BI30 Remission of a large plantar verruca vulgaris in an immunocompromised patient postincisional punch biopsy

Abstract

Abstract We report the case of a 41-year-old renal transplant recipient who has been attending dermatology for skin surveillance following a cadaveric renal transplant. His immunosuppressive treatment consists of tacrolimus, mycophenolate mofetil and prednisolone 5 mg once daily. His primary dermatological complaint was that of a large wart on the plantar aspect of his right foot. Given the location of this lesion, there was significant associated pain, which also resulted in a functional impediment, impacting on his ability to exercise or work. On examination, he had a large, hyperkeratotic, papillomatous nodule measuring 3.5 × 3 cm on the plantar aspect of his right foot, clinically in keeping with verruca vulgaris. This had been recalcitrant to extensive treatment, including topical salicylic acid, 5-fluorouracil, cantharidin and numerous courses of cryotherapy and paring over the previous 6 years. Following administration of xylocaine 1% with adrenaline as the local anaesthetic, we performed three incisional 4-mm punch biopsies through the centre of the wart to the depth of the dermis. We ensured visualization of haemorrhage at the base of each punch incision. The biopsy cores were left in situ and the wound was dressed with petroleum jelly, Kaltostat® and Opsite. At his 6-week follow-up review, the verruca vulgaris had completely resolved. No postprocedural complications were noted by the patient. Further skin surveillance was scheduled for 6 months later, at which time no recurrence of this verruca vulgaris had occurred. Verruca vulgaris is a benign papillomatous proliferation of epidermal cells driven by human papillomavirus (HPV) infection, commonly acquired in childhood. For many patients, verruca vulgaris will spontaneously regress. However, it can represent a therapeutic challenge when persistent, as it is recalcitrant to multiple treatment modalities, particularly in immunosuppressed patients. To our knowledge, our case is the first documented resolution of a giant plantar wart in an immunocompromised patient using such an approach. Renal transplant patients represent a unique cohort in relation to verruca vulgaris, whereby impaired cell-mediated immunity can increase their susceptibility to HPV, thereby reducing effective treatment options and meaning definitive clearance may never be achieved. Our case highlights that incisional punch biopsy may represent an accessible and cost-effective approach to the treatment of verruca vulgaris in immunosuppressed patients, where alternative treatment options would necessitate numerous hospital visits.