Dermatologic Therapy, Vol.

24, 2011, 137143

Printed in the United States All rights reserved

2011 Wiley Periodicals, Inc.

DERMATOLOGIC THERAPY
ISSN 1396-0296

THERAPEUTIC HOTLINE
Intradermal injection of PPD as a
novel approach of immunotherapy in
anogenital warts in pregnant women
Bayoumy I. Eassa*, Amany A. Abou-Bakr &
Mohamed A. El-Khalawany*
*Departments of Dermatology and Venereology, Al-Hussein University
Hospital, Al-Azhar University, Tanta, Gharbia Governorate and Department
of Pathology, National Cancer Institute, Cairo University, Cairo, Egypt

ABSTRACT: Immunotherapy for treatment of recalcitrant warts was used through different modalities
including intralesional injection of purified protein derivative (PPD), which is an extract of Mycobacterium tuberculosis, used for testing exposure to tuberculin protein, either from a previous vaccination or
from the environment. This method is used to evaluate the efficacy of a new approach of intradermal
injection of PPD in the treatment of anogenital warts in pregnant women. A total of 40 pregnant
women, aged 2035 years, and presented with anogenital warts were enrolled in this study. Human
papillomavirus (HPV) typing was done using the GP5+/GP6+ PCR assay. The patients were treated with
weekly injections of PPD given intradermally in the forearms, and evaluated for the response regularly.
HPV type-6 was the predominant genotype (67.5%). Overall, the improvement in this study was 85%
and was related to the extent of tuberculin reactivity. Nineteen (47.5%) patients demonstrated complete
clearance, 15 (37.5%) had partial response, and three (7.5%) had minimal response. Three (7.5%) cases
did not respond to treatment. Side effects were minimal and insignificant. Treatment of anogenital
warts in pregnant women with intradermal injection of PPD was found to be a unique, safe, and
effective modality of immunotherapy.
KEYWORDS: anogenital warts, immunotherapy, PPD

Introduction
Warts are common in humans and account for 8%
of visits to dermatologists. Although many warts
resolve spontaneously over several years, most
patients seek treatment because the warts are
unsightly and often tender or painful (1). Warts are
Address correspondence and reprint requests to: Mohamed A.
El-Khalawany, Department of Dermatology, Al-Hussein
University Hospital, Box 32515, Al-Darasa, Cairo, Egypt, or
email: makhalawany@gmail.com.

caused by human papillomaviruses (HPV) small

50- to 55-nm-diameter DNA viruses which are
associated with multiple benign and malignant
lesions of cutaneous and mucosal epithelia (2).
Until today, more than 100 different HPV genotypes
have been identified and are referred to by number,
of which approximately 40 have been detected in
the anogenital area (3). Potentially high-risk genotypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 66, and
69 have been defined based on their prevalence in
intraepithelial neoplasia and carcinomas. The HPV
genotypes 6, 11, 34, 40, 42, 43, 44, 53, 54, 55, 59, 61,

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Eassa et al.

