Query: management of plane warts

title: Role of autoinoculation in the management of cutaneous warts: a comparison study with 100% tricholoroacetic acid application
abstract: Persistent and recurrent warts pose a challenge to physicians despite the availability of multiple treatment options. Autoinoculation exposes HPV antigens to the dermis and vasculature thereby activating a delayed hypersensitivity response, facilitating clearance of both local and distant warts. The aim of this study was to assess the efficacy of autoinoculation and compare it with chemical cautery using 100% trichloroacetic acid.  A non blinded interventional study was conducted at Goa Medical College, a tertiary care centre. Non immunocompromised patients with 5 or more non genital warts were included. Group 1: a wart was removed by punch biopsy, minced and implanted in the dermis. The procedure was repeated at 4 and 8 weeks. Group 2: weekly trichloroacetic acid (100% application. Response was assessed at 4, 8 and 12 weeks in terms of percentage reduction in the number of warts. Statistical correlation with respect to age, sex, duration, number and type of warts was assessed using Welch ANOVA.  In group 1, 63 patients and in group 2, 54 patients completed the study. Post autoinoculation, complete clearance was seen in 46.0% and 3.2% had partial clearance. With TCA application, 33.3% patients had complete and 13% had partial clearance. Response differed with the type of warts. Palmoplantar, periungual warts and verruca vulgaris showed better response to autoinoculation. Filiform and plane warts showed better response to TCA.  Autoinoculation is an efficacious treatment modality which can be performed routinely especially for palmoplantar and periungual warts which are particularly challenging to treat with other modalities.

title: A recalcitrant case of facial verruca plana successfully treated with topical calcipotriol alone
abstract: Dear Editor, Verruca plana is a benign epidermal proliferative cutaneous condition mainly caused by human papillomavirus (HPV) types 3 and 10. HPV 27, 28, 38, 41, and 49 may also rarely cause verruca plana. Face located plane warts usually cause important aesthetic concerns in patients and lead them to seek treatment. The management of verruca plana poses a therapeutic challenge for clinicians, as there is no single method that has been proven to be efficient for completely treating the disease. An 18 year old woman presented with an 8 months history of asymptomatic numerous small brown lesions on the chin. She was otherwise healthy and her past medical history was unremarkable. The lesions did not respond to previously treatments including oral zinc, topical tretinoin, and topical adapalene. Dermatological examination revealed numerous, plane, yellowish to brown irregular papular lesions ranging in size from 0.1 to 0.4 cm distributed on the left side of the chin (Figure 1A) Dermatoscopic examination showed numerous tiny dotted (pinpoint) vessels on a light brown background  No other lesions were observed elsewhere. Based on the clinical and dermatoscopic examinations, a diagnosis of verruca plana was made. Daily simple application of topical calcipotriol ointment allowed a complete resolution after 8 weeks without adverse reactions  No recurrence was observed during 6 months of follow up. Common therapeutic options for verruca plana include cryotherapy, electrocoagulation, topical salicylic acid, topical retinoids, topical imiquimod, topical immunotherapy, laser or conventional/daylight photodynamic therapy. Most of these options may cause dyspigmentation, pain, and even scarring. Furthermore, no treatment has been uniformly effective and, treatment resistance is common. There are very few studies on the effectiveness of topical vitamin D derivatives in the treatment of viral warts. Imagawa et al reported a series of 17 cases of hand or foot located warts successfully treated with topical maxacalcitol. Egawa et al managed three immunocompromised cases with recalcitrant warts, using topical maxacalcitol with a half day occlusive dressing technique. Labandeira et al reported a case of giant wart successfully treated with topical calcipotriol. Rind et al reported the successful use of topical calcipotriol in a case of anogenital wart in an infant. Recently, it has been shown that intralesional vitamin D3 injection may be a simple, safe and cost effective treatment modality with minimal side effects. In a single blinded placebo controlled study investigating effectivity of intralesional vitamin D3 injection in the treatment of common warts, complete clearance of the target injected warts occurred in 40% of patients in cases group, while it occurred only in 5% of patients in control groups. Topical vitamin D3 derivatives are considered as first line therapy in the treatment of chronic plaque psoriasis. Biologic effects of

title: Aeromedical Evacuations Within the French Armed Forces: Analysis of 2,129 Patients.
