Case and Research Letter
Extensive Bowenoid Papulosis of the Vulva Treated by Carbon Dioxide Laser in a Patient With AIDS
Tratamiento con láser de dióxido de carbono de una papulosis bowenoide vulvar extensa en paciente con sida
M. Llamas-Velasco
, E. Vargas, Y. Delgado, A. García-Diez
Autor para correspondencia
Servicio de Dermatología, Hospital Universitario de La Princesa, Madrid, Spain
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Múltiples lesiones parduscas aplanadas en la vulva. B. Herida con tejido de granulación 10 días tras el tratamiento con láser. C. En abril de 2009 nuevas placas blanquecinas con superficie aterciopelada diagnósticas de papulosis bowenoide. D. Resultado posquirúrgico tras el segundo tratamiento con láser de CO<span class="elsevierStyleInf">2</span>. E-G. Posteriores recurrencias, controladas con tratamiento.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Llamas-Velasco, E. Vargas, Y. Delgado, A. García-Diez" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Llamas-Velasco" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Vargas" ] 2 => array:2 [ "nombre" => "Y." "apellidos" => "Delgado" ] 3 => array:2 [ "nombre" => "A." 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Llamas-Velasco, E. Vargas, Y. Delgado, A. García-Diez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Llamas-Velasco" "email" => array:1 [ 0 => "mar.llamasvelasco@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Vargas" ] 2 => array:2 [ "nombre" => "Y." "apellidos" => "Delgado" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "García-Diez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitario de La Princesa, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento con láser de dióxido de carbono de una papulosis bowenoide vulvar extensa en paciente con sida" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1488 "Ancho" => 1547 "Tamanyo" => 129959 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The red line shows the patient's CD4 count during follow-up. The <span class="elsevierStyleItalic">y</span> axis shows the CD4 count as cell s/μL, and the <span class="elsevierStyleItalic">x</span> axis, the month and year each sample was taken.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Bowenoid papulosis of the genitalia in immunocompromised patients is associated with a high risk of recurrence and transformation to infiltrating squamous cell carcinoma on the one hand, and poor response to treatment on the other.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the case of a 50-year-old female smoker diagnosed with human immunodeficiency virus (HIV) infection in 1989 and invasive cervical cancer in 2000. She also had chronic hepatitis C infection complicated by cirrhosis. She had had histopathologically confirmed bowenoid papulosis since 2004. Treatments had included electrocoagulation, cryotherapy, podophyllin resin, as well as imiquimod, but with poor response and tolerance.</p><p id="par0015" class="elsevierStylePara elsevierViewall">When the patient first visited our hospital in March 2005, she had a brownish plaque with well-defined borders and a verrucous surface covering almost the entire area of the external genitalia and the perianal area (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). A new biopsy confirmed the diagnosis of bowenoid papulosis. In December 2005, we decided to administer continuous-wave carbon dioxide (CO<span class="elsevierStyleInf">2</span>) laser therapy at a power of 7.5 W to treat the affected area and the acetowhite lesions identified; a lateral safety margin of 4 to 5 mm was also treated due to the possible presence of subclinical human papillomavirus (HPV) infection. The procedure was performed with the patient under epidural anesthesia. The treated areas were subsequently cleaned and dressed with an antibiotic ointment, and prophylactic valacyclovir was prescribed at a dose of 500 mg every 8<span class="elsevierStyleHsp" style=""></span>hours until complete reepithelization. Total clinical resolution of the lesions was observed at 1 month. The patient underwent follow-up examinations every 3 to 6 months, in addition to 4 treatment sessions with the same anesthesia, fluence, and postoperative care in October 2006, December 2007, April 2009, and June 2009. Complete clinical resolution was achieved each time (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> B-G). The patient's CD4 count during follow-up is shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>. The control biopsies showed typical