USE OF ACYCLOVIR FOR THE TREATMENT OF CONDYLOMATOSIS

The present invention relates to the use of acyclovir for the treatment of- Condylomatosis. More in particular, the present invention relates to the use of Acyclovir for the treatment of laryngeal as well as genital condylomatosis, both male and female.

The genital Condylomatosis or genital infection by Human Papillomavirus (H.P.V.) was known since the time of ancient Greeks and Romans and had always been considered as a disease undergoing sexual transmission, so that for long time, until its viral etiology was proved, it was considered to be a clinical manifestation of the syphilis. Certainly the most common way of contraction of the disease is through sexual exposure, although the presence of the H.P.V. on vehicle materials such as underwear, speculem, biopsy forceps, and towels has been extensively demonstrated. Moreover, it has been documented a vertical transmission to the fetus at parturition via the maternal birth channel. In infants born naturally from mothers affected by vulvo-vaginalis exophytic Condylomatosis, the risk of contraction of laryngeal papillomatosis is increased of about 30 times. The condyloma appears as a benign neoplasia, raised up from the underlying epithelium via a single implantation basis, sessile or pedunculate, displaying a roundish or rough surface. The first manifestations appear generally on the fourchette as well as on the posterior part of the vulvar vestibulum, both areas undergoing mostly a traumatic stress during sexual intercourses. The Condylomas can develop in groups on the external organs as well as around the urethral meatus and in the clitoral area; they often expand in the first third inferior of the vagina, extending sometimes throughout its length, with a clinical involvement also of the cervix.

The disease can develop in the anterior area of the vulva up to the mons Veneris, as well as more posterior toward the perineum and perianus, so that around 25 % of roundish women display concomitant anal warts, not necessarily indicatives of their sexual habits. The Condylomatosis of the anal channel is more frequent than people may think, and when this remained not diagnosed or properly treated it could give rise to recurrent lesions of the vulva. Symptoms can be accented and may include itching, burning and pain.

Up to date, the natural history of H.P.V. infection has not been understood yet. An estimation of the real prevalence of the pathology in

the general population has been made difficult by the lack of a unified organization in the specialized clinical services. The incidence of the disease, which has been estimated of around 0,5 -1 ,2 % between the age of 18 and 25 ^' , is continuously increasing both in the developing countries as well as in the Western world. In the United Kingdom for example, such increase seems to be of about 10% every year and American studies document around one million of new infections per year.

During the last decade, the scientific interest toward the virus has exploded because of its relation with the pre-cancerous and cancerous degeneration of the genital tract. However, the intimate mechanism underlying the integration of the viral genome with that of the host cell is not known yet. Such integration is a condition unique and necessary for initiating the pre-neoplastic process.

The H.P.V. belongs to the family of the PA.PO.VA. (Papilloma, Polyoma, Vacuolation), and is an epitheliotrophic virus, species-specific, not reproducible in vitro, with a diameter of about 50-55 μm. This virus replicates in vivo onto the squamous epithelium, starting from the basal layer that can be reached via microtrauma-induced passages.

Up to date, a specific presidium against H.P.V. virus is not available. What is available is a miscellanea of different and debated approaches which always require a tight follow up, or eventually a change in the therapeutic strategy in the presence of the always feared relapse and\or of an unfortunate iatrogenic outcome. Specular features can be described in the partner, who has a 45 - 60 % probability to contract the disease.

The actual therapeutic approaches are trying to treat the identifiable lesions, to reduce signs and symptoms, to prevent the consequences, to restore the morphological physiology of the tissues, to prevent the transmission. All of the above, considering that the H.P.V. infection, as known, can interest a much larger area than the one identifiable by the clinical lesions; up to date there are no clinical studies that can document a reduction of the incidence of such infection by the deletion of its lesions; such strategy indeed results more from the common sense than from controlled scientific observations. The above rationale let us understand how aleatory is the prevention of relapse or transmission. Moreover, all the therapeutic

strategies available at the moment do not help restoring the morphological physiology of the tissue.

