Treatment of xanthelasma palpebrarum with bichloracetic acid

BACKGROUND

Although many treatment modalities have been described for xanthelasma palpebrarum, no single technique has emerged as dominant.

OBJECTIVES

Our purpose was to review the various therapeutic modalities for xanthelasma and to assess the efficacy of topical bichloracetic acid.

METHODS

Thirteen patients with 25 xanthelasma were treated with topical 100% bichloracetic acid. Efficacy was assessed over a follow-up period of 7 months to 10.5 years (average, 64 months).

RESULTS

Eighty-five percent of patients experienced initial complete clearing, and 72% of their lesions have not required retreatment over an average period of 68 months. Recurrences responded well to repeat treatment. Eighty-three percent of recurrent or poorly responsive lesions were associated with high cholesterol. The most resistant patient had four-lid involvement. Excellent cosmetic results and high patient satisfaction were seen.

CONCLUSIONS

Topical bichloracetic acid is a viable alternative to other modalities in the management of xanthelasma. Advantages include simplicity, cost-effectiveness, speed, safety, and efficacy.

[Lactate metabolism and lactic acidosis]

Lactate can be viewed as a metabolic dead end in that it can only be produced or utilized via pyruvate. Lactate production is determined primarily by pyruvate concentration and to a lesser extend by the redox state. Increased lactate production may result from tissue hypoxia, alkalosis, catecholamine and alanine transamination to pyruvate. Hyperlactatemia is observed in many pathological conditions. Current diagnostic criteria for lactic acidosis are a pH less than 7.35 and lactate concentration greater than 5 to 6 mmol/l. In our study series, malignancy was the most common underlying disease accompanied by lactic acidosis. Organ failure, cardiovascular disease and diabetes mellitus were also common. The prognosis of patients with these diseases were grave. In cases of lactic acidosis associated with diabetes mellitus, alcoholic liver disease, rhabdomyolysis and diabetic comas were noticeable as complications. Alcohol abuse was the most common cause of lactic acidosis associated with diabetes mellitus. In these cases, laboratory data showed prominent hyperlactatemia, hyperglycemia and acidemia and elevated anion gap. The mortality rate in these cases was 36% and higher in cases with organ failure. Treatment of lactic acidosis consists of alkalization by sodium bicarbonate with carbicarb, insulin-glucose-infusion, dichloroacetate therapy, tham administration, bicarbonate-buffered peritoneal dialysis and high bicarbonate-containing dialysis.

Magnetic resonance spectroscopy: use in monitoring MELAS treatment

BACKGROUND

Sodium dichloroacetate has been used to treat patients with mitochondrial myopathy, encephalopathy, lactic acidosis, and strokelike episodes (MELAS). Magnetic resonance spectroscopy (MRS) has been used to assess cerebral metabolism in MELAS, but to our knowledge, the findings of serial MRS studies performed after therapeutic intervention of strokelike episodes have not been reported.

METHODS

Proton MRS was serially used to measure brain metabolites in strokelike regions and in clinically uninvolved brain regions in a patient with MELAS.

PATIENT

A patient with MELAS and a strokelike episode clinically improved after treatment with sodium dichloroacetate. An elevated lactate-creatine ratio in the "stroke" region decreased on MRS studies after treatment. After a second episode, the lactate-creatine ratio increased from baseline in a region of the brain that was normal on magnetic resonance imaging scans.

CONCLUSIONS

To our knowledge, this is the first study to assess the response to treatment of a MELAS strokelike episode and the first to show an increase in the lactate-creatine ratio in a brain region that was associated with a clinical abnormality, even though it appeared normal on magnetic resonance imaging. We conclude that MRS may help to monitor therapeutic efficacy in mitochondrial encephalomyopathies.

Effects of dichloroacetate in three patients with MELAS

We present the clinical and laboratory effects of dichloroacetate (DCA) in three children with mitochondrial myopathy, encephalopathy, lactic acidosis, and strokelike episodes (MELAS) who had not responded to other medications. Administration of DCA lowered the elevated levels of lactate and pyruvate in the serum and CSF. DCA ameliorated abdominal pain, headache, and strokelike episodes, and improved cognitive function and fatigability in the three patients during the study period. Some transient liver dysfunction, hypocalcemia, and peripheral neuropathy were observed. The use of DCA in MELAS merits further study.