abstract: The doctrine of medical support during French military operations is based on a triptych: forward medical stabilization, forward damage control surgery, and early strategic aeromedical evacuation (Strategic AE) The aim of this study was to describe the last piece, the evacuation process of the French Strategic AE.  We conducted a retrospective cohort analysis using patient records from 2015 to 2017. All French service members requiring an air evacuation from a foreign country to a homeland medical facility were included. Data collected included age, medical diagnosis, priority categorization, boarding location, distance from Paris, type of plane and flight, medical team composition, timeline, and dispatch at arrival.  We analyzed 2,129 patients evacuated from 71 countries, most from Africa (1,256) the Middle East (382) and South America (175) Most patients (1,958) were not severely injured, although some considered priority (103) or urgent (68) Diagnoses included disease (48.6% nonbattle injuries (43% battle stress (5.3% and battle injuries (3% 246 Strategic AE used medical teams in flight, 136 of them in a dedicated Falcon aircraft. The main etiologies for those evacuations were battle injuries (24% cardiovascular (15.4% infections (8% and neurologic (7.3% The median time of management for urgent patients was about 16 hours but longer for priority patients (26 hours) Once in France, 1,146 patients were admitted to a surgery department and 96 to an intensive care unit.  This is the first study to analyze the French Strategic AE system, which is doctrinally unique when compared to its North Atlantic Treaty Organization allies. North Atlantic Treaty Organization allies favor care in the theatre in place of the French early Strategic AE. However, in the event of a high intensity conflict, a combination of these two doctrines could be useful.

title: Intralesional 2% zinc sulfate solution for plane warts: A case report
abstract: Warts are benign epithelial proliferations of the skin and mucous membranes caused by human papilloma viruses (HPVs) Plane warts are mainly caused by HPV 3 and HPV 10. There is no absolute effective single treatment, and multiple treatment modalities may be combined. One must take into consideration the probability of spontaneous regression, and so the therapeutic approach should not be too aggressive. We report a case of 11 years immunocompetent child presenting with recalcitrant multiple plane warts who was successfully treated with intralesional 2% zinc sulfate solution injection in one lesion after a failure of many other treatment modalities. Our case may represent a starting point for further studies to evaluate the best dose used for management and to avoid any side effects. Intralesional zinc sulfate injection could be a promising treatment option for plane warts.

title: Adapalene in the management of warts in pediatric population
abstract: Warts are a common skin infection caused by human papillomavirus. Although any age group can be affected, plane warts and verruca vulgaris occur mostly in children and young adults. A large number of treatment modalities are available which include electrodessication, cryotherapy, topical imiquimod, tretinoin, and phenol application but most of these are not well tolerated by children owing to irritation or painful nature. Adapalene is a retinoid derivative with lesser irritant potential than tretinoin which has been tried in the management of warts.  We carried out this study to assess the safety and efficacy of adapalene in the management of warts in the pediatric population.  It was a prospective study carried out over a period of one and a 1/2 year where 50 patients in the age group of 3 18 years with different types of warts were included. After taking an informed consent from the attendants/parents of the patients, they were treated with topical bedtime application of adapalene 0.1% gel and were followed up every month for 3 months to assess the response. Exclusion criteria were extensive lesions, lesions on genitalia, eyelid involvement, secondary infection, or patients on any immunosuppressive therapies.  Out of 50 patients, 44 patients (M:F 25:19) completed the study. The age of patients varied from 3 to 18 years with a mean age of 11.3 4.6 years. The most common type of warts in our study were plane warts in 61.36% (n 27) followed by verruca vulgaris in 27.27% (n 12) and plantar warts in 11.36% (n 5) After 3 months of therapy, complete clearance of lesions was observed in 59.09% (n 26) patients, partial clearance in 25% (n 11) whereas no response was seen in 15.9% (n 7) patients. Adverse effects in the form of erythema, irritation, and dryness were observed in six patients (13.64%  Adapalene can be used a safe and effective treatment modality in the management of plane and common warts especially in the pediatric age group.

