DOI: 10.1111/j.1365-3164.2008.00674.
Azithromycin therapy of papillomatosis in dogs:
Blackwell Publishing Ltd
a prospective, randomized, double-blinded,
placebo-controlled clinical trial
Bu©rahan Bekir Ya©cı*, Kerem Ural†, Naci
Öcal* and Ali Evren Haydardedeo©lu‡
*Department of Internal Medicine, Faculty of Veterinary Medicine,
Kirikkale University, Kirikkale, Turkey
†Republic of Turkey, The Ministry of Agriculture and Rural Affairs,
Board of High Stewards, Ankara, Turkey
‡Department of Internal Medicine, Faculty of Veterinary Medicine,
Ankara University, Ankara, Turkey
Correspondence: Dr Kerem Ural, Birlik Mahallesi 5, Cadde No: 3-6
Erkan Apartmani, 06420 Cankaya, Ankara, Turkey.
E-mail: uralkerem@gmail.com [correction made after online
publication 20 May 2008: corresponding author details updated]
What is known about the topic of this paper
• Azithromycin, an azalide, is a subclass macrolide antibiotic,
effective, well-tolerated and safe therapeutic alternative
for papillomatosis therapy in human.
• Papillomaviruses induce severe, nonregressing and
recurrent infections in animal and human hosts, and are
responsible for affecting the oral mucous membranes
and skin of young dogs and older dogs, respectively.
• The purpose of the present prospective, randomized,
double-blinded, placebo-controlled clinical trial was to
investigate the clinical efficacy of azithromycin on oral
and cutaneous papilloma in dogs.
What this paper adds to the field of veterinary
dermatology
• The beneficial effect of azithromycin in this study is in
keeping with the therapeutic inflammatory potential effect
of azithromycin reported on human papillomatosis.
• In the present study in all treated cases, the lesions
disappeared contemporary with the classical signs of
cutaneous papilloma in response to an azithromycin therapy,
suggesting that azithromycin therapy may be useful
therapy choice in most of the cases.
• Perhaps azithromycin eradicates an unknown organism
involved in predisposition to papillomatosis or an alternative
explanation may be that it could help to suppress an
autoimmune phenomenon leading to formation of
papillomatosis.
Abstract
Azithromycin, an azalide subclass macrolide antibiotic,
is an effective, well-tolerated and safe therapeutic
option for treatment of papillomatosis in humans. This
study reports the clinical and histopathological results
from a prospective, randomized, double-blinded,
placebo-controlled trial of 17 dogs of various breeds
with diagnosis of oral (n = 12) and cutaneous papillo-
matosis (n = 5) treated with azithromycin. Papillomas
194 © 2008 The Authors. Journal compilation © 2008 ESVD and ACVD. 19; 194–198
appeared as whitish, verrucous, hyperkeratotic papules
1–2.7 mm in size. The cases were randomly assigned
to azithromycin (n = 10) and placebo treatment groups
(n = 7). Both owners and investigators were blinded to
the allocation to the groups. Azithromycin (10 mg/kg)
was administered per os every 24 h for 10 days. Clinical
evaluations were done by the same investigator
throughout the trial. Azithromycin treatment signifi-
cantly decreased clinical scores (P < 0.001), whereas
there was no change seen in the placebo group. In the
azithromycin treatment group, skin lesions disappeared
in 10–15 days. One case in the placebo had spontane-
ous regression of its papillomas by day 41, but
lesions were still evident at day 50 in the remaining
six cases. There was no recurrence of papillomatosis
in the azithromycin treated dogs (follow up 8 months).
No adverse effects were seen in either group. In con-
clusion, azithromycin appears to be a safe and effective
treatment for canine papillomatosis.
Accepted 20 March 2008
This study is self-funded.
No conflicts of interest have been declared.
Introduction
Papillomaviruses induce severe, nonregressing and
recurrent infections in animal and human hosts.1 Papillomas
affect the oral mucous membranes and skin of young and
older dogs, respectively.2 Although the underlying mechanisms
are not completely understood,1 papillomavirus is implicated
as an aetiological factor in canine oral papillomatosis,1,3–5
but there is a less consistent association between cutaneous
papillomas and papillomavirus in older dogs.2 Reports also
indicate that dogs with immunosuppressive disorders are
predisposed to developing canine papillomatosis.2
To the authors’ knowledge vaccination is the most
commonly used traditional treatment option in dogs with
papillomatosis. However, the lack of a commercially and
readily available papillomavirus vaccine is a disadvantage.
Individually prepared vaccines are labour intensive, which
is not cost-effective, and cause various side-effects.
