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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Anogenital warts are produced by specific genotypes of human papillomavirus &#40;HPV&#41;&#46; Although this condition is benign&#44; its treatment can prove difficult owing to the lack of response&#44; local adverse effects&#44; and frequent recurrences<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; The mechanism of action of photodynamic therapy &#40;PDT&#41; involves destruction of specific previously sensitized cells and tissues with an exogenous photosensitizer that is activated by light of a given wavelength for an appropriate duration of exposure<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; The literature provides few data on its use in the treatment of genital warts&#44; and&#44; given that it is applied off-label<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a>&#44; no clear guidelines have been prepared&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 56-year-old man from Peru was evaluated for treatment of several anogenital warts on the penis&#46; He had a long history of pustular psoriasis that had been treated with different drugs both in monotherapy and in combination with other agents &#40;methotrexate&#44; acitretin&#44; ciclosporin&#44; infliximab&#44; etanercept&#44; and ustekinumab&#41;&#44; nonalcoholic fatty liver disease&#44; and pulmonary tuberculosis during adolescence that had been treated appropriately&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">He had had anogenital warts for 15 years&#46; Biopsy and genotyping revealed HPV subtypes 6&#44; 16&#44; 40&#44; 42&#44; 53&#44; and 61&#46; After the initial diagnosis&#44; the patient had received various local treatments&#44; which&#44; in order of prescription&#44; included podophyllotoxin solution&#44; imiquimod 5&#37; cream&#44; and treatments to which he did not respond&#58; topical cidofovir 1&#37; for 4 months&#44; with partial but insufficient improvement of the lesions&#44; as well as cryotherapy and sinecatechins&#44; again with no response&#46; The patient then received PDT based on methyl aminolevulinate<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> &#40;2 cycles of 2 sessions&#41;&#44; with a minimal clinical response&#46; From then on&#44; treatment was with imiquimod 5&#37; &#40;3 times weekly for 12 weeks&#41;&#59; the response was partial although insufficient and temporary&#46; The patient&#8217;s psoriasis improved during therapy with imiquimod&#44; thus making it possible to reduce his immunosuppressive treatment &#40;from methotrexate and ustekinumab to ustekinumab in monotherapy&#41;&#46; Given the poor response to previous treatments &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; a new cycle of PDT was started with 5-aminolevulinic acid<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> at a concentration of 78<span class="elsevierStyleHsp" style=""></span>mg&#47;g&#46; The incubation time was 3 hours&#44; and the irradiation time was 8&#46;2 minutes with red light at 635<span class="elsevierStyleHsp" style=""></span>nm &#40;Aktilite CL 128&#44; Galderma&#41;&#46; Local anesthetic with mepivacaine 2&#37; was administered to minimize pain at the treatment site&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A clinical response was observed as early as the first cycle&#44; with flattening of the lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; and a complete response was achieved after a further 3 cycles administered weekly&#46; Four months after the end of treatment&#44; the only finding was an atrophic plaque of scar tissue &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Tolerance was excellent&#44; and no local or systemic adverse effects were recorded&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">PDT receives little attention in the literature&#44; and reports are mainly case studies and series&#46; Use of PDT as monotherapy<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and in combination with other treatments &#40;previous carbon dioxide laser<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a>&#44; cryotherapy<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#44; and curettage<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#41; is promising&#44; with response rates greater than 70&#37;&#8212;in some series all patients achieve complete remission&#8212;and a low incidence of recurrence&#44; possibly because this treatment modality also acts on subclinical lesions<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; Nevertheless&#44; these data should be interpreted with caution&#46; In the present case&#44; the fact that the response to treatment came some months after reducing immunosuppressive treatment leads us to believe that the absence of response to the previous treatments &#40;including the first one with PDT&#41; can be explained&#8212;at least in part&#8212;by the immunosuppression induced by the drugs the patient was taking&#46; Patients with cellular immunosuppression of any cause are more susceptible to diseases induced by various types of viruses&#46; The lesions induced by HPV in particular produce a more florid clinical picture &#40;i&#46;e&#46;&#44; more numerous and larger lesions&#41;&#44; a diminished response to treatment&#44; and a greater incidence of relapse than in immunocompetent patients&#46; Furthermore&#44; the first application of PDT could have proven insufficient in the present case&#44; since only 2 cycles were administered&#44; compared with the 3 cycles subsequently administered&#46; As this treatment is administered off-label&#44; we do not know if there are differences in efficacy between the 2 photosensitizers currently sold for treatment of anogenital warts&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the present case&#44; 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Case and Research Letter
Refractory Anogenital Warts: Good Response to Photodynamic Therapy
Condilomas acuminados resistentes a los tratamientos convencionales con buena respuesta a tratamiento con terapia fotodinámica
B. Pinilla Martín
Autor para correspondencia
belenpinillamartin@gmail.com

Corresponding author.
