Recalcitrant cutaneous warts treated with recombinant quadrivalent human papillomavirus vaccine (types 6, 11, 16, and 18) in a developmentally delayed, 31-year-old white man.

A 31-year-old white man with developmental delay and a history of epilepsy was seen in February 2008 with multiple warts on his hands that had been present for several years. He had previously been treated with podophyllin, 2 different concentrations of salicylic acid (25% and 40%), and oral cimetidine, and his regular medications included lamotrigine, valproate, topiramate, and levetiracetam. He denied other risk factors for human immunodeficiency virus (HIV) or AIDS and lived at home with his parents. He also denied a history of other autoimmune conditions and allergies and had no relevant family history of other illnesses or dermatologic conditions. On examination, we found that he had multiple hyperkeratotic warty lesions on the dorsal and palmar aspects of his hands bilaterally (Figure 1). In addition, he had multiple warts on his chin, both knees, and right third metatarsophalangeal joint. In total, he had about 30 warts, the largest of which was on the right thumb. Several additional treatments were tried, including cryotherapy and 6 weeks of nightly application of imiquimod cream. We considered acitretin therapy, but this was not initiated owing to his neurologists’ concerns about potential interactions with his antiepileptic medications. Owing to the persistence and extensive nature of the warts, we performed a complete blood cell count; tests for electrolyte, urea, creatinine, and fasting glucose levels; liver function tests; thyroid function tests; and an HIV screen, the results of which were all normal. No human papillomavirus (HPV) typing was performed. A genetic underlying immune deficiency was thought to be very unlikely, given his relatively older age at presentation. The patient denied having a sexual partner, and no genital warts were found on examination. The patient and his family also denied a history of genital warts. THERAPEUTIC CHALLENGE