Clinical and radiologic improvements in mitochondrial encephalomyelopathy following sodium dichloroacetate therapy

We administered sodium dichloroacetate (DCA), which reduces the circulating lactate and pyruvate concentrations by stimulating the activity of the pyruvate dehydrogenase complex (PDHC), to three children with mitochondrial encephalomyelopathy. Significant clinical, biochemical and radiologic improvements were obtained following DCA therapy (approximately 30 mg/kg per day, divided into three doses). All three patients had non-pyruvate dehydrogenase complex (PDHC) deficiencies: two exhibited Leigh syndrome (complex I deficiency and unknown etiology), and one abnormal myelination (multienzyme deficiency), demonstrated on magnetic resonance imaging (MRI). The lactic and pyruvic acid concentrations in serum and cerebrospinal fluid (CSF) were decreased significantly by the oral DCA treatment. The lactic acid peak on MR spectroscopy also markedly decreased in parallel with the CSF level. In addition, the brain lesions observed on MRI were improved in all patients. No exacerbation was observed in any of the patients, who have been followed-up more than 21 months following the DCA therapy. These results suggest that DCA therapy should be considered in all patients with a mitochondria-related enzyme deficiency.

Dichloroacetate as metabolic therapy for myocardial ischemia and failure

This article critically reviews the pharmacologic effects of the investigational drug dichloroacetate (DCA), which activates the mitochondrial pyruvate dehydrogenase enzyme complex in cardiac tissue and thus preferentially facilitates aerobic oxidation of carbohydrate over fatty acids. The pharmacologic effects of DCA are compared with other interventions, such as glucose plus insulin, inhibitors of long chain fatty acid oxidation and adenosine, that are also thought to exert their therapeutic effects by altering myocardial energy metabolism. Short-term clinical and laboratory experiments demonstrate that intravenous DCA rapidly stimulates pyruvate dehydrogenase enzyme complex activity and, therefore, aerobic glucose oxidation in myocardial cells. Typically these effects are associated with suppression of myocardial long chain fatty acid metabolism and increased left ventricular stroke work and cardiac output without changes in coronary blood flow or myocardial oxygen consumption. Although long-term studies are lacking, short-term parenteral administration of DCA appears to be safe and capable of significantly improving myocardial function in conditions of limited oxygen availability by increasing the efficient conversion of myocardial substrate fuels into energy.

Concomitant administration of sodium dichloroacetate and vitamin B1 for lactic acidemia in children with MELAS syndrome

Myoclonic seizures, intractable abdominal pain, and headaches resolved during the concomitant administration of sodium dichloroacetate and vita min B1 in two Japanese siblings with the MELAS syndrome (mitochondrial myopathy, encephalopathy, lactic acidosis and strokelike syndrome).

Pharmacokinetics of dichloroacetate in adult patients with lactic acidosis

The pharmacokinetic properties of the lactate-lowering drug dichloroacetate were investigated in 111 adult patients with lactic acidosis who were randomized to receive dichloroacetate as part of a placebo-controlled clinical trial. The clinical symptoms and etiology of lactic acidosis varied markedly among patients. Dichloroacetate, at a dose of 50 mg per kilogram of body weight, was administered in a 30-minute intravenous infusion into a peripheral vein. A second dose, identical to the first, was administered 2 hours after beginning the first infusion. Plasma levels of dichloroacetate were determined from blood samples collected periodically up to 288 hours after administration and the data were subjected to pharmacokinetic modeling. The pharmacokinetic properties of dichloroacetate in these acutely ill patients were complex and differed markedly from those in healthy volunteers, whose data fitted a one-compartment pharmacokinetic model. In contrast, the data from patients fitted one-, two-, or three-compartment pharmacokinetic models or even none of these, depending on the individual. Drug clearance in plasma tended to decrease as the number of compartments required to fit the data increased or as the number of drug treatments increased.

Dichloroacetate treatment in Leigh syndrome caused by mitochondrial DNA mutation

Sodium dichloroacetate (DCA) was administered to a 1-year-old female case of Leigh syndrome, who had a T > G point mutation at nt 8993 of mitochondrial DNA. Her biochemical and clinical symptoms improved gradually, but proton magnetic resonance spectroscopy revealed reduction of the N-acetylaspartate/creatine ratio, and magnetic resonance imaging showed progressive cerebral atrophy despite the DCA therapy. These results suggest that DCA therapy may not retard the progress of the primary disease in Leigh syndrome, but produced clinical improvement most likely by reducing toxic accumulation of lactate.