62, 67, 68, 71, and 74 are classified as putative lowrisk factors since they are not associated with the
development of carcinomas (4,5).
HPV infection may spread through direct
contact or autoinoculation. The incubation period
varies from 1 to 12 months with an average of 23
months (6). There are many types of warts, such as
common, plane, planter, filliform periungual oral,
and genital (condylomata acuminata) (7). Genital
HPV infection is estimated to be subclinical in up
to 70%, i.e., unnoticed by the patient but detected
by full clinical, histological, and cytological examination or molecular analysis (8).
Genital warts have a high infectivity; the thinner
mucosal surface is more susceptible to inoculation
of virus than the thicker keratinized skin; in addition, lesions are noted to be commonest in sites
subjected to greatest coital friction in both sexes.
Anogenital warts in adult are usually but not always
transmitted sexually (9). The infectivity of maternal
genital HPV as regards laryngeal papilloma in the
child seems low (10). However, the risk of transmission from mother to child with subsequent development of the diseases in the child has been
estimated to be between 1 in 80 and 1 in 1500,
respectively (11).
During pregnancy, genital warts may proliferate
rapidly because of altered immunity and increased
blood supply, and they can be present in clinical or
subclinical (latent) form (12). The clinical form
leads to more emotional and physical suffering
for the patient because of the expected surgical
delivery or the risk of contamination of the
newborn baby with HPV during spontaneous
vaginal delivery (13).
The latent form of high-risk HPV infection might
be the reason for materno-fetal transmission of
HPV. The high rate of high oncogenic risk types of
HPV in pregnancies complicated by intrauterine
growth retardation (IUGR) might suggest the correlation between HPV infection and IUGR etiology
(14). HPV infection of extravillous trophoblast
induces cell death and may reduce placental invasion into the uterine wall. Thus, HPV infection may
cause placental dysfunction and is associated with
adverse pregnancy outcomes, as spontaneous
preterm delivery (15).
Primary treatment modalities for warts include
destructive therapies, such as topical chemical
cautery, cryotherapy with liquid nitrogen, electric
cautery (electro-surgery), excision, bleomycin
sulfate injection, and laser vaporization, but none
of them offers a guarantee of cure and recurrence is
common (16). Because warts proliferation is controlled by the immune system, various methods

138

have been used to stimulate the immunologic

response to the HPV. Among these are topically
applied inorganic molecules capable of eliciting
contact hypersensitivity, imiquimod, and intralesional interferon (17). Immunotherapy possesses
theoretical advantage in that the immune system
modulates proliferation of HPV (18). The role of
immunity is documented by the appearance and
persistence of warts in immunosuppressed populations, and spontaneous regression of the majority
of warts is related to cellular immunity (19).
Intralesional immunotherapy using injection of
Candida, mumps, or trichophyton skin test antigens has been used for treatment of warts, and was
found to be effective as indicated by significantly
higher response rates. Untreated warts that resolve
after injection of only single wart prompt speculation that intralesional immunotherapy induces
HPV-directed immunity (16). Immunotherapeutic
modalities like PPD was used intralesionally for
treatment of recalcitrant warts (20). PPD is an
extract of Mycobacterium tuberculosis, used for
testing exposure to tuberculin protein, either from
a previous vaccination or from the environment
(21), whereas BCG is a bacterial preparation of a
strain called Bacillus Calmette-Guerin. It contains
live, attenuated Mycobacterium bovis that has lost
its virulence in humans by being especially cultured in an artificial medium for years, and was
developed as a vaccine against tuberculosis (22).
The aim of the present authors was to evaluate a
novel approach of immunotherapy in the treatment of anogenital warts in pregnant women.

Patients and methods

A total of 40 pregnant Egyptian women were
enrolled in this study. The patients were randomly
collected from the outpatient dermatology clinic in
Al-Hussein University Hospital, Cairo, Egypt. Pretreatment investigations were done for all patients,
which included blood sugar, complete blood
count, chest x-ray, and general health profile (liver
function test, renal function test, lipid profile).
Screening for human immunodeficiency virus,
Venereal Disease Research Laboratory, Treponema
pallidum hemagglutination test (TPHA), hepatitis
B and C tests were also done.
Formal written consent was signed by all
patients after explaining them the details about the
nature of this therapy. Pre- and follow-up treatment photographs were taken and labeled by specific number to identify each patient before
starting treatment. All the patients were examined