title: Network Innovation using OpenFlow: A Survey
abstract: OpenFlow is currently the most commonly deployed Software Defined Networking (SDN) technology. SDN consists of decoupling the control and data planes of a network. A softwarebased controller is responsible for managing the forwarding information of one or more switches; the hardware only handles the forwarding of traffic according to the rules set by the controller. OpenFlow is an SDN technology proposed to standardize the way that a controller communicates with network devices in an SDN architecture. It was proposed to enable researchers to test new ideas in a production environment. OpenFlow provides a specification to migrate the control logic from a switch into the controller. It also defines a protocol for the communication between the controller and the switches. As discussed in this survey paper, OpenFlow based architectures have specific capabilities that can be exploited by researchers to experiment with new ideas and test novel applications. These capabilities include software based traffic analysis, centralized control, dynamic updating of forwarding rules and flow abstraction. OpenFlow based applications have been proposed to ease the configuration of a network, to simplify network management and to add security features, to virtualize networks and data centers and to deploy mobile systems. These applications run on top of networking operating systems such as Nox, Beacon, Maestro, Floodlight, Trema or Node.Flow. Larger scale OpenFlow infrastructures have been deployed to allow the research community to run experiments and test their applications in more realistic scenarios. Also, studies have measured the performance of OpenFlow networks through modelling and experimentation. We describe the challenges facing the large scale deployment of OpenFlow based networks and we discuss future research directions of this technology.

title: Guidelines for the Management of Cutaneous Warts
abstract: Sponsoring Organization: British Association of Dermatologists Target Population: Primary care providers, dermatologists, pediatricians Background and Objective Warts, or verrucae, are a common skin condition caused by human papilloma virus (HPV) infection. More than 150 genotypes have been identified. HPV types 1, 2, 4, 27, and 57 are the most frequent strains in common warts, and HPV 3 and 10 cause plane warts (verruca plana) Compilers of these guidelines reviewed research on the management of warts published between January 1999 and March 2014 in the English language literature.

title: A Rapidly Regressed Giant Plantar Wart Following Biopsy
abstract: I read the case reported by Jin et al.1, with great interest, because I recently experienced a rapidly regressed giant plantar wart, which followed a biopsy. A 23 year old male came to our department for a large hyperkeratotic plaque on his left plantar surface. It appeared more than 18 months prior to the presentation as multiple small pimplelike lesions, which had been slowly growing and coalescing  His medical and family histories were noncontributory. A punch biopsy was taken, and the histopathological findings were acanthotic epidermis with hyperkeratosis, papillomatosis, parakeratosis, and koilocytes. The diagnosis of wart was made. The lesion rapidly regressed within 2 weeks of the biopsy, and it had completely disappeared when the patient presented for the follow up after one month  Warts, or verrucae, are benign proliferations of the skin and mucosa that are caused by an infection with human papillomavirus (HPV) These viruses do not produce acute signs or symptoms, but induce a slow, focal expansion of the epithelial cells. Lesions may remain subclinical for long periods, or may grow into large fulminating masses that persist for months or even years2. The management of warts depends on the degree of physical and emotional discomfort, the extent and duration of the lesions, the patient's immunologic status, and the patient's desire for therapy2. Irrespective of the treatment modality, a host immune response is the key to achieving a complete clearance of the wart. Immunocompromised individuals may never achieve wart clearance. The role of immunity in HPV infection is not completely understood. The decrease in the frequency of warts with age implies that the resistance to infection develops over time, and much of this resistance may be immunologic3. There are instances in which the treatment of one or more warts leads to a complete clearance in immuno competent individuals. Specific cell mediated immunity against viral infected keratinocytes took place in plane warts, under spontaneous regression4. CD4 positive lymphocyte predominance in the regression of genital warts had been demonstrated5. Tissue biopsy might have exposed viral antigens to the host immune system, which subsequently triggered HPV specific immunity. It is possible that the biopsy may have then exposed viral antigens and induced a delayed hypersensitivity reaction, which led to the rapid regression of the lesion. We suggest that a similar mechanism has been in the works in our case. There have been many cases of warts with spontaneous regression, but there has been no report of large plantar wart regression, following a small biopsy. In conclusion, wart regression can be achieved if the HPV specific immunity can be stimulated. Therefore, inducing and boosting such a response is critical for the treatment of warts. I report here on a case of a rapidly regressed large plantar wart, following a biopsy without any additional treatment. Fig. 1 Before biopsy; large hyperkeratotic plaque on his left plantar surface (inset: close up view) Fig. 2 Six weeks later following biopsy, the wart had completely disappeared (inset: close up view)

