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Can Oral Retinoids Have An Impact For Recalcitrant Warts?

Cutaneous warts are an extremely common skin disorder caused by various strains of the human papillomavirus (HPV). The type of epithelium affected dictates the wart’s appearance and response to treatment. The most well established treatments for warts include salicylic acid and cryotherapy with liquid nitrogen. The thickness of the plantar skin and hyperkeratosis associated with the plantar warts can render these standard treatment modalities less successful. When conventional modalities fail, the treatment of plantar warts can be difficult.

Retinoids are medications that are chemically related to vitamin A. Available as both topical and oral medications, these drugs exert their effect by regulating epithelial cell growth. Physicians have used retinoids in the treatment of many skin disorders including acne, psoriasis, actinic keratosis and photoaging.

Acitretin (Soriatane, Stiefel Laboratories) is a second-generation oral retinoid that is most commonly in use for the treatment of psoriasis. Researchers have shown this medication is a successful modality in the treatment of recalcitrant warts. Joshipura and colleagues recently reported the successful treatment of a case of recalcitrant plantar warts with oral acitretin and 40% urea cream.1 While not specific to plantar warts, several other studies have found acitretin to be a successful treatment modality for extensive and recalcitrant viral warts.2-5

Studies have shown that other systemic oral retinoids are successful in the management of cutaneous warts. Researchers have shown that isotretinoin, a first-generation retinoid, is useful in treating plane warts, epidermodysplasia verruciformis, condylomata acuminata and other recalcitrant warts associated with immune-compromised states.6-13 Further research should examine the role of other oral retinoids in the management of plantar warts.

Systemic retinoids are contraindicated during pregnancy due to their risk of causing numerous birth defects. Due to the long half-life of acitretin and the risk of severe birth defects associated with this medication, pregnant women should not use it and women who plan to get pregnant within the next three years should also not use acitretin.14 Additionally, patients who have received acitretin should not donate blood for three years following use of this medication due to the risk of birth defects.14 Women of childbearing age should avoid acitretin and if they use it, women should also use two forms of birth control for one month prior to starting the medication and for three years following its use.14 Similar precautions should be in place when prescribing other systemic retinoids.

References

1.      Joshipura D, Goldminz A, Greb J, Gottlieb A. Acitretin for the treatment of recalcitrant plantar warts. Dermatol Online J. 2017;23(3).

2.      Choi YL, Lee KJ, Kim WS, et al. Treatment of extensive and recalcitrant viral warts with acitretin. Int J Dermatol. 2006;45(4):480-482.

3.      El-Khayat RH, Hague JS. Use of acitretin in the treatment of resistant viral warts. J Dermatolog Treat. 2011;22(4):194-196.

4.      Proietti I, Skroza N, Bernardini N, et al. Acitretin in management of diffuse common warts: a case report. Dermatol Ther. 2011;24(6):581-583.

5.      Krupa Shankar DS, Shilpakar R. Acitretin in the management of recalcitrant warts. Indian J Dermatol Venereol Leprol. 2008;74(4):393-395.

6.      Olguin-Garcia MG, Jurado-Santa Cruz F, Peralta-Pedrero ML, Morales-Sanchez MA. A double-blind, randomized, placebo-controlled trial of oral isotretinoin in the treatment of recalcitrant facial flat warts. J Dermatolog Treat. 2015;26(1):78-82.

7.      Miljkovic J. A novel therapeutic approach to plane warts: a report on two cases. Acta Dermatovenerol Alp Pannonica Adriat. 2012;21(3):63-64.

8.      Rallis E, Papatheodorou G, Bimpakis E, Butanska D, Menounos P, Papadakis P. Systemic low-dose isotretinoin maintains remission status in epidermodysplasia verruciformis. J Eur Acad Dermatol Venereol. 2008;22(4):523-525.

9.      Zampetti A, Giurdanella F, Manco S, et al. Acquired epidermodysplasia verruciformis: a comprehensive review and a proposal for treatment. Dermatol Surg. 2013;39(7):974-980.

10.    Akyol M, Ozcelik S. Non-acne dermatologic indications for systemic isotretinoin. Am J Clin Dermatol. 2005;6(3):175-184.

11.    Yildirim M, Inaloz HS, Baysal V, Kesici D, Candir O. A case of condyloma acuminatum treated successfully with low-dose isotretinoin and interferon. Int J Clin Pract. 2004;58(9):889-891.

12.    Monastirli A, Matsouka P, Pasmatzi E, et al. Complete remission of recalcitrant viral warts under oral isotretinoin in a patient with low-grade B-cell lymphoma. Acta Derm Venereol. 2005;85(4):358-360.

13.    Euvrard S, Kanitakis J, Thivolet J, Claudy A. Retinoids for the management of dermatological complications of organ transplantation. BioDrugs. 1997;8(3):176-184.

14.    Stiefel. Soriatane Important Safety Information. 2017; October 22, 2017. Available at: http://www.soriatane.com/ - isi-content.

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