The surgical presidia applied against the H.P.V. include Laser- surgery CO ₂ , Radio-frequency (Leep), Cryotherapy, Electro-surgery, CoId- blade bistouries. In terms of healing these methods lead to equivalent result, in percentage values that fluctuate between 70% and 90% following the first application. The first mentioned technique is the most expensive due to the high costs of the equipment as well as of the operator long training required. The medical presidia applied against the H.P.V. include the cytotoxic therapy, which consists in the administration of Podophyillin and Podophyllotoxin, Trichloracetic Acid, 5-Fluorouracil, and the immunomodulating therapy via the use of interferon (alpha, beta, gamma), retinoids, cytokine inducers, Imiquinod, and Vaccines (tetravalent or bivalent) certainly very expensive and just partially covering the risk of infection.

None of the mentioned treatments is able to eradicate the virus. To the scope, the vaccine, although very futuristic, represents a hope. During the third national congress ESIDOG-O9 the need of a combined approach has clearly emerged, which include the synergistic usage of different presidia in combination with the destructive or excisional surgical therapy. Regardless the therapeutic choice, between the 10% and 15% of the patients relapse for several years.

In light of the above, it is evident the need of new methods for the treatment of Condylomatosis which allow to overcome the limits of the so far adopted techniques.

Acyclovir is a synthetic analogue of a purinic nucleoside, which displays an inhibitory activity, both in vitro and in vivo, against the human herpetic viruses, including the Herpes Simplex Virus (HSV) type 1 and 2 and the Varicella Zoster Virus (VZV). Acyclovir is therefore indicated for the treatment of mucosal and skin infections by Herpes simplex, including the Herpes genitalis in the primary or relapsing form, for the suppression of the relapse in Herpes simplex infections in immunodeficient patients, and for the treatment of chickenpox and Herpes zoster. The author of the present invention has now found that the

Acyclovir, administered orally and\or topically, is able to eliminate the H.P.V. virus, without relapse or unfortunate iatrogenic outcome at the level

of tissues and with perfect tissue regeneration. Moreover, it has been possible to gradually give back to the patient serenity and confidence in the treatment, thanks to the immediate response to the therapy, already quantifiable in 7-10 days from the beginning. Therefore, it is an object of the present invention a pharmaceutical composition comprising or consisting of acyclovir as active compound in combination with one or more excipients and\or adjuvants pharmaceutically acceptable for use in the treatment of both male and female condylomatosis, in particular genital condylomatosis, including also the giant condylomatosis (or Buschke-Lowenstein Carcinoma), or laryngeal condylomatosis, in particular in neonates. The composition according to the present invention can comprise further one or more extra active compounds chosen among the group consisting of: a disinfectant such as, for example, Sodium hypochlorite, for example in the concentration of 5 % over the total weight of the composition, an antiinflammatory, as for example calendula, mauve, licorice, and an emollient. The composition can be administered topically as well as systemically for example in form of cream, ovule, tablet, capsule, syrup, solution or suspension. The concentration of acyclovir in the composition can vary from 3% to 8% over the total weight of the composition, preferentially 5%. The quantity of acyclovir per tablet or capsule can vary from 200 mg to 800 mg.

It is further object of the present invention the use of acyclovir for the preparation of a medicament for the treatment of of both male and female condylomatosis, in particular genital condylomatosis, including also the giant condylomatosis (or Buschke-Lowenstein Carcinoma), or laryngeal condylomatosis, in particular in neonates. The acyclovir can also be utilized in combination with one or more extra active compounds chosen among the group consisting of: a disinfectant such as, for example Sodium hypochlorite, for example in the concentration of 5 % over the total weight of the composition, an anti-inflammatory, as for example calendula, mauve, licorice, and an emollient. Acyclovir can be administered topically as well as systemically for example in form of cream, ovule, tablet, capsule, syrup, solution or suspension. The concentration of acyclovir in the composition can vary from 3% to 8% over the total weight of the composition, preferentially 5%. The quantity of acyclovir per tablet or capsule can vary from 200 mg to 800 mg.

