warts are mucocutaneous growths ( exo- or endophytic ) caused by human papilloma virus ( hpv ) .
common therapeutic modalities ablate the growth without the generation of specific immunity against the wart .
this often leads to irritation , pain , recurrence , scars , and prolonged morbidity ( especially in palmoplantar warts ) .
the stimulation of the immune system by exposing the virus to immune mediators forms an ideal modality of treatment due to spontaneous regression of the wart with long - lasting immunity .
however , serotypes other than those in vaccine ( hpv 6 , 11 , 16 and 18 ) also cause warts and hence this modality may not be effective always .
autoimplantation is a novel , one - time procedure which treats the warts by stimulating an immune response against hpv .
as it is an autograft technique , it is more likely that immunity against the same serotype is elicited ( in contrast to the hpv vaccine where immunity is developed only against hpv 6 , 11 , 16 and 18 ) .
this is done by extracting a subcutis deep wart tissue and implanting it into the uninvolved skin .
the autowart injection involves multiple sessions of injection of wart suspension . in this study , we extracted the donor tissue by paring the wart instead of removing a part of the wart under local anaesthesia .
this was adopted to reduce the discomfort , risk of infection and hasten the time taken for performing the procedure .
this study was conducted in the dermatology outpatient department of a tertiary care rural hospital .
thirty - five patients with multiple ( more than five warts ) , recurrent verruca vulgaris ( warts which have recurred after any modality of treatment ) and palmoplantar warts were enrolled in the study after an informed consent and ethics committee approval .
pregnant , lactating mothers , immunocompromised individuals and those with verruca plana were excluded from study .
donor tissue for autograft was harvested by paring a verrucous lesion or a palmoplantar wart .
the lesion to be pared was cleansed with spirit - povidone iodine  spirit to achieve asepsis .
11 autografting was done either on the non - dominant flexural forearm or the upper anteromedial thigh .
the site for engraftment was cleansed with spirit - povidone iodine - spirit and infiltrated with about 0.5 ml of lignocaine with adrenaline ( 1:200,000 )
. a subcutis deep stab incision of about 35 mm was made using the same surgical blade of no .
the pared tissue was introduced deep into the subcutis using adson 's forceps or an insulin syringe used for infiltration [ figure 3 ] .
the margins of the wound were approximated by pressure and a micropore plaster was applied on it .
amoxycillin 500 mg + clavulanic acid 125 mg , bid ) and if required , analgesics orally .
11 used to pare the wart introducing the pared tissue deep into the subcutis using adson 's forceps patients were assessed monthly , and resolution of all warts within 3 months was taken as complete clearance .
out of 35 patients , 8 were lost to follow - up and 27 patients were available for evaluation .
the commonest age group affected was that of 2040 years ( 13 patients , 48.1% ) .
a total of 20 ( 74.1% ) patients showed the resolution of the warts within 3 months [ figures 4 and 5 ] , 5 ( 18.5% ) patients had no improvement at all [ table 1 ] and in 1 patient ( 3.7% ; male , 17 years of age ) with multiple warts , except one lesion , others had resolved completely .
one ( 3.7% ) male patient aged 16 years had relapse , with a new lesion occurring at a different site .
he underwent autoimplantation of the new wart , which healed over a period of 1 month .
recurrent wart on the lateral aspect of the right second toe complete resolution of the wart after autoimplantation summary of characteristics of non - responding patients three ( 11.1% ) patients developed erythematous tender nodules at the site of engraftment , with a purulent discharge from them in one patient .
warts are one of the common viral infections of the mucocutaneous surfaces and often induce papillomatous growth .
the commonest modality of treatment for warts is ablation using electrocautery , radiofrequency , laser or cryogens .
these treatments destroy the wart - containing tissue but may not stimulate the immune system against the pathogen .
hence , for the effective treatment of warts , there should be immune stimulation which can lead to long - term immunity against hpv .
specific immune stimulation against hpv has been tried by autoimplantation of the wart tissue into the uninvolved skin , injecting the suspension of the crushed wart into the muscle or skin [ table 2 ] and by quadrivalent hpv vaccines .
patients with regression of warts either spontaneously or following successful therapy or injection of antigens showed the development of cell - mediated immunity and appearance of virus - specific igm and igg antibodies .