title: First results about on ground calibration of the Silicon Tracker for the AGILE satellite
abstract: The AGILE scientific instrument has been calibrated with a tagged g ray beam at the Beam Test Facility (BTF) of the INFN Laboratori Nazionali di Frascati (LNF) The goal of the calibration was the measure of the Point Spread Function (PSF) as a function of the photon energy and incident angle and the validation of the Monte Carlo (MC) simulation of the silicon tracker operation. The calibration setup is described and some preliminary results are presented.  The AGILE mission AGILE (Astro rivelatore Gamma a Immagini LEggero) is a Small Scientific Mission of the Italian Space Agency (ASI) launched ll rights reserved. attaneo) on April 2007 and dedicated to high energy astrophysics  The AGILE satellite is designed to detect and image photons in the 18 60 keV, 30 MeV 50 GeV and 350 keV 100 MeV energy bands with excellent spatial resolution, timing capability, and large field of view. AGILE is the most compact 0:25 m3) light (120 kg for the instrument, 350 kg for the whole satellite) and low power 60 W) scientific instrument ever developed for high energy astrophysics.  A schematic view of the AGILE scientific instrument. P.W. Cattaneo et al. Nuclear Instruments and Methods in Physics Research A 630 (2011) 251 257 252 The AGILE scientific payload (shown in Fig. 1) consists of three detectors with independent detection capability. The Gamma Ray Imaging Detector (GRID) consists of a Si W converter tracker [2] sensitive in the g ray energy range 30 MeV 50 GeV, a shallow (1.5 X0 on axis) CsI Calorimeter  and a segmented AntiCoincidence system based on plastic scintillators  In addition to the GRID, a coded mask hard X ray imaging system (SuperAGILE) made of a Si detector plane and a W mask, ensures coverage in the range 18 60 keV  The AGILE main feature is the combination of two co aligned imaging detectors (SuperAGILE and GRID) sensitive in the hard X ray and in the g ray ranges with large field of view 1:0 sr and 2:5 sr, respectively) Moreover the CsI MiniCalorimeter (MCAL) can operate in stand alone 'burst mode' in the 350 keV 100 MeV range to detect GRB. On ground and subsequently on flight calibrations of a detector are essential to the interpretation of its results. The purpose of the calibration of a scientific instrument is to reproduce, under controlled condition, the detector response in operation. This paper describes the on ground calibration of the silicon tracker and some results on the instrument performances derived by it. 2. The silicon tracker The core of the GRID is the Silicon Tracker (ST) that converts the g rays and measures the trajectories of the resulting e/e pairs [2 6] The ST consists of 12 trays with distance between middle planes equal to 1.9 cm optimized by simulation. The first 10 trays consist of a W converter layer 245mm thick followed by pairs of single sided Si microstrip planes with strips orthogonal to each other to provide three dimensional points (corresponding to a total thickness 0.01(Si)+0.07(W) X0) The last two trays have no W converter layers since the GRID trigger logic requires at least three contiguous Si planes. The detector unit is a 9.5 9.5 cm tile, 410mm thick with strip pitch 121mm. Four tiles are bonded together to form a 'ladder' Every ST plane consists of four ladders. Only every second strip is readout to limit the power consumption. The non readout strips contribute to the resolution through the principle of capacitive charge division. Each ladder is read out by three TAA1 ASICs, each operating 128 channels at low noise, low power configuration (o400mW/ channel) self triggering ability and analog readout. The ST position resolution is below 40mm for a large range of particle incidence angles [6] 2.1. The GRID simulation The GRID as mounted on the spacecraft and as installed in the test beam is simulated using the GEANT 3.21 package [7] This package provides for a detailed simulation of the materials and describes with high precision the passage of particles through matter including the production of secondary particles. The simulation output is formatted to be readable by the reconstruction programs used for the analysis of in flight data. 2.2. Direction and energy reconstruction The g ray direction reconstruction is obtained from the identification and the analysis of the e/e tracks stemming from the conversion vertex. Each microstrip silicon plane measures separately the X and Y hit coordinates. The first step of the event analysis requires to find two tracks among the possible associations of the hits detected by the ST layers. The second step consists in fitting the track trajectories through the hits accounting for the presence of energy loss and multiple scattering. These steps are performed separately for the X and Y coordinates producing four tracks, two for each projection. The three dimensional direction is obtained requiring a correct association of the two projections of each track. The track parameters are fitted by a Kalman filter smooth algorithm  A special implementation of the filter [9] exploits the measurement of the angular scattering of the e7 due to the interactions with the material to estimate the track energies. Combining the track energies the g ray energy is estimated. 