Anogenital warts in pregnant women

for the presence of the previous scar of BCG

vaccine, and all patients enrolled in this study had
an obvious scar in the left upper arm.
Tuberculin test (Mantoux tuberculin skin test)
was done for all patients with PPD RT23 SSI
(0.1 mL) with strength 2 TU /0.1 mL:0.04 microgram tuberculin PPD/dose (Holder of marketing
authorization and manufacture, Statens Serum
Institute, 5, Artllerivej, DK-2300 Copenhagen
S.) at the middle third of ventral aspect of left
forearm with a short bevel needle gauge-25
(insulin syringe) strictly intradermal confirmed
by appearance of small papule at the site of injection with whitening of the skin over it. The reaction of the test was evaluated 48-72 hours after
injection.
All patients were advised to avoid any other
type of treatment for this condition or to be given
any medication that affects immunity either by
stimulation or by suppression. Patients with a
negative test (5 mm in diameter indurated
papule) were excluded from the study, but
patients with a positive test (5 mm and 15 mm
in diameter indurated plaque) were included in
this study.
Biopsy specimen (46 mm) from the wart lesion
was taken from each patient. Half of each specimen was fixed in 10% neutral buffered formalin,
paraffin embedded, and examined by routine
pathology. The other half was kept at -80C for
DNA extraction and HPV detection. High molecular weight DNA was extracted from samples
according to standard protocol (23). The purified
DNA was subjected to polymerase chain reaction
(PCR) amplification using general-purpose HPV
primers (GP5+ and GP6+) which amplify conserved
sequences in the HPV L1 region (150 bp) as previously described (24). To determine the HPV type,
aliquots (10 mL) of each PCR product were separated by electrophoresis on 1.5% agarose gel, transferred onto a nylon membrane (Hybond N+,
Amersham, London, England), and analyzed
using digoxigenin-labeled type-specific probes by
chemiluminescent detection. The HPV probe consisted of a cocktail of high-risk low-risk types.
The 40 pregnant women were divided into two
groups. Group A included 20 patients who were
treated with intradermal injection of (0.1 mL) PPD
at the middle third of ventral aspect of both
forearm and the injection was repeated every week
for 12 weeks. Group B included 20 patients and
were injected with 0.1 mL distilled water at similar
site as in Group A and repeated weekly for 4 weeks,
and then shifted to (0.1 mL) PPD given weekly for
12 weeks.

All patients were examined and evaluated for

response to treatment and for any local or systemic
side effect on every visit. Assessment of the cases
was done by comparing pre- and posttreatment
photographs by the authors. The response to treatment was evaluated according to the following criteria: (i) complete resolution (excellent response
100%); (ii) partial (more than 50% and 100%
reduction in size) response; (iii) minimal response
(less than 50% reduction in size); and (iv) no
response.

Results
Forty pregnant women were enrolled in this study.
The age ranged from 20 to 35 years; the mean age
was 28.3 years, and the duration of gestations was
2428 weeks (mean: 26 weeks). Patients were
divided into two groups and were treated according to the protocol mentioned above. HPV type-6
was the predominant genotype in our patients and
was detected in 67.5% of the patients, whereas
type-11 in 25% and type-16 in 7.5% as shown in
Tables 1 and 2.
Group A, which included 20 patients positive for
PPD skin test, started showing improvement after
the second injection by reduction in the size of
warts and disappearance of the smaller lesions.
After the fourth injection and during examination
of the patient before giving the fifth one; most
patients showed up to 75% reduction in size of
the warts. By the end of the eighth injection, 14
patients achieved more than 75% response. We
decided to give another four injections. After a total
of 12 injections, complete resolution occurred in 10
patients (50%) (FIG. 1), partial in seven patients
(35%), minimal in two patients (10%), and no
response in one (5%).
Group B included 20 patients who were treated
with placebo weekly for four weeks. No improvement was noticed and no adverse effects were
reported except slight pain and burning sensation
at the site of injection lasting for few minutes. The
patients were shifted to the same treatment protocol as in Group A, and after a total of 12 injections,
complete resolution occurred in nine patients
(45%), partial in eight patients (40%), and minimal
in one patient (5%). No response was recorded in
two patients (10%).
Total or partial response was observed in
patients with strong tuberculin test (1015 mm
indurated plaques), but the patients with tuberculin test (5<10 mm) had minimal or no response.
All patients with complete resolution were fol-

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Eassa et al.

