Nonavalent HPV Vaccine for the Treatment of Multiple Recalcitrant Warts Journal of the American Academy of Dermatology

TAKE-HOME MESSAGE

• A cohort of 45 adults with recalcitrant plantar or periungual warts was treated with the recombinant 9-valent human papilloma virus (HPV) vaccine at 0, 2, and 6 months. Complete clearance 3 months after the final vaccination dose was seen in 62.2% of patients, while 8.9% had a partial response, and 28.9% showed no response. The mean time to response was 12.8 weeks after the first injection. In the complete response group, no recurrence was observed, but the follow-up time was not specified.

• In some patients, a course of the 9-valent HPV vaccine may lead to complete clearance of recalcitrant warts. Further prospective trials would be useful to confirm these findings, but this treatment modality can be added to the existing array of wart treatments.

–  Margaret Hammond, MD

Written by




Alfredo Siller Jr., MD

Written by




Austinn Miller MD

Written by




Stephen K. Tyring MD, PhD

Despite the numerous modalities available to treat warts, those which are recalcitrant continue to represent a challenge among experienced clinicians. An increasing number of reports have mentioned recalcitrant warts treated with intralesional human papillomavirus (HPV) vaccine. In 2019, Waldman et al performed a retrospective cohort study reviewing 16 cases of recalcitrant warts treated with intralesional quadrivalent HPV vaccine. Results were promising, with 7 (44.0%) demonstrating complete clearance, comparable to outcomes reported for warts treated with Candida antigen, imiquimod, and squaric acid dibutylester, which are all among therapies study participants had previously failed.

More recently, this article presents an open-label, uncontrolled, single-arm study exploring the use of intralesional 9-valent HPV vaccine in 45 patients with recalcitrant warts. The majority of patients had plantar/periungual warts and were injected at 0, 2, and 6 months, with a final assessment performed 3 months after completing all vaccinations. Complete clearance was seen in 28 patients (62.2%). No recurrence was observed during this period. Interestingly, the response rate in patients aged >26 years (55.0%) was lower than that in patients aged 9 to 26 years (84.0%). This indicates that the efficacy of HPV vaccination might decrease with increasing age.

Given these results, it appears the HPV vaccine (especially the 9-valent) is a promising modality for recalcitrant warts. It possesses advantages of less pain and convenience over conventional destructive methods. Although controlled studies comparing the nonavalent vaccine to adjuvant are needed to determine its true effectiveness, clinicians should consider intralesional administration of a 9-valent HPV vaccine for recalcitrant warts. Moreover, it deserves consideration for eligible (aged <46 years with insurance) candidates who require HPV vaccination to prevent HPV-related anogenital cancer.

Beyond HPV vaccines, numerous intralesional treatments for recalcitrant warts are being explored. Preliminary studies on therapeutic agents that have demonstrated approximately ≥90% clearance include vitamin D, zinc, bleomycin, and cidofovir.

Abstract

Although there are various therapeutic modalities for the management of warts, no single treatment has proven definitive. Recently, an increasing number of reports have mentioned warts treated with the human papillomavirus (HPV) vaccine. The mechanism of action of the HPV vaccine might be considered as a cross-protective effect and systemic response.¹ Only a few cases treated with 9-valent HPV vaccine have been reported. We performed an open-label, uncontrolled, single arm study of a 9-valent HPV vaccine for the treatment of multiple recalcitrant warts. The study was approved by the institutional review board of Pusan National University Hospital (IRB No.05-2020-255).

Journal of the American Academy of Dermatology

Nonavalent Human Papilloma Virus Vaccine for the Treatment of Multiple Recalcitrant Warts: An Open Label Study

J Am Acad Dermatol 2021 Mar 27;[EPub Ahead of Print], JO Shin, JH Son, J Lee, HS Kim, HC Ko, BS Kim, MB Kim, K Shin