3. The c ray calibrations 3.1. Calibration goals The goal of the calibration is to estimate the instrument response function by exposing it to a g ray beam with energy and direction known to an accuracy better than the resolving power of the instrument. The required accuracy of ST is driven by its use during the AGILE mission: the systematic errors introduced by the calibration should be smaller than the statistic errors expected from a bright celestial source. The detector properties to be evaluated by the calibration are: the detection efficiency, the angular resolution, the energy resolution. In this paper we concentrate on evaluating the Point Spread Function (PSF) as a function of the g ray energy and incident angle. The calibration is also intended to validate the MC simulation program. This simulation will be required to complement the calibration data in the untested parts of parameter space. In particular the information above the maximum energy available at BTF can be obtained only through the simulation. impact of reduced momentum electron BTF e beam Si target tagging detector bending magnet Bremsstrahlung photon electrons interacting non Fig. 2. A schematic of the g ray line: the target, the bending magnet and the PTS. P.W. Cattaneo et al. Nuclear Instruments and Methods in Physics Research A 630 (2011) 251 257 253 The calibration is designed to cover a wide range of the geometries and conditions realized in space. The ST was calibrated at the INFN LNF in the period 2 20 November 2005, thanks to the collaboration between the AGILE Team and INFN LNF. 3.2. Calibration strategy To meet the calibration accuracy requirements, we have determined the number of g rays required for the calibration of AGILE, taking into account the photon fluence of a characteristic g rays reference source as Vela. With a cover up efficiency of 50% and an effective area of 500 cm2, the number of counts estimated is about 10 for E 4100 MeV, after two months of observation. The requirement on the number of calibration photons detected by the GRID is 4 10 for Eg430 MeV, 4 10 for Eg4100 MeV. 3.3. Calibration set up 3.3.1. The beam test facility For the ST calibration we used the Beam Test Facility (BTF) in the Frascati DAFNE collider complex, which includes a LINAC at high e /e currents, an accumulator of e /e and two accumulation rings at 510 MeV. The e/e beam from the LINAC is led into the accumulation ring to be subsequently injected in the principal ring. When the beam is not transferred in the accumulator, it can be transported from the LINAC in the test beam area through a dedicated transfer line: the BTF line. The BTF provides a collimated beam of e /e in the energy range 20 800 MeV with a pulse rate of 50 Hz. The pulse duration can vary from 1 to 10 ns and the number of particles for bunch can range from 1 to 10. We operated with energy beam of 463 MeV and a pulse duration of 2 ns. 3.3.2. Target g rays were produced by Bremsstrahlung in a thin silicon target; subsequently a magnet bent away the e while the g rays could impinge on the GRID. The target is constituted by two pairs of silicon microstrip single sided detectors of 8.75 8.75 cm and 0.41 mm thick, including 384 strips with 228mm pitch. The target measures the passage of the e and cause the emission of Bremsstrahlung g ray. 3.3.3. Tagging system Our Team developed and installed in the BTF area a Photon Tagging System (PTS) for the detection of the particles interacting with the target. The e are tagged using microstrip Si detectors located on the internal walls of the bending dipole magnet  Depending on the energy loss in the target, the e impinge on different strips. The correlation of the measurements of the e by the target Si planes and by the PTS tags the photon; the position on the PTS measures the photon energy. The PTS operates in self trigger mode, i.e. it is readout independently from the GRID. This point has a great relevance for the following analysis. During the 18 days of calibration, about 2,10 tagged g rays were produced, of which 40% interacted with the GRID. 3.4. Instrument Ground Support Equipment (GSE) We developed and installed specific equipment required to coordinate and, whenever possible, automate the instrument management and the data gathering and analysis as required by the calibration procedures. The Mechanical Ground Support Equipment (MGSE)  hosts the payload and allows the precise motorized translations and manual rotations of the detector volume in front of the beam. In near real time, the Science Console (SC)  archives all the instrument data and performs the quick look to check

title: A rapidly regressing wart following biopsy.
