Genital warts at the site of healed herpes progenitalis: the isotopic response

A 53-year-old man presented with a crop of papular and somewhat warty lesions on the internal aspect of his prepuce (Fig. 1). They had appeared over the last 3 months and lately had been enlarging; this persuaded the patient to seek dermatovenereologic advice. The patient, who was uncircumcised, denied any extramarital intercourse, but reported a clear medical history of recurrent herpes progenitalis that had afflicted him and his spouse for many years. Recurrent attacks of this infection, each lasting about 2 weeks, had occurred with variable frequency in his forties, and the last episode could be dated exactly to the age of 49 years. The herpetic infection had been managed with topical and sometimes oral acyclovir, but no considerable therapeutic benefit had been noticed. On admission, the patient's main concern was that the new lesions could represent a relapse of the herpes progenitalis. Although they were completely different from the herpetic lesions objectively (solid and not vesicular), subjectively (asymptomatic and not tingling or painful), and in their course (lasting unmodified for months and not evolving into erosions), they had arisen in the area in which the herpetic vesicles had appeared in the past. Despite the obvious clinical diagnosis of genital warts and in compliance with the patient's explicit request, a punch biopsy was made. The epithelium showed moderate parakeratosis, pronounced acanthosis, diffuse cell vacuolization, and no signs of nuclear dysplasia (Fig. 2). Mild edematous changes, dilated capillaries, and a discrete lymphocytic infiltrate were observed in the dermis. The diagnosis of genital warts was made and the lesions were successfully treated with liquid nitrogen.