patient was treated with acyclovir 800mg five times daily for ten days. Five days after completion of the medication, the patient presented to podiatry for discussion of surgical removal of persistent verruca. However, only one 1mm verruca remained, with complete resolution at next follow-up visit, rendering the procedure unnecessary.
DISCUSSION
There have been two previous case reports demonstrating the efficacy of oral valacyclovir in treating verruca, unresponsive to standard therapies. Table 1 provides a brief overview of the clinical findings of these reports. The patients in which treatment with valacyclovir has reportedly been effective share common characteristics of a long history of verrucous lesions and ineffectiveness of conventional therapies.8 To date, there are no double-blind placebo-controlled trials assessing the efficacy of oral acyclovir or valacyclovir in verruca.
The use of topical acyclovir in the treatment of verruca has been controversial. Gipson, et al. demonstrated lack of statistical significance of acyclovir cream in the treatment of viral verruca when compared with liquid nitrogen and placebo.6 Conversely, a brief Letter to the editor of Cutis described successful treatment with acyclovir cream in twenty-four patients with a variety of warts unresponsive to prior treatments.9 Acyclovir cream was reported successful in an additional three case reports of patients with verruca that had persisted for years following ineffective traditional therapies.7,10
In the case described above, the patient possessed similar characteristics to previous case reports analyzing the use of valacyclovir in treatment-resistant verruca in that traditional therapies including debridement and topical creams had proven ineffective in resolving their plantar warts. However, unlike previous reports, resolution of the majority of the warts was evident only 5 days after conclusion of oral acyclovir therapy.
The mechanism behind the possible efficacy of acyclovir in the treatment of plantar warts was briefly discussed by Bauer.10 It has been suggested that if in vitro studies of human wart tissue evidenced the capacity to convert acyclovir to its active form through viral thymidine kinase, acyclovir treatment in plantar warts could be justified.
In this case, acyclovir was prescribed for the acute treatment of herpes zoster. Upon follow-up for scheduled debridement, it was noted that the verruca, persistent following previous seven rounds of debridement and monochloroacetic acid application, was completely resolved. While an exact causal relationship cannot be elicited in regards to acyclovir and verruca healing, based on previous case reports and findings from this case, further controlled clinical trials are warranted. To our knowledge, this is the first case to present a patient with failed trials of standard therapy that responded to a short course of acyclovir.
CONCLUSION
The case described above is suggestive of the utility of oral acyclovir therapy in the treatment of verruca resistant to standard therapy. While few cases have previously suggested this correlation, primarily using topical creams, this is the first to exhibit verruca improvement with a short course of oral acyclovir therapy. Additional trials are necessary to affirm a direct causal relationship between acyclovir and verruca resolution.
DISCLOSURE
The authors have no conflicts of interest to report and no funding was received for this paper.
REFERENCES
- Rivera A, Tyring SK. Therapy of cutaneous human Papillomavirus infections. Dermatol Ther. 2004;17(6):441-8.
- Gibbs S, Harvey I, Sterling JC, Stark R. Local treatments for cutaneous warts. Cochrane Database Syst Rev. 2003;(3):CD001781.
- Kwok CS, Gibbs S, Bennett C, Holland R, Abbott R. Topical treatments for cutaneous warts. Cochrane Database Syst Rev. 2012;9:CD001781.
- Simonart T, De maertelaer V. Systemic treatments for cutaneous warts: a systematic review. J Dermatolog Treat. 2012;23(1):72-7.
- Acyclovir. [package insert] Elizabeth, NJ: Purepac Pharmaceutical Co; 2004.
- Gibson JR, Harvey SG, Barth J, Darley CR, Reshad H, Burke CA. A comparison of acyclovir cream versus placebo cream versus liquid nitrogen in the treatment of viral plantar warts. Dermatologica. 1984;168(4):178-81.
- Pechman KJ. Does acyclovir have an adjunctive role in plantar wart therapy?. Cleve Clin Q. 1983;50(2):213.
- Tandeter H, Tandeter ER. Treatment of plantar warts with oral valacyclovir. Am J Med. 2005;118(6):689-90.
- Hurwitz RM. Verrucae vulgares and acyclovir ointment. Cutis. 1984;34(1):84, 86.
- Bauer DJ. Treatment of plantar warts with acyclovir. Am J Med. 1982;73(1A):313-4.
CONCLUSION
AUTHOR CORRESPONDENCE
Autumn Bagwell PharmD BCPS……................................... autumndbagwell@gmail.com