Effect of hypothermia, dichloroacetate, and deferoxamine in the treatment for cortical edema and functional recovery after experimental cortical impact in the rat

OBJECTIVE

To investigate the effects of hypothermia alone or in combination with dichloroacetic acid (DCA) and/or deferoxamine (DFO) in reducing cortical edema (CE) and improving neurologic functional recovery after moderate closed and head trauma with controlled cortical impact (CCI).

METHODS

Anesthetized rats were randomized to receive right parietal moderate CCI (impact depth 2 mm, speed 3.5 m/sec) or sham operations. Immediately after trauma, the animals underwent selective brain cooling to 30 degrees C (temporalis muscle temperatures). Ten minutes after trauma, the randomized animals received intraperitoneal doses of DCA (25 mg/kg), DFO (50 mg/kg), both DCA and DFO, or equivolume normal saline. For evaluation of cortical edema, some animals (n = 42) were sacrificed 4 hours after trauma and cortical specific gravity (SpG) was determined gravimetrically. The other animals (n = 47) were evaluated for functional recovery beginning 6 days posttrauma. Neurobehavioral performance was assessed in the Morris water maze.

RESULTS

Cortical edema was significantly less in the animals treated with hypothermia (SpG = 1.041 +/- 0.001, p < 0.05) compared with the untreated traumatized animals (SpG = 1.037 +/- 0.001). Combination treatment with hypothermia and drug treatment did not reduce cortical edema when compared with no treatment. Hypothermia with and without drug treatment did not improve neurobehavioral performance when compared with no treatment.

CONCLUSIONS

In this pilot study with a relatively small sample size, hypothermia alone significantly reduced post-CCI cortical edema as measured by SpG. Hypothermia combined with drug treatment did not reduce posttraumatic cortical edema. Hypothermia with and without drug therapy did not improve functional neurologic recovery in the rats subjected to CCI.

Combined aerobic training and dichloroacetate improve exercise capacity and indices of aerobic metabolism in muscle cytochrome oxidase deficiency

There is no generally effective therapy for mitochondrial myopathies. In this study, we measured responses to combined aerobic training and oral dichloroacetate (DCA) therapy in a 25-year-old woman with a mitochondrial myopathy caused by cytochrome oxidase deficiency. The patient trained for 14 weeks, and DCA therapy was begun after 8 weeks. Independent indices of aerobic capacity and oxidative metabolism showed substantial improvement. Venous lactate concentrations at rest, and after a constant amount of work, decreased by approximately 50% after 8 weeks of aerobic training, and by more than 70% with the combination of training and DCA treatment. Heart rate at rest and after a constant amount of submaximal work decreased progressively. Aerobic capacity on a graded submaximal exercise test improved by 71% from baseline by the end of the treatment period. 31P magnetic resonance spectroscopy measurements of rate constants for recovery of muscle phosphocreatine increased 1.7-fold and metabolically active adenine diphosphate increased 2.8-fold after 8 weeks of training alone, and 4.5-fold and 23.0-fold after 14 weeks of training plus DCA treatment. Responses to the SF-36 Health Survey suggested a marked reduction in handicap. Thus, in this open study of a patient with cytochrome oxidase deficiency, a combination of aerobic training and DCA treatment resulted in substantial improvements in biochemical indices, exercise performance, and handicap. We conclude that exercise limitation in patients with mitochondrial myopathy may arise from effects of chronic deconditioning in addition to the effects of primary mitochondrial dysfunction and may be partially reversed by training and administration of DCA.

Oxidative phosphorylation defect associated with primary adrenal insufficiency

An 18-month-old girl with an oxidative phosphorylation defect had neonatal onset of chronic lactic acidosis, lipid storage myopathy, bilateral cataracts, and primary adrenal insufficiency. Chronic lactic acidosis responded to treatment with dichloroacetate. Sequential muscle biopsies demonstrated resolution of the lipid storage myopathy associated with the return to normal muscle free carnitine levels. This case demonstrates a new clinical phenotype associated with a defect in oxidative phosphorylation and the need to consider mitochondrial disorders in the differential diagnosis of primary adrenal insufficiency in childhood.