abstract: Warts are also known as verrucae, and these are benign proliferative lesions of the epidermis that are caused by human papilloma virus (HPV) infections1. There are many treatment modalities for warts, which implies that no single modality is uniformly effective. The choice of treatment depends on the location, size, number and type of wart, as well as on the patient's age and cooperation. Irrespective of the treatment modality, a host immune response is the key to achieving complete clearance. As such, immune compromised individuals may never achieve wart clearance2. In other words, wart eradication can be achieved if the HPV specific immunity can be stimulated. We report here on a case of a rapidly regressed wart following biopsy without any additional treatment. A 50 year old woman presented to our clinic with a complaint of a papule located on her right cheek. The lesion was flesh to light brown in color and about 1 cm in diameter. It appeared more than 6 months prior to her presentation as a small pimple like lesion, which had been slowly growing  without any associated pain or itching sensation. Its clinical appearance resembled seborrheic keratosis or other benign papules. A 2 mm punch biopsy was taken at the center of the lesion without suturing. The histopathological findings were hyperkeratosis and papillomatosis, with elongated rete ridges and koilocytes. Immunohistochemical staining for CD3, CD4, CD8, CD20, CD56 and cytotoxic T cell intracellular antigen 1 (TIA 1) was performed. The dermal lymphocytes were predominantly CD3 and CD4 positive T cells. The intraepidermal exocytotic cells were mildly positive for CD8 and TIA 1. The staining for CD20 and CD56 was negative. A diagnosis of wart was made. The lesion rapidly regressed within one week of the biopsy  and it had completely disappeared when the patient presented for follow up after one month.  (A) Before biopsy; a flesh to light brown colored papule that was about 1 cm in diameter on the patient's right cheek (inset: close up view) (B) One week later following biopsy, the wart had nearly disappeared, leaving only slight erythema (inset: close up The role of immunity in HPV infection is not completely understood3,4. The decreasing trend of the prevalence of wart with age suggests that resistance to HPV infection develops over time, and much of this phenomenon may be immunological2. Individuals with impaired cell mediated immunity are particularly susceptible to HPV infections, and these individuals' warts are recalcitrant to treatment5. There are instances in which treatment of one or more warts leads to complete clearance in immune competent individuals. Children with warts may not require treatment since spontaneous regression is common as their immunity develop1. One report has suggested that specific cell mediated immunity against viral infected keratinocytes took place in the process of spontaneous plane wart regression6. Another study demonstrated CD4 positive lymphocytes predominated in regressing genital wart7. Our case could also be interpreted in a similar context. Tissue biopsy might have exposed viral antigens to the host immune system, which subsequently triggered HPV specific immunity. The immunohistochemical staining for TIA 1 was positive in the epidermis, which also means there was an activated cytotoxic T cell infiltration. It is also possible that this patient had already developed HPV specific cell mediated immunity prior to the biopsy, and without the intervention the verruca could have remained as a solitary papule. The biopsy may have then exposed viral antigens and induced a delayed hypersensitivity reaction, which led to rapid regression of the lesion. A cutaneous wart management guideline has proposed curettage and light cautery for facial warts2. This was the similar course of action we took for our patient. There have been many cases of warts with spontaneous regression, but there has been no report of wart regression following a small biopsy. In conclusion, wart regression requires an immune reaction to viral antigens. Therefore, inducing and mounting such a response are critical for the management of warts.