features of bowenoid papulosis, with no signs of infiltrating squamous cell carcinoma. During follow-up, the patient was diagnosed with hepatocellular carcinoma in 2008 and with a high-grade anal neoplasm in 2009. The respective treatments were chemoembolization and surgery followed by consolidation radiation therapy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In all, over a period of 6 years we performed 5 sessions of CO<span class="elsevierStyleInf">2</span> laser therapy, the last of which was in April 2009; no adverse effects were observed in any of the sessions. The patient remained free of lesions in the vulvar area from September 2009 until December 2010, when she died following progression of her hepatocellular carcinoma. The only treatment required during this period was cryotherapy of isolated lesions in the area.</p><p id="par0025" class="elsevierStylePara elsevierViewall">CO<span class="elsevierStyleInf">2</span> laser therapy causes minimal postoperative pain<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and produces better cosmetic results than other methods, especially when used on the external genitals.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It has been used since 1988 to treat large bowenoid papulosis lesions that are difficult to treat with other methods.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The primary complications described to date are vesicovaginal fistulas<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and vulvodynia, especially of the posterior commissure or the vulval vestibule.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> CO<span class="elsevierStyleInf">2</span> laser therapy for bowenoid papulosis lesions achieves complete response, and the rate of recurrence is between 12.5% and 21%.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The cure rate appears to be lower (just 34.5%) in HIV-positive patients, in whom HPV infection persists.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Differences in cure rates are less substantial in condylomas treated with CO<span class="elsevierStyleInf">2</span> laser.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In our case, due to the slight fluctuations in CD4 count during follow-up, it is reasonable to rule out an improvement in symptoms due to immune recovery. A number of approaches have been used to treat bowenoid papulosis in immunocompromised patients, such as electrocoagulation, cryotherapy, 5-fluorouracil, intralesional interferon gamma, imiquimod, podophyllin resin, CO<span class="elsevierStyleInf">2</span> laser, and Nd:YAG laser. However, the effectiveness of these treatments is difficult to assess due to the scarcity of cases in the literature.</p><p id="par0030" class="elsevierStylePara elsevierViewall">As evidenced in the present case, immunocompromised patients are more susceptible to HPV-related neoplasms. We have presented this case because we achieved a good clinical response and high patient satisfaction with the cosmetic outcome after only 5 treatment cycles and with no adverse effects. In light of these results, CO<span class="elsevierStyleInf">2</span> laser therapy may be considered an appropriate treatment for immunocompromised patients with extensive and recurrent lesions.</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: Llamas-Velasco M, Vargas E, Delgado Y, García-Diez A. Tratamiento con láser de dióxido de carbono de una papulosis bowenoide vulvar extensa en paciente con sida. Actas Dermosifiliogr. 2013;104:934–936.</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" => 1074 "Ancho" => 1301 "Tamanyo" => 299418 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Multiple brownish flattened lesions on the vulva. B, Wound with granulation tissue 10 days after laser treatment. C, New whitish velvety plaques diagnosed as bowenoid papulosis (April 2009). D, Postoperative result following the second treatment session with carbon dioxide laser. E-G, Subsequent instances of recurrence, controlled with treatment.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1488 "Ancho" => 1547 "Tamanyo" => 129959 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The red line shows the patient's CD4 count during follow-up. The <span class="elsevierStyleItalic">y</span> axis shows the CD4 count as cell s/μL, and the <span class="elsevierStyleItalic">x</span> axis, the month and year each sample was taken.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Extensive human papillomavirus-related disease (bowenoid papulosis, Bowen's disease, and squamous cell carcinoma) in a patient with hairy cell leukemia: clinical and immunologic evaluation after an interferon alfa trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Lebbe" 1 => "M. Rybojad" 2 => "S. Ochonisky" 3 => "J.M. Miclea" 4 => "O. Verola" 5 => "F. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 14 | 6 | 20 |
