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
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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. 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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" ]
| año/Mes | Html | Total | |
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| 2021 Octubre | 78 | 55 | 133 |
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| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Septiembre | 8 | 0 | 8 |
| 2019 Agosto | 2 | 0 | 2 |
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| 2018 Noviembre | 1 | 0 | 1 |
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| 2018 Septiembre | 2 | 0 | 2 |
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| 2018 Enero | 33 | 25 | 58 |
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