Table 1. Clinical characteristics, HPV typing, PPD test result, and response rate in Group A
Patient
no.

Age
(Years)

Gestation
(weeks)

Duration of the
disease (weeks)

HPV
typing

PPD test site

indurations (mm)

Response
rate (%)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

20
31
35
32
25
28
34
20
29
21
33
25
34
35
27
26
27
28
24
30

22
21
25
25
23
28
27
25
28
20
20
25
27
21
28
23
22
24
20
21

5
5
4
4
5
5
8
9
8
7
6
8
6
8
8
8
10
7
10
9

11
6
6
6
11
6
6
16
6
6
6
6
6
6
11
11
11
6
6
6

14
10
11
5
14
15
12
15
6
13
5
11
10
11
13
12
14
15
13
12

100
70
80
40
100
100
100
100
No
100
30
85
60
75
100
90
100
100
100
95

Table 2. Clinical characteristics, HPV typing, PPD test result, and response rate in Group B
Patient
no.

Age
(Years)

Gestation
(weeks)

Duration of the
disease (weeks)

HPV
typing

PPD test site

indurations (mm)

Response
rate (%)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

22
33
32
30
20
26
30
28
26
35
30
23
35
28
24
25
35
26
28
23

27
22
28
20
24
25
28
26
22
22
35
22
21
23
25
35
20
26
23
35

8
6
8
8
6
9
4
5
7
9
4
10
7
5
6
4
10
8
9
10

6
6
11
6
6
6
6
16
6
11
6
6
6
11
6
6
11
6
11
16

12
15
5
10
14
14
13
13
10
13
5
11
10
13
14
5
13
12
10
14

90
100
no
80
100
100
95
100
75
100
30
85
70
100
100
no
100
85
75
100

lowed up for more than 6 months without any

clinical recurrence. Adverse effects were minimal
including local reaction in the form of pain at the
site of injection, erythema, and tenderness, but no
systemic side effects were recorded.

140

Discussion
A global search was done in medical literature but
no paper could be found using this unique modality (intradermal injection of PPD antigen in the

Anogenital warts in pregnant women

Before treatment

2 weeks after treatment

4 weeks after treatment

8 weeks after treatment

12 weeks after treatment

After 8 months follow-up

FIG. 1. The clinical response throughout the12-week duration and follow-up after the end of treatment.

forearms) for treatment of warts in general and

anogenital warts in particular. In the current series,
HPV-6 was the predominant genotype. Similar
results were reported in a previous study on 12
patients with condylomata acuminata. They found
that 7 of 12 (58%) patients were positive for HPV,
including five who were positive for HPV-6 (25). In
another study on HPV infection in adolescent
populations, it was stated also that low-risk HPV
types (HPV-6 or 11) were associated with the development of anogenital warts (26). In the present
study, the high-risk HPV-16 was detected in three
(7.5%) patients. In a study done by Daneshpouy
et al. on three patients with condylomata acuminata, one patient was positive for HPV-18 (27).
The present study is designed to investigate the
efficacy of the intradermal injection of tuberculin
antigen (PPD) in the forearms in the treatment of
anogenital warts in pregnant women instead of
intralesional as mentioned in all previous studies

using immunomodulating therapy for warts,

taking advantage of the vaccination schedule in
our country, which includes vaccination against
tuberculosis. This idea of treatment is attributed to
the observation of some authors of the clearance of
remote warts after intralesional immunotherapy of
warts with mumps, Candida, and trichophyton
skin test antigens (16). Also resolution of warts at
anatomically distant sites was observed in patients
treated with intralesional tuberculin (20), and with
intralesional injection of mumps or Candida skin
test antigens (28).
Also, we decided to give this modality of treatment to pregnant women infected with anogenital
warts because this group of patients is difficult to
treat and this type of treatment is a category C in
pregnancy. Animal reproduction studies have not
been conducted with PPD; however, the Advisory
Council for the Elimination of Tuberculosis states
that tuberculin skin testing is considered valid and