comparison of the present study with previous studies in their study on the autoimplantation technique , shivakumar et al . extracted a subcutis deep part of the wart using a 18 g needle and implanted it into the skin elsewhere .
this resulted in two wounds . also , hpv is an epidermal infection and there is no added advantage with the extracting donor tissue containing dermis and subcutis .
hence , in this study , we harvested the donor by paring the wart to get the stratum corneum tissue containing virus . by this method , we avoided wound at the donor site and also circumvented the issue of taking the unwanted deeper tissues for engraftment .
in contrast to the autowart injection therapy , this is a single sitting procedure and avoids the risk of injection abscess .
most of our patients were males and belonged to the 20- to 40-year age group in parlance with other studies .
a complete clearance of warts was observed in 74.1% of patients [ table 2 ] , greater than that observed by usman et al .
we had one patient with multiple warts in whom one of the warts persisted at the end of 3 months .
non - responders were minimal in the study , using autowart injection , by srivastava et al .
one of our patients had clearance of warts after autoimplantation but developed a new lesion at a new site .
this probably could be due to infection by a different serotype of hpv . as we were unable to isolate the species of hpv ,
this further supports the hypothesis . in one patient , warts healed with transient hypopigmentation . of the 27 patients , only 2 had anogenital warts in addition to verruca vulgaris and these also cleared completely with the autoimplantation of warts .
hence , the final outcome was much better in our study ( 74.1% ) when compared with other autoimplantation as well as autowart injection techniques ( 4473.3% ) .
reaction at the site of engraftment in the form of erythematous tender nodules was observed in three patients , with a purulent discharge in one from the nodules .
shivakumar et al . also noticed reactions at the injection site in some patients but have not disclosed the exact number .
other researchers of the autoimplantation or autowart injection technique have not commented on any such reactions .
this could be due to intense inflammation caused by implanted squames which act as a foreign body in the dermis and subcutis analogous to an inflammatory reaction which occurs in the case of a ruptured follicle .
a quadrivalent hpv vaccine has shown promising results in the treatment of warts . however , the presence of only anecdotal reports , partial clearance in one of the two studies and a limited access in resource - restricted countries are the drawbacks of this vaccine
. limitations of our study include a small sample size , lack of controls to assess spontaneous resolution of warts and lack of serotyping of persistent warts or checking for serospecific hpv antibodies .
we also need to study the cause for the partial clearance or occurrence of new warts in spite of the clearance of all previous warts .
the modified technique of autoimplantation using the pared stratum corneum tissue of the wart instead of the subcutis deep wart tissue for autografting is a safe , efficacious , less traumatic and rapid procedure for the treatment of multiple , recurrent and palmoplantar warts .
 background : ideal treatment for warts should be effective , safe , have less morbidity and provide long - lasting immunity against human papilloma virus . this can optimally achieved by the stimulation of the immune system against the virus . 
 the autoimplantation of warts , autowart injection and quadrivalent vaccines have been used for this purpose . 
 autoimplanatation is a simple technique where the subcutis deep wart tissue is harvested as a donor and implanted into the uninvolved skin . 
 however , this led to two wounds , at donor and recipient sites.aim:the aim was to evaluate the safety and efficacy of a novel modification of autoimplantation therapy in the treatment of multiple , recurrent and palmoplantar warts.subjects and methods : thirty - three patients with multiple , recurrent and palmoplantar warts were enrolled . instead of taking a bit of the wart tissue , 
 the donor tissue was harvested by paring the wart . 
 the pared tissue was implanted deep into the subcutis by stab incision done using the same surgical blade no . 
 11 . 
 the resolution of all warts within 3 months after the procedure was considered successful . 
 patients with complete clearance were followed up for 1 month for any recurrence.results:out of 35 patients , 27 patients were available for follow - up . 
 a total of 20 ( 74.1% ) patients showed a complete clearance of warts within 3 months . 
 partial clearance was seen in 1 patient . 
 erythematous nodules developed at the site of implantation in 3 ( 11.1% ) patients . 
 there was relapse in one patient.conclusion:a modified technique of autoimplantation of warts employing the pared stratum corneum tissue from the wart is a simple , effective , less traumatic and rapid procedure in the treatment of multiple , recurrent and palmoplantar warts . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION
CONCLUSION