Protective effect of dichloroacetate in a rat model of forebrain ischemia

Dichloroacetate (DCA) activates the pyruvate dehydrogenase complex (PDHC), and improves the recovery of cerebral pH, lactate, ATP, and PCr following reperfusion in animal models of forebrain ischemia. In order to determine whether this results in neuroprotection, rats were administered NaDCA (100 mg/kg or 10mg/kg i.v.) 10 min before 12 min of normothermic forebrain ischemia (bilateral carotid artery occlusion plus systemic hypotension, 45 mmHg). Neuronal injury assessed histopathologically 7 days post-ischemia was significantly reduced in the CA1 region of the hippocampus, the dorsal lateral striatum, and the neocortex, in rats treated with 100 mg/kg NaDCA, but not in rats treated with 10 mg/kg NaDCA.

Pyruvate dehydrogenase inactivity is not responsible for sepsis-induced insulin resistance

OBJECTIVE

To determine whether activation of pyruvate dehydrogenase with dichloroacetate can reverse sepsis-induced insulin resistance in humans or rats.

DESIGN

Prospective, controlled study.

SETTING

Intensive care unit (ICU) and laboratory at a university medical center.

SUBJECTS

Nine patients were admitted to the ICU with Gram-negative sepsis, confirmed by cultures. In addition, chronically instrumented, Sprague-Dawley rats, either controls or with live Escherichia coli-induced sepsis.

INTERVENTIONS

Hyperinsulinemic euglycemic clamp, with or without coadministration of dichloroacetate.

MEASUREMENTS AND MAIN RESULTS

In humans, a primed, constant infusion of [6,6-2H2]glucose was used to determine endogenous glucose production and whole-body glucose disposal. Septic humans exhibited impaired maximal insulin-stimulated glucose utilization (39.5 +/- 2.7 mumol/kg/min), despite complete suppression of endogenous glucose production. In rats, a primed, constant infusion of [3-3H]glucose was used to determine endogenous glucose production and whole-body glucose disposal. Tissue glucose uptake in vivo was determined by [14C]-2-deoxyglucose uptake. Maximal, whole-body, insulin-stimulated glucose utilization was 205 +/- 11 and 146 +/- 9 mumol/kg/min in control and septic rats, respectively. The defect was specific to skeletal muscle and heart. Stimulation of pyruvate dehydrogenase with dichloroacetate caused a 50% decrease in plasma lactate concentration but failed to improve whole-body insulin-stimulated glucose utilization in either the septic human or rat. Dichloroacetate reversed the impairment of insulin-stimulated myocardial glucose uptake in septic rats, but did not influence skeletal muscle glucose uptake either under basal conditions or during insulin stimulation.

CONCLUSIONS

Activation of pyruvate dehydrogenase with dichloroacetate does not ameliorate the impairment of whole-body, insulin-stimulated glucose uptake in septic humans or rats, or reverse the specific defect in insulin-mediated skeletal muscle glucose uptake by septic rats. Therefore, the decreased pyruvate dehydrogenase activity associated with sepsis does not appear to mediate sepsis-induced insulin resistance during insulin-stimulated glucose uptake at either the whole-body or tissue level.

In vivo metabolic response of glucose to dichloroacetate in humans

Hyperglycemia is common in severely ill patients and is related principally to an increase in glucose production. Dichloroacetate (DCA), which is known to increase the rate of pyruvate oxidation, has been shown to lower plasma glucose concentrations in normal fasting subjects and in diabetics and thus may be efficacious in treating stress induced hyperglycemia. However, the mechanism by which DCA lowers the plasma glucose concentration in humans has not been elucidated. To examine the human in vivo metabolic alterations induced by DCA, six fasting volunteers were infused with 6,6-D2-glucose and indirect calorimetry was performed prior to and following DCA administration. Glucose, lactate, and alanine net balance across the leg were also quantitated. Following DCA administration, plasma glucose concentrations decreased by 9% due to a proportional decrease in the rate of glucose production (P < 0.05). DCA had no affect on glucose clearance or leg net balance; however, the rate of glucose oxidation increased by 24% from baseline (P < 0.05). This increase in glucose oxidation without a compensatory change in peripheral glucose consumption suggests an improved efficiency in peripheral glucose utilization induced by DCA. Plasma concentrations of lactate and alanine were also lowered by DCA (56% for lactate, 66% for alanine, P < 0.05) without a significant alteration in leg net balance. These results suggest that DCA may decrease gluconeogenesis by limiting the availability of the precursor substrates lactate and alanine. Thus dichloroacetate may be an appropriate alternative to insulin in correcting mild elevations in plasma glucose concentrations. Furthermore, DCA may be especially effective in severely ill patients where hyperglycemia is largely due to increases in gluconeogenesis.