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Eassa et al.

safe throughout pregnancy. No teratogenic effects

of testing during pregnancy have been documented (29).
There are several treatment options for common
and genital warts. Most are ineffective, many are
painful, and some are dangerous (30). Manipulating the immune system to achieve a therapeutic or
protective response against diseases caused by
HPV is an active field of investigation. Interferon
alfa-2b is approved by the Food and Drug Administration (FDA) for the treatment of condylomata
acuminata, requiring twice weekly injection for 3
weeks for optimal results (16). Topical imiquimod
induces the release of several cytokines by immune
system cells, resulting in local antiviral, antitumor,
and immunoregulatory activity. It is also reported
to have a beneficial effect in the treatment
of nongenital warts and is FDA approved for the
treatment of anogenital warts (31). Dinitrochlorobenzene, squaric acid dibutyl ester, diphenylcyclopropenone, and Toxicodendron extract have all
been successfully used as a topical immunotherapy for warts (32).
Topical immunotherapy with tuberculin jelly for
common warts was tried previously with a cure
rate of 57%. The major disadvantage of topical
tuberculin jelly was the long duration of treatment
as the disappearance of warts occurred within 34
months of treatment (33). Topical BCG in the treatment of genital warts was reported as a good treatment modality with a high success rate (80%)
compared with the placebo solution, with insignificant side effects and no recurrence (34). Gupta
et al. reported that intralesional immunotherapy
of anogenital warts with Mycobacterium w (Mw)
vaccine cleared both injected as well as noninjected lesions and seems to be a promising new
approach (35).
The improvement in our study (complete clearance or reduction in wart size greater than 50%)
was higher (85%) when compared with traditional
modalities (varying between 30 and 70%)
(30,36,37). Using intralesional immunotherapy in a
previous study, 74% of subjects experienced
resolution of the treated warts (28). In another
single-blinded, randomized, and controlled trial
evaluating the effectiveness of intralesional immunotherapy with skin test antigens, the response rate
was 60% (16). In children, in all of whom two
treatment modalities had failed, 47% of subjects
responded to intralesional mumps or Candida
antigens, and 34% cleared untreated distant warts
(38). We noticed that the intensity of the therapeutic response was related to the extent of tuberculin
reactivity where total or partial response was

142

observed in patients with strong tuberculin test

(1015 mm indurated plaques) suggesting that
these patients are better candidates.
The exact mechanism of wart clearance in our
approach is still unclear and may reside in the
acquisition of HPV-directed immunologic reaction. Injection of PPD may generate strong cytokine and T-cell responses. Minimal or no response in
our cases may be due to a lack of immunity. First,
patients with warts may lack a memory T-cell
population able to target HPV. Second, patients
may possess HPV-specific T cells, but these lymphocytes fail to expand clonally with appropriate
stimulation. Third, patients possess sufficient circulating HPV-specific T cells, but these lymphocytes are unable to traffic to the sites of HPV
infection. Fourth, HPV-specific lymphocytes are
weak effectors in terms of elaboration of necessary
cytokines and/or recruitment of additional effectors cells. Finally, HPV may elude host recognition.
Side effects noted in our patients were minimal.
They included local reaction in the form of pain at
the site of injection, erythema, and tenderness, but
none of the patients had any systemic side effects.
Immediate hypersensitivity reaction after use of
tuberculin skin test was reported and the incidence
was very low and represent one per million doses
(39). Also, immediate hypersensitivity reaction
was reported after tuberculin skin-prick testing;
however, this occurred in tuberculous patients and
was suggested to occur in patients with more
severe tuberculosis and are more likely to produce
IgE antibodies to tuberculosis (40).

Conclusion
We believe that intradermal injection of PPD in the
forearms instead of intralesional injection in the
treatment of anogenital warts in pregnant women
is an acceptable and safe modality and is a promising therapy for warts in general especially in
countries where vaccination against tuberculosis is
performed routinely and mandatorily.

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