warts are mucocutaneous growths ( exo- or endophytic ) caused by human papilloma virus ( hpv ) . common therapeutic modalities ablate the growth without the generation of specific immunity against the wart . this often leads to irritation , pain , recurrence , scars , and prolonged morbidity ( especially in palmoplantar warts ) . the stimulation of the immune system by exposing the virus to immune mediators forms an ideal modality of treatment due to spontaneous regression of the wart with long - lasting immunity . however , serotypes other than those in vaccine ( hpv 6 , 11 , 16 and 18 ) also cause warts and hence this modality may not be effective always . autoimplantation is a novel , one - time procedure which treats the warts by stimulating an immune response against hpv . as it is an autograft technique , it is more likely that immunity against the same serotype is elicited ( in contrast to the hpv vaccine where immunity is developed only against hpv 6 , 11 , 16 and 18 ) . this is done by extracting a subcutis deep wart tissue and implanting it into the uninvolved skin . the autowart injection involves multiple sessions of injection of wart suspension . in this study , we extracted the donor tissue by paring the wart instead of removing a part of the wart under local anaesthesia . this was adopted to reduce the discomfort , risk of infection and hasten the time taken for performing the procedure . this study was conducted in the dermatology outpatient department of a tertiary care rural hospital . thirty - five patients with multiple ( more than five warts ) , recurrent verruca vulgaris ( warts which have recurred after any modality of treatment ) and palmoplantar warts were enrolled in the study after an informed consent and ethics committee approval . pregnant , lactating mothers , immunocompromised individuals and those with verruca plana were excluded from study . donor tissue for autograft was harvested by paring a verrucous lesion or a palmoplantar wart . the lesion to be pared was cleansed with spirit - povidone iodine  spirit to achieve asepsis . 11 autografting was done either on the non - dominant flexural forearm or the upper anteromedial thigh . the site for engraftment was cleansed with spirit - povidone iodine - spirit and infiltrated with about 0.5 ml of lignocaine with adrenaline ( 1:200,000 ) . a subcutis deep stab incision of about 35 mm was made using the same surgical blade of no . the pared tissue was introduced deep into the subcutis using adson 's forceps or an insulin syringe used for infiltration [ figure 3 ] . the margins of the wound were approximated by pressure and a micropore plaster was applied on it . amoxycillin 500 mg + clavulanic acid 125 mg , bid ) and if required , analgesics orally . 11 used to pare the wart introducing the pared tissue deep into the subcutis using adson 's forceps patients were assessed monthly , and resolution of all warts within 3 months was taken as complete clearance . out of 35 patients , 8 were lost to follow - up and 27 patients were available for evaluation . the commonest age group affected was that of 2040 years ( 13 patients , 48.1% ) . a total of 20 ( 74.1% ) patients showed the resolution of the warts within 3 months [ figures 4 and 5 ] , 5 ( 18.5% ) patients had no improvement at all [ table 1 ] and in 1 patient ( 3.7% ; male , 17 years of age ) with multiple warts , except one lesion , others had resolved completely . one ( 3.7% ) male patient aged 16 years had relapse , with a new lesion occurring at a different site . he underwent autoimplantation of the new wart , which healed over a period of 1 month . recurrent wart on the lateral aspect of the right second toe complete resolution of the wart after autoimplantation summary of characteristics of non - responding patients three ( 11.1% ) patients developed erythematous tender nodules at the site of engraftment , with a purulent discharge from them in one patient . warts are one of the common viral infections of the mucocutaneous surfaces and often induce papillomatous growth . the commonest modality of treatment for warts is ablation using electrocautery , radiofrequency , laser or cryogens . these treatments destroy the wart - containing tissue but may not stimulate the immune system against the pathogen . hence , for the effective treatment of warts , there should be immune stimulation which can lead to long - term immunity against hpv . specific immune stimulation against hpv has been tried by autoimplantation of the wart tissue into the uninvolved skin , injecting the suspension of the crushed wart into the muscle or skin [ table 2 ] and by quadrivalent hpv vaccines . patients with regression of warts either spontaneously or following successful therapy or injection of antigens showed the development of cell - mediated immunity and appearance of virus - specific igm and igg antibodies . comparison of the present study with previous studies in their study on the autoimplantation technique , shivakumar et al . extracted a subcutis deep part of the wart using a 18 g needle and implanted it into the skin elsewhere . this resulted in two wounds . also , hpv is an epidermal infection and there is no added advantage with the extracting donor tissue containing dermis and subcutis . hence , in this study , we harvested the donor by paring the wart to get the stratum corneum tissue containing virus . by this method , we avoided wound at the donor site and also circumvented the issue of taking the unwanted deeper tissues for engraftment . in contrast to the autowart injection therapy , this is a single sitting procedure and avoids the risk of injection abscess . most of our patients were males and belonged to the 20- to 40-year age group in parlance with other studies . a complete clearance of warts was observed in 74.1% of patients [ table 2 ] , greater than that observed by usman et al . we had one patient with multiple warts in whom one of the warts persisted at the end of 3 months . non - responders were minimal in the study , using autowart injection , by srivastava et al . one of our patients had clearance of warts after autoimplantation but developed a new lesion at a new site . this probably could be due to infection by a different serotype of hpv . as we were unable to isolate the species of hpv , this further supports the hypothesis . in one patient , warts healed with transient hypopigmentation . of the 27 patients , only 2 had anogenital warts in addition to verruca vulgaris and these also cleared completely with the autoimplantation of warts . hence , the final outcome was much better in our study ( 74.1% ) when compared with other autoimplantation as well as autowart injection techniques ( 4473.3% ) . reaction at the site of engraftment in the form of erythematous tender nodules was observed in three patients , with a purulent discharge in one from the nodules . shivakumar et al . also noticed reactions at the injection site in some patients but have not disclosed the exact number . other researchers of the autoimplantation or autowart injection technique have not commented on any such reactions . this could be due to intense inflammation caused by implanted squames which act as a foreign body in the dermis and subcutis analogous to an inflammatory reaction which occurs in the case of a ruptured follicle . a quadrivalent hpv vaccine has shown promising results in the treatment of warts . however , the presence of only anecdotal reports , partial clearance in one of the two studies and a limited access in resource - restricted countries are the drawbacks of this vaccine . limitations of our study include a small sample size , lack of controls to assess spontaneous resolution of warts and lack of serotyping of persistent warts or checking for serospecific hpv antibodies . we also need to study the cause for the partial clearance or occurrence of new warts in spite of the clearance of all previous warts . the modified technique of autoimplantation using the pared stratum corneum tissue of the wart instead of the subcutis deep wart tissue for autografting is a safe , efficacious , less traumatic and rapid procedure for the treatment of multiple , recurrent and palmoplantar warts .