The present invention will now be described in reference to exemplifying but not limiting preferred embodiments thereof:

Example 1 : Study on the efficacy of the therapy based on Acyclovir in the treatment of the genital Condylomatosis Patients were treated according to the therapeutic protocol as follow:

1) Diluted Amuchina for soaks: 1 table spoon/1 /4 liter of lukewarm water for soaks 2-3 times per day, every 4 hours, before the topic application of Acyclovir cream; 2) Acyclovir, tablets 400 mg, 1 tablet twice a day as an attack dosage for 7 days, then 1 tablet per day until clinical resolution;

3) Acyclovir cream 10 g for external and internal intravaginal application;

4) Immune support with fermented Papaya, 1 pack per day throughout the therapeutic cycle, up to an overall period of 3 months or more.

It is suggested to avoid local detergents, as well as to take a special hygienic care for the clothing. Case study

Following are reported 5 cases of vulvar condylomatosis treated with the therapeutic protocol described above.

The basic features that link and characterize the reported cases are the absence of relapse together with a perfect restitutio ad integrum of the tissue.

Each of the documented cases is indeed completed by a follow up analysis that lasts for about 4 years in the first case to 6 months in the last one, up to now.

Clinical case n. 1 : female patient of the age of 46, married, two eutocic parturitions, school level: high school, employed.

The patient used to undertake every year the clinical monitoring with cytoiogical screening. The patient noticed an alteration at the level of the vulva. At the objective examination, a large vulvar condylomatosis appeared, extended from half of the right greater lip of pudendum, to the fourchette, up to the superior edge of the left greater lip of pudendum. A sessile condyloma, of the size of a Spanish bean, was found, isolated on the medial surface of the left gluteus, upon the genito-crural fold.

The application of the therapeutic protocol in object leads to a restitutio ad integrum after 3 months of treatment. The following monitorings at 3 months, 6 months, 1 year up to 3 years, did not document any relapse. ^" Clinical case n. 2: female patient of the age of 34, single, nullipara, school level: diploma, employed. This patient as well used to undertake regularly clinical monitoring with cytological screenings every year. The cause of the medical visit was this time the presence of discomfort at the level of the vulva, characterized by sensation of burning. At the objective examination the presence of condylomatotic lesions was uncovered, distributed onto the surface of the vulvar mucosa. The vulvoscopic examination optimized the reliability of the diagnosis.

The therapeutic protocol in object was applied, the symptomatic remission was obtained, as well as the disappearance of the lesions and the restitutio ad integrum of the tissue within 3 months.

The regular monitoring within the following three years did not reveal any relapse.

Clinical case n. 3: gynecological examination on a patient of the age of 25, single, nullipara, school level: high school, employed. The patient experienced burning pain, and noticed the presence of malodorous leucorrhoea, and the appearance since some time before, of a sessile condyloma on the medial surface of the left gluteus. The objective examination revealed several condylomatotic lesions on the internal surface of the greater and lesser lips of pudendum, at the level of the fourchette, of the perianus and of the anogenital raphe. A Gardnerella Vaginalis super-infection was present, as confirmed afterward by the bacteriological analysis.

In this situation as well it was established the therapeutic protocol in object, to be combined with an appropriate anti-mycotic vaginal therapy. At the resolution of the vaginitis, after 15 days since the beginning of the local treatment, the cytological screening was repeated: a negative result for H.P.V. infection was given by pap-test as well as by the bacteriological screening. After three months of antiviral therapy the symptomatic remission was obtained, together with the disappearance of the lesions, with restitutio ad integrum.

The regular monitoring at three months, 6 months and 1 year documented the absence of relapse.