, R. Rivera Díaz, V. Monsálvez Honrubia
Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Anogenital warts are produced by specific genotypes of human papillomavirus &#40;HPV&#41;&#46; Although this condition is benign&#44; its treatment can prove difficult owing to the lack of response&#44; local adverse effects&#44; and frequent recurrences<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; The mechanism of action of photodynamic therapy &#40;PDT&#41; involves destruction of specific previously sensitized cells and tissues with an exogenous photosensitizer that is activated by light of a given wavelength for an appropriate duration of exposure<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; The literature provides few data on its use in the treatment of genital warts&#44; and&#44; given that it is applied off-label<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a>&#44; no clear guidelines have been prepared&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 56-year-old man from Peru was evaluated for treatment of several anogenital warts on the penis&#46; He had a long history of pustular psoriasis that had been treated with different drugs both in monotherapy and in combination with other agents &#40;methotrexate&#44; acitretin&#44; ciclosporin&#44; infliximab&#44; etanercept&#44; and ustekinumab&#41;&#44; nonalcoholic fatty liver disease&#44; and pulmonary tuberculosis during adolescence that had been treated appropriately&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">He had had anogenital warts for 15 years&#46; Biopsy and genotyping revealed HPV subtypes 6&#44; 16&#44; 40&#44; 42&#44; 53&#44; and 61&#46; After the initial diagnosis&#44; the patient had received various local treatments&#44; which&#44; in order of prescription&#44; included podophyllotoxin solution&#44; imiquimod 5&#37; cream&#44; and treatments to which he did not respond&#58; topical cidofovir 1&#37; for 4 months&#44; with partial but insufficient improvement of the lesions&#44; as well as cryotherapy and sinecatechins&#44; again with no response&#46; The patient then received PDT based on methyl aminolevulinate<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> &#40;2 cycles of 2 sessions&#41;&#44; with a minimal clinical response&#46; From then on&#44; treatment was with imiquimod 5&#37; &#40;3 times weekly for 12 weeks&#41;&#59; the response was partial although insufficient and temporary&#46; The patient&#8217;s psoriasis improved during therapy with imiquimod&#44; thus making it possible to reduce his immunosuppressive treatment &#40;from methotrexate and ustekinumab to ustekinumab in monotherapy&#41;&#46; Given the poor response to previous treatments &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; a new cycle of PDT was started with 5-aminolevulinic acid<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> at a concentration of 78<span class="elsevierStyleHsp" style=""></span>mg&#47;g&#46; The incubation time was 3 hours&#44; and the irradiation time was 8&#46;2 minutes with red light at 635<span class="elsevierStyleHsp" style=""></span>nm &#40;Aktilite CL 128&#44; Galderma&#41;&#46; Local anesthetic with mepivacaine 2&#37; was administered to minimize pain at the treatment site&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A clinical response was observed as early as the first cycle&#44; with flattening of the lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; and a complete response was achieved after a further 3 cycles administered weekly&#46; Four months after the end of treatment&#44; the only finding was an atrophic plaque of scar tissue &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Tolerance was excellent&#44; and no local or systemic adverse effects were recorded&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">PDT receives little attention in the literature&#44; and reports are mainly case studies and series&#46; Use of PDT as monotherapy<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and in combination with other treatments &#40;previous carbon dioxide laser<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a>&#44; cryotherapy<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#44; and curettage<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#41; is promising&#44; with response rates greater than 70&#37;&#8212;in some series all patients achieve complete remission&#8212;and a low incidence of recurrence&#44; possibly because this treatment modality also acts on subclinical lesions<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; Nevertheless&#44; these data should be interpreted with caution&#46; In the present case&#44; the fact that the response to treatment came some months after reducing immunosuppressive treatment leads us to believe that the absence of response to the previous treatments &#40;including the first one with PDT&#41; can be explained&#8212;at least in part&#8212;by the immunosuppression induced by the drugs the patient was taking&#46; Patients with cellular immunosuppression of any cause are more susceptible to diseases induced by various types of viruses&#46; The lesions induced by HPV in particular produce a more florid clinical picture &#40;i&#46;e&#46;&#44; more numerous and larger lesions&#41;&#44; a diminished response to treatment&#44; and a greater incidence of relapse than in immunocompetent patients&#46; Furthermore&#44; the first application of PDT could have proven insufficient in the present case&#44; since only 2 cycles were administered&#44; compared with the 3 cycles subsequently administered&#46; As this treatment is administered off-label&#44; we do not know if there are differences in efficacy between the 2 photosensitizers currently sold for treatment of anogenital warts&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the present case&#44; we observed an optimal response to treatment&#44; with no recurrences during the 4 months of follow-up after the end of treatment&#46; We administered local anesthetic to prevent pain during exposure to the light source&#44; and tolerance of treatment was excellent&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion&#44; PDT could be a safe and effective approach for the treatment of anogenital warts&#46; It is especially useful in immunosuppressed patients with lesions refractory to standard treatment&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest with respect to the drug used in the present report&#46;</p></span></span>"
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ISSN: 00017310
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