The disposition and effects of two doses of dichloroacetate in adults with severe falciparum malaria

1 Dichloroacetate (DCA) is a promising treatment for lactic acidosis complicating severe malaria. The pharmacokinetics, pharmacodynamics and toxicity of dichloroacetate were evaluated in 11 patients with severe malaria, and their lactate responses compared with nine control patients in an open-label prospective study. 2 Intravenous DCA (46 mg kg-1 infused in 30 min) or saline placebo was given on admission to the study, and 12 h later, as an adjunct to standard quinine treatment. 3 An open one-compartment model with the following parameters described the pharmacokinetics of DCA after one dose (mean [s.d.]): V = 0.44(0.2) 1 kg-1; CL = 0.13 [0.027] 1 h-1 kg-1; Cmax = 106[28] mg1-1; t1/2 = 3.4(2.2) h. After two doses of DCA (n = 9) the pharmacokinetic parameters were similar to those after the first dose. 4 DCA decreased venous plasma lactate concentrations by 42% of baseline values 8 h after admission, normalized arterial pH from a mean(s.d.) of 7.367(0.063) to 7.39(0.1), and decreased the calculated base deficit from 9.2(7.3) mEq 1-1 to 6.4(10.4) mEq 1-1. In control patients lactate concentrations fell by approximately 14% of baseline concentrations (P < 0.02 compared with DCA recipients). Venous lactate concentrations fell a further 16% from baseline values after the second dose of DCA but this change was not significantly different from controls. There was no electrocardiographic or other evidence of toxicity associated with DCA. 5 These data suggest that a single intravenous infusion of DCA rapidly reduces hyperlactataemia in patients severely ill with malaria, and that DCA should be evaluated further as an adjunct to conventional antimalarial and supportive measures for such patients with lactic acidosis.

Therapeutic efficacy of a case of pyruvate dehydrogenase complex deficiency monitored by localized proton magnetic resonance spectroscopy

We experienced a case of pyruvate dehydrogenase deficiency observed by proton magnetic resonance spectroscopy (1H MRS). This case was diagnosed as West syndrome by characteristic convulsion and the periodic hypsarrhythmia pattern of EEG. At the age of 11 months, the first examination of 1H MRS revealed a high peak of lactate, and the high concentration of lactate and pyruvate was confirmed in sampled cerebrospinal fluid (CSF). Deficiency of pyruvate dehydrogenase complex was finally diagnosed by genetic examination. Dichloroacetate was administered to the patient as therapy. Decrease of lactate in the brain was found by 1H MRS. Lactate and pyruvate in the CSF was also decreased. In accordance with the suspension of dichloroacetate, increase of lactate in the brain was detected and the convulsions reappeared. After readministration of dichloroacetate, the patient was almost symptom free and lactate in the brain and CSF had decreased to the normal extent. We considered that 1H MRS provides useful information for screening metabolic disorders of infants and assessing the efficacy of therapy.

Effects of chemical pretreatment on posttraumatic cortical edema in the rat

The purpose of this study was to evaluate the effects of mannitol (Man), dexamethasone (DM), dichloroacetic acid (DCA) and 1,3-butanediol (BD) in reduction of posttraumatic cortical edema following brain deformation injury to rats. Ten minutes prior to fluid percussion injury, each animal received one of four pretreatments or placebo: Man, 1 g/kg intravenously, DM 3.0 mg/kg intravenously, DCA 25 mg/kg intraperitoneally BD 0.5 mg/kg intraperitoneally (n = 12 per treatment group), or equivolume saline (n = 8 per corresponding trauma group). Six hours after trauma, cortical tissue was harvested. Using a benzene-kerosene gradient column calibrated with potassium sulfate standards, the specific gravity (SpG) of cortical tissue from each group was measured and compared (ANOVA, P < .05). The measured cortical SpG from traumatized animals receiving Man (mean 1.037 +/- SEM .001), DCA (1.038 +/- .001), and BD (1.039 +/- .001) were equal to SpG from untraumitized cortex (1.041 +/- .001), and were significantly greater than SpG from traumatized cortex for animals receiving DM (1.035 +/- .001) or placebo (1.033 +/- .002). Pretreatment with DCA, Man, and BD appears to protect against development of posttraumatic cortical edema when measured 6 hours after blunt head trauma in the rat. Each of these chemical treatments appears effective in preventing or reducing posttraumatic cortical edema.

