomas,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> lymphangioma circumscriptum,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> and Kaposi sarcoma<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> affecting both genital<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> and nongenital areas.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, we reported on a case of acquired vulvar lymphangioma circumscriptum, a condition that can, given the site affected, present a diagnostic challenge because of the similarities with genital warts as well as a therapeutic challenge because it tends to recur. With respect to treatment, some authors have reported the usefulness of ablative approaches, including surgical excision, laser therapy, and cryotherapy and of topical antiangiogenic treatments, particularly imiquimod and rapamycin.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Padilla-España L, Repiso-Jiménez JB, Millán-Cayetano JF. Verrugas genitales, linfangioma y tratamiento con imiquimod. Actas Dermosifiliogr. 2018;109:664–665.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 678 "Ancho" => 900 "Tamanyo" => 86744 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical appearance of vulvar lesions following surgery and electrocoagulation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lesiones seudoverrugosas vulvares de reciente aparición" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 9 | 19 |
| 2024 October | 84 | 35 | 119 |
| 2024 September | 86 | 22 | 108 |
| 2024 August | 90 | 58 | 148 |
| 2024 July | 68 | 37 | 105 |
| 2024 June | 87 | 37 | 124 |
| 2024 May | 75 | 35 | 110 |
| 2024 April | 91 | 33 | 124 |
| 2024 March | 75 | 38 | 113 |
| 2024 February | 55 | 28 | 83 |
| 2024 January | 41 | 34 | 75 |
| 2023 December | 46 | 15 | 61 |
| 2023 November | 63 | 29 | 92 |
| 2023 October | 43 | 29 | 72 |
| 2023 September | 49 | 30 | 79 |
| 2023 August | 38 | 23 | 61 |
| 2023 July | 36 | 56 | 92 |
| 2023 June | 40 | 20 | 60 |
| 2023 May | 40 | 26 | 66 |
| 2023 April | 23 | 20 | 43 |
| 2023 March | 60 | 25 | 85 |
| 2023 February | 49 | 17 | 66 |
| 2023 January | 24 | 31 | 55 |
| 2022 December | 38 | 29 | 67 |
| 2022 November | 47 | 32 | 79 |
| 2022 October | 21 | 27 | 48 |
| 2022 September | 23 | 30 | 53 |
| 2022 August | 25 | 39 | 64 |
| 2022 July | 33 | 40 | 73 |
| 2022 June | 20 | 27 | 47 |
| 2022 May | 40 | 32 | 72 |
| 2022 April | 56 | 42 | 98 |
| 2022 March | 64 | 63 | 127 |
| 2022 February | 44 | 39 | 83 |
| 2022 January | 39 | 36 | 75 |
| 2021 December | 57 | 43 | 100 |
| 2021 November | 62 | 49 | 111 |
| 2021 October | 74 | 52 | 126 |
| 2021 September | 49 | 42 | 91 |
| 2021 August | 27 | 37 | 64 |
| 2021 July | 42 | 35 | 77 |
| 2021 June | 34 | 34 | 68 |
| 2021 May | 37 | 46 | 83 |
| 2021 April | 90 | 58 | 148 |
| 2021 March | 77 | 54 | 131 |
| 2021 February | 60 | 30 | 90 |
| 2021 January | 39 | 18 | 57 |
| 2020 December | 35 | 16 | 51 |
| 2020 November | 20 | 22 | 42 |
| 2020 October | 13 | 8 | 21 |
| 2020 September | 38 | 23 | 61 |
| 2020 August | 31 | 16 | 47 |
| 2020 July | 24 | 15 | 39 |
| 2020 June | 26 | 28 | 54 |
| 2020 May | 19 | 21 | 40 |
| 2020 April | 17 | 13 | 30 |
| 2020 March | 19 | 15 | 34 |
| 2018 September | 1 | 0 | 1 |
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