Clinical case n.4: clinical monitoring on a patient of the age of 34, single, nullipara; school level: diploma, teacher. The patient used to undertake regularly clinical monitoring with cytological screenings every year and complained of local symptoms characterized by continuous burning, with exacerbations and itching combined with fluor albus, with alterations in tactile perception, at the moment of cleaning of the external genitalia. The patient was diagnosed with vulvar Condylomatosis combined with mycotic vaginitis. Bacteriological analysis and pap-test were performed. A mixed treatment was applied initially: anti-mycotic vaginal therapy and protocol in object against the condylomatosis. A new monitoring as well as the cytological test was repeated after 15 days, and, when the mycotic infection disappeared, the cytological test revealed alterations by H. P. V. The therapeutic protocol applied so far was carried on and, after three months, the restitutio ad integrum was observed, with negative pap-test. A new monitoring at 6 months revealed the absence of relapse.

Clinical case n. 5: clinical monitoring of a young woman of the age of 27, single, nullipara; school level: diploma.

The patient referred that she had been waiting for 3 weeks before asking for being examined, meanwhile several alterations had been appearing. At the anamnesis no data were described that could be due to previous diseases. An acute Candida vaginal inflammation was evident, which was responsible for the vaginal secretions that were deposited onto the formations, extended up to the fornix. The pap-test and the cyto-brush were performed that confirmed the presence of the inflammation and the nature of the infection, as well as the presence of cytopatic lesions by H.P.V.

The therapeutic protocol in object was designed with an increase of the attack dosage, because of the large extension of the vulvar condylomatosis and locally, where it was impressively altered the morphology of the external genitalia and at the level of the vagina, up to the fornix. The patient was examined again after 15 days and, due to an immediate therapeutic answer locally, it was decided to carry on with the protocol applied so far. The therapy was carried on with follow-ups at 15 days interval, up to 2 months, when the strong evidence of the symptomatic regression made it an important therapeutic stage. The cytological test as well as the

histological test, via biopsy, were performed at the level of the portio vaginalis, now free from the mycotic infection: such analysis revealed persistency in the H.P.V. infection as well as diagnostic doubt among severe dysplasia and giant condyloma. The clinical and cytological examinations were repeated after one month, resulting this time in a negative cytological readout.

Two months afterward a new monitoring indicated a perfect restitutio ad integrum and new negative result following a cytological cervical analysis. In the case described above, a higher dosage per os was applied together with vaginal applications of Acyclovir cream, for 4 months. At the sixth month since the beginning of the therapy, a new follow up was performed with complete negative result.

Clinical case n. 6: patient of the age of 27 undertook a clinical examination due to signs and symptoms of vaginal Candidosis, which she had been fighting against since long time with no success. In addition to the motivation above mentioned, the patient complained of burning symptoms at the level of external genitalia.

At the objective examination it was revealed the presence of a cervical vaginitis by Candida Albicans infection, accompanied by abundant white secretions. Vulvitis was consensually diagnosed. Repeated cycles of an anti-mycotic therapy were designed also for the partner. The following monitoring in August revealed the resolution of the infection and, with it, the presence of irregular zones of ectopia on a portio vaginalis. It was decided for a therapy of preparation of D.T.C. After 2 months, at the monitoring, the presence of micro-condylomatosis on the vaginal fourchette and on the vestibulum was revealed via vulvoscopic examination. The itching symptom had gradually been replaced by burning. It was therefore applied the therapeutic protocol in object, with consequent clinical resolution evident at the monitoring after two months. Considerations

On the basis of the absence of documented relapse as well as of the negative results of the cytological examinations, a mechanism of action of Acyclovir can be hypothesized where Acyclovir interferes in the life dynamics of H.P.V. Same thing not being assessable in the case of herpes genitalis lesions of type 1 , for which, up to date, we had not noticed absence of relapse. The sanitary operator that has the chance to follow a

patient over time, can often notice that the mycotic infections are somehow favored by primary viral infections, and that moreover the last ones can be diagnosed just when the "veil" of the secondary infection or super-infection has been removed, thanks to an appropriate therapy, with clear patient compliance.