Leigh disease with deficiency of lipoamide dehydrogenase: treatment failure with dichloroacetate

A 6-month-old female infant with hypotonia and keto and lactic acidosis was diagnosed with lipoamide dehydrogenase (E3) deficiency. This enzyme is a component of the pyruvate, alpha-ketoglutarate, and branched chain alpha-ketoacid dehydrogenase complexes. At the time of diagnosis her plasma contained elevated branched chain amino acids, alanine, alloisoleucine, ketones, pyruvate, and lactate, and her urine contained elevated branched chain ketoacids and lactate. By neuroimaging she was found to have Leigh subacute necrotizing encephalomyelopathy. Modest branched-chain amino acid restriction led to the disappearance of alloisoleucine and normalization of her branched chain amino acid values, while institution of a high fat diet precipitated hypoglycemia and acidosis. A trial of lipoic acid led to a transient modest improvement in her lactic acidemia. Use of dichloroacetate to activate the pyruvate dehydrogenase complex led to a significant decline in lactate levels, but this was also transient. The patient had significant growth failure despite a high carbohydrate, high calorie diet, yet remained clinically well until 28 months of age when she developed acute acidosis and brainstem dysfunction and died.

[Medicinal therapy for lysosomal storage diseases]

Lysosomes contain several dozen different enzymes, mostly acid hydrolases. Materials not digested due to deficient lysosomal enzymes are usually large cellular molecules, which are deposited within the cells. The strategy for medicinal therapy of lysosomal storages disease may be to develop the activators of enzymes, to promote coenzyme and cofactor supplementation and to eliminate undegraded materials from blood into urine. In the last several decades, many trials for these strategies has been done. Cysteamine for cystinosis and penicillamine for Wilson's disease has proved useful in treating these patients. Recently, DMSO has been proved to be an activator of acid sphingomyelinase and to accelerate the intracellular mobilization of LDL-derived cholesterol. We treated patients with Niemann-Pick disease type C by oral administration of DMSO, resulting in some clinical benefits such as decreased size of hepatosplenomegaly, and lesser frequency of seizures with improved EEG. However, the progressive clinical course has not been changed although it appeared to slow down. New activators of lysosomal enzymes should be developed for medicinal therapy of lysosomal storage diseases.

The therapy of respiratory chain encephalomyopathy: a critical review of the past and current perspective

The mitochondrial respiratory chain encephalomyopathies represent an important group of multisystem disorders. No curative treatment is currently available. A number of measures have been reported to have a theoretical potential to improve respiratory function. These treatment strategies have variable scientific support, many reports being anecdotal. We critically review the various therapeutic measures employed and suggest future treatment directions.

Autogenous vaccine: the best therapy for perianal condyloma acuminata?

PURPOSE

Treatment of perianal condyloma acuminata is frustrating because most treatment options are fraught with high recurrence rates and patient discomfort. We propose that surgical excision followed by vaccination with an autogenous condyloma acuminata vaccine is the most effective therapy available in primary and recurrent perianal condyloma acuminata.

METHODS

Eighty-three patients with perianal condyloma acuminata were treated from 1985 to 1992. Treatment was divided for patients as follows: surgical excision, 20; bichloroacetic acid, 10; podophyllin and interferon A, 5; excision followed by autogenous condyloma acuminata vaccination twice weekly using 0.1 ml subcutaneously for three weeks increasing to 1.0 ml subcutaneously for seven weeks, 43. Syphilis was diagnosed in seven patients; two were human immunovirus-positive. All but three patients were male. Of those patients treated with the vaccination protocol, 25 had primary and 18 had recurrent disease.

RESULTS

Recurrence rates were: excision alone and bichloroacetic acid, 50 percent; podophyllin and interferon A, 85 percent; whereas only 4.6 percent recurred when treated with excision and vaccination. Mean follow-up was 13 (range, 6-23) months. All patients treated with the vaccination protocol tolerated the full course of therapy.

CONCLUSION

We believe that excision of perianal condyloma acuminata followed by autogenous condyloma acuminata vaccination for approximately ten weeks is the most effective and definitive treatment option and, moreover, should be considered in all patients with perianal condyloma acuminata.