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
Autor para correspondencia
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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 9 | 9 | 18 |
| 2024 Octubre | 84 | 35 | 119 |
| 2024 Septiembre | 86 | 22 | 108 |
| 2024 Agosto | 90 | 58 | 148 |
| 2024 Julio | 68 | 37 | 105 |
| 2024 Junio | 87 | 37 | 124 |
| 2024 Mayo | 75 | 35 | 110 |
| 2024 Abril | 91 | 33 | 124 |
| 2024 Marzo | 75 | 38 | 113 |
| 2024 Febrero | 55 | 28 | 83 |
| 2024 Enero | 41 | 34 | 75 |
| 2023 Diciembre | 46 | 15 | 61 |
| 2023 Noviembre | 63 | 29 | 92 |
| 2023 Octubre | 43 | 29 | 72 |
| 2023 Septiembre | 49 | 30 | 79 |
| 2023 Agosto | 38 | 23 | 61 |
| 2023 Julio | 36 | 56 | 92 |
| 2023 Junio | 40 | 20 | 60 |
| 2023 Mayo | 40 | 26 | 66 |
| 2023 Abril | 23 | 20 | 43 |
| 2023 Marzo | 60 | 25 | 85 |
| 2023 Febrero | 49 | 17 | 66 |
| 2023 Enero | 24 | 31 | 55 |
| 2022 Diciembre | 38 | 29 | 67 |
| 2022 Noviembre | 47 | 32 | 79 |
| 2022 Octubre | 21 | 27 | 48 |
| 2022 Septiembre | 23 | 30 | 53 |
| 2022 Agosto | 25 | 39 | 64 |
| 2022 Julio | 33 | 40 | 73 |
| 2022 Junio | 20 | 27 | 47 |
| 2022 Mayo | 40 | 32 | 72 |
| 2022 Abril | 56 | 42 | 98 |
| 2022 Marzo | 64 | 63 | 127 |
| 2022 Febrero | 44 | 39 | 83 |
| 2022 Enero | 39 | 36 | 75 |
| 2021 Diciembre | 57 | 43 | 100 |
| 2021 Noviembre | 62 | 49 | 111 |
| 2021 Octubre | 74 | 52 | 126 |
| 2021 Septiembre | 49 | 42 | 91 |
| 2021 Agosto | 27 | 37 | 64 |
| 2021 Julio | 42 | 35 | 77 |
| 2021 Junio | 34 | 34 | 68 |
| 2021 Mayo | 37 | 46 | 83 |
| 2021 Abril | 90 | 58 | 148 |
| 2021 Marzo | 77 | 54 | 131 |
| 2021 Febrero | 60 | 30 | 90 |
| 2021 Enero | 39 | 18 | 57 |
| 2020 Diciembre | 35 | 16 | 51 |
| 2020 Noviembre | 20 | 22 | 42 |
| 2020 Octubre | 13 | 8 | 21 |
| 2020 Septiembre | 38 | 23 | 61 |
| 2020 Agosto | 31 | 16 | 47 |
| 2020 Julio | 24 | 15 | 39 |
| 2020 Junio | 26 | 28 | 54 |
| 2020 Mayo | 19 | 21 | 40 |
| 2020 Abril | 17 | 13 | 30 |
| 2020 Marzo | 19 | 15 | 34 |
| 2018 Septiembre | 1 | 0 | 1 |
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