DISCUSSION
Standard therapy methods for periungual warts include cryotherapy, laser, surgery, interferon, or local drug therapy, which causes severe pain, scar ulcers, and irreversible destruction of the nail matrix, leading to nail deformation4, 5. SXRT is effective at treating periungual warts, and is associated with mild side effects, such as pruritus, hyperpigmentation, erythema, pain and swelling3. Therefore, we made the decision to use SXRT to treat our patient.
Radiotherapy treatment for warts might range from 1200r to 3000r (1r corresponds to, roughly, 0.876 cGy) total dose, which may be administered at once, or divided into four fractions3, 6. Our previous study showed that SXRT combined with Tretinoin is effective for periungual warts3. Given that side effects, such as radiation ulcer, are more likely to occur when higher dosage is used, we administered a 5 Gy fraction per week, up to a total dose of 20 Gy. The warts began to shed after three fractions and were completely removed 26 days after treatment completion (Figures 2 and 3). The patient showed mild pruritus. No recurrence was observed after one year follow-up.
Warts are caused by human papilloma viruses (HPVs). Cellular replication induced by viral DNA amplification leads to the formation of hyper keratinized papules that form the wart.7 Therefore, tissue defects caused by warts are highly unlikely to occur. In the reported case, a lesion of roughly 4mm was observed, which is a rare occurrence. Such lesion might result from the lack of treatment for a prolonged period of time. Furthermore, the exposure to alkaline intestinal fluid might have enhanced the damages to the soft tissue during this period.
To the best of our knowledge, this is the first clinical report concerning a fingertip defect caused by warts, which was successfully treated, imposing only mild side effects. SXRT combined with Tretinoin is recommended for refractory warts, when acute pain is associated with conventional treatments. Nevertheless, we acknowledge that our report might be biased, as the clinical presentation might have been somehow related to the contact of the affected areas with alkaline intestinal fluid.