| 2024 Octubre | 132 | 50 | 182 |
| 2024 Septiembre | 131 | 27 | 158 |
| 2024 Agosto | 159 | 57 | 216 |
| 2024 Julio | 130 | 47 | 177 |
| 2024 Junio | 131 | 54 | 185 |
| 2024 Mayo | 118 | 39 | 157 |
| 2024 Abril | 136 | 20 | 156 |
| 2024 Marzo | 127 | 43 | 170 |
| 2024 Febrero | 113 | 43 | 156 |
| 2024 Enero | 90 | 32 | 122 |
| 2023 Diciembre | 165 | 16 | 181 |
| 2023 Noviembre | 171 | 20 | 191 |
| 2023 Octubre | 178 | 13 | 191 |
| 2023 Septiembre | 163 | 47 | 210 |
| 2023 Agosto | 96 | 18 | 114 |
| 2023 Julio | 111 | 39 | 150 |
| 2023 Junio | 114 | 25 | 139 |
| 2023 Mayo | 129 | 26 | 155 |
| 2023 Abril | 65 | 26 | 91 |
| 2023 Marzo | 57 | 33 | 90 |
| 2023 Febrero | 58 | 25 | 83 |
| 2023 Enero | 48 | 32 | 80 |
| 2022 Diciembre | 71 | 41 | 112 |
| 2022 Noviembre | 31 | 31 | 62 |
| 2022 Octubre | 37 | 21 | 58 |
| 2022 Septiembre | 55 | 40 | 95 |
| 2022 Agosto | 31 | 49 | 80 |
| 2022 Julio | 84 | 37 | 121 |
| 2022 Junio | 103 | 44 | 147 |
| 2022 Mayo | 148 | 56 | 204 |
| 2022 Abril | 89 | 37 | 126 |
| 2022 Marzo | 87 | 50 | 137 |
| 2022 Febrero | 97 | 34 | 131 |
| 2022 Enero | 107 | 50 | 157 |
| 2021 Diciembre | 79 | 40 | 119 |
| 2021 Noviembre | 74 | 55 | 129 |
| 2021 Octubre | 75 | 45 | 120 |
| 2021 Septiembre | 87 | 50 | 137 |
| 2021 Agosto | 69 | 35 | 104 |
| 2021 Julio | 65 | 37 | 102 |
| 2021 Junio | 77 | 47 | 124 |
| 2021 Mayo | 103 | 42 | 145 |
| 2021 Abril | 370 | 39 | 409 |
| 2021 Marzo | 175 | 30 | 205 |
| 2021 Febrero | 165 | 19 | 184 |
| 2021 Enero | 74 | 20 | 94 |
| 2020 Diciembre | 77 | 16 | 93 |
| 2020 Noviembre | 73 | 21 | 94 |
| 2020 Octubre | 73 | 29 | 102 |
| 2020 Septiembre | 98 | 12 | 110 |
| 2020 Agosto | 65 | 36 | 101 |
| 2020 Julio | 67 | 21 | 88 |
| 2020 Junio | 68 | 36 | 104 |
| 2020 Mayo | 70 | 25 | 95 |
| 2020 Abril | 52 | 39 | 91 |
| 2020 Marzo | 35 | 35 | 70 |
| 2020 Febrero | 3 | 15 | 18 |
| 2020 Enero | 4 | 9 | 13 |
| 2019 Diciembre | 6 | 5 | 11 |
| 2019 Noviembre | 4 | 13 | 17 |
| 2019 Octubre | 0 | 11 | 11 |
| 2019 Septiembre | 0 | 11 | 11 |
| 2019 Agosto | 9 | 6 | 15 |
| 2019 Julio | 4 | 22 | 26 |
| 2019 Junio | 5 | 35 | 40 |
| 2019 Mayo | 6 | 88 | 94 |
| 2019 Abril | 2 | 66 | 68 |
| 2019 Marzo | 2 | 26 | 28 |
| 2019 Febrero | 1 | 21 | 22 |
| 2019 Enero | 4 | 13 | 17 |
| 2018 Diciembre | 0 | 11 | 11 |
| 2018 Noviembre | 2 | 3 | 5 |
| 2018 Octubre | 2 | 0 | 2 |
| 2018 Septiembre | 53 | 5 | 58 |
| 2018 Agosto | 0 | 21 | 21 |
| 2018 Julio | 0 | 23 | 23 |
| 2018 Junio | 0 | 12 | 12 |
| 2018 Mayo | 0 | 9 | 9 |
| 2018 Abril | 0 | 13 | 13 |
| 2018 Marzo | 42 | 4 | 46 |
| 2018 Febrero | 216 | 14 | 230 |
| 2018 Enero | 263 | 16 | 279 |
| 2017 Diciembre | 252 | 10 | 262 |
| 2017 Noviembre | 266 | 14 | 280 |
| 2017 Octubre | 220 | 7 | 227 |
| 2017 Septiembre | 244 | 11 | 255 |
| 2017 Agosto | 255 | 14 | 269 |
| 2017 Julio | 246 | 17 | 263 |
| 2017 Junio | 218 | 36 | 254 |
| 2017 Mayo | 90 | 28 | 118 |
| 2017 Abril | 50 | 13 | 63 |
| 2017 Marzo | 61 | 37 | 98 |
| 2017 Febrero | 148 | 19 | 167 |
| 2017 Enero | 200 | 24 | 224 |
| 2016 Diciembre | 177 | 14 | 191 |
| 2016 Noviembre | 250 | 27 | 277 |
| 2016 Octubre | 232 | 26 | 258 |
| 2016 Septiembre | 286 | 25 | 311 |
| 2016 Agosto | 238 | 17 | 255 |
| 2016 Julio | 135 | 5 | 140 |
| 2016 Junio | 15 | 5 | 20 |
| 2016 Mayo | 7 | 15 | 22 |
| 2016 Abril | 4 | 15 | 19 |
| 2016 Marzo | 10 | 1 | 11 |
| 2016 Febrero | 10 | 1 | 11 |
| 2016 Enero | 9 | 17 | 26 |
| 2015 Diciembre | 9 | 12 | 21 |
| 2015 Noviembre | 13 | 10 | 23 |
| 2015 Octubre | 6 | 19 | 25 |
| 2015 Septiembre | 4 | 3 | 7 |
| 2015 Agosto | 6 | 3 | 9 |
| 2015 Julio | 238 | 9 | 247 |
| 2015 Junio | 178 | 4 | 182 |
| 2015 Mayo | 215 | 10 | 225 |
| 2015 Abril | 207 | 4 | 211 |
| 2015 Marzo | 232 | 2 | 234 |
| 2015 Febrero | 191 | 6 | 197 |
| 2015 Enero | 157 | 9 | 166 |
| 2014 Diciembre | 151 | 4 | 155 |
| 2014 Noviembre | 121 | 5 | 126 |
| 2014 Octubre | 143 | 10 | 153 |
| 2014 Septiembre | 112 | 4 | 116 |
| 2014 Agosto | 79 | 6 | 85 |
| 2014 Julio | 92 | 7 | 99 |
| 2014 Junio | 112 | 7 | 119 |
| 2014 Mayo | 84 | 10 | 94 |
| 2014 Abril | 68 | 4 | 72 |
| 2014 Marzo | 59 | 4 | 63 |
| 2014 Febrero | 52 | 6 | 58 |
| 2014 Enero | 16 | 4 | 20 |
| 2013 Diciembre | 17 | 5 | 22 |
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