Azithromycin, an azalide subclass macrolide antibiotic,
has been extensively tested and is licensed for the treatment
of various clinical infections in humans and animals. It has
been shown to be effective against human papillomatosis.6–10

In dogs, azithromycin is administered as a tablet, suspension
or injection formulation for the treatment of pyodermas,11
babesiosis12 and bartonellosis.13 Given the efficacy of
azithromycin in human papillomatosis, and experience of
safe use in dogs, it was hypothesized that azithromycin
would also be effective and well tolerated in dogs with
papillomatosis. The purpose of this prospective, randomized,
double-blinded, placebo-controlled clinical trial was to
investigate the clinical efficacy of azithromycin in treating
oral and cutaneous papillomatosis in dogs.
Materials and methods
Study design
Prospective, randomized, placebo-controlled, double-blinded clinical trial.
Animals
The dogs enrolled in this study comprised 17 breeds: Golden retriever
(n = 4), boxer (n = 2), Beagle (n = 1), Siberian Husky (n = 3), German
shepherd dog (n = 1), Labrador retriever (n = 1), French bulldog (n = 1)
and cross-breed dogs (n = 4).
Evaluation of lesions and laboratory work-up
Physical examination was performed for all dogs. Complete blood
count and serum chemistry panels were available for nine and seven dogs,
respectively. A tentative diagnosis of oral or cutaneous papillomatosis
was made based on the history and physical examination. All dogs
were anaesthetized, and biopsies of the oral and cutaneous lesions
were taken for histopathological examination. Tissue samples were
fixed in 10% buffered formalin, processed routinely and embedded in
paraffin. Four- to five-micrometre paraffin sections were stained with
haematoxylin and eosin.
Allocation to treatment group and owners’ evaluation
Dogs were randomized into the two treatment groups by tossing a
coin to determine treatment group for the first case. The remaining
dogs were enrolled in alternating treatment groups. Both owners and
investigators were blinded regarding the allocation to groups. One
group, consisting of 10 dogs, received azithromycin suspension
(Zithromax®, Pfizer, New York, NY, USA) at a dosage of 10 mg/kg per
os every 24 h for 10 days, while the placebo group consisted of seven
dogs. The ingredients of the placebo included purified water.
Investigator’s evaluation of clinical lesions
Dogs were clinically scored on days 0, 5, 10, 15, 20, 25, 30 and 45.
Clinical scoring consisted of assessing the severity (absent = 0, mild
= 1, moderate = 2, severe = 3) of the papilloma lesions. The lesion
scoring was carried out by an investigator blinded to the treatment
the animals had received. While being handled for clinical scoring,
the dogs were also checked for localized and systemic signs of any
adverse reactions to the azithromycin treatment. For the duration of
the treatment, all dogs were checked daily for adverse reactions to
treatment.
Statistical analysis
Differences in the clinical score between the two groups on
the examination days were assessed using Mann–Whitney U-tests. The
clinical success rates of each treatment group were compared on the
examination days by using Wilcoxon tests (Windows version of SPSS
13.0, SPSS Inc., Chicago, IL, USA). Significance was defined as P < 0.05.
Results
Physical examination of the present dogs revealed no
dermatological abnormalities, other than the oral (n = 12;
seven in the azithromycin group and five in the placebo
© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.
Azithromycin therapy of canine papillomatosis
group) or cutaneous papillomas (n = 5; three in the azithro-
mycin group and two in the placebo group). These con-
sisted of small round growths with a rough surface located
on the lips (n = 7), tongue (n = 5), nipple (n = 1), vulva-
vaginal junction (n = 1), ventral abdomen (n = 1) and the
eyelids (n = 2). They appeared as whitish, verrucose, 1- to
2.7-mm papules. Results of the complete blood counts
available in nine dogs and serum chemistry panels available
in seven dogs were within normal limits.
Papillomatosis was confirmed in all cases by the
histopathological examination. There was parakeratotic
hyperkeratosis, and marked acanthosis with the affected
epidermis three to four times thicker than neighbouring
normal epidermis and exhibiting finger-like projections into
the dermis (Fig. 1). The superficial keratinocytes were
characterized by pycnosis and numerous keratohyalin
granules, and perinuclear vacuoles that completely encir-
cled the nucleus in some cases. No inclusion bodies were
noticed in the keratinocytes. One case was diagnosed
with pigmented papilloma, which was characterized by
presence of melanin deposition in the basal layer of the
epidermis in addition to above findings (Fig. 2).
Treatment with azithromycin for 10 days resulted in
complete healing of all skin lesions in all 10 dogs. Complete
clinical remission was seen in 10–15 days. One case in the
placebo group showed spontaneous regression of
papillomas by day 41. In the remaining six cases treated
with placebo, papillomas were still evident by day 50. The
azithromycin treated cases were followed for 8 months,
during which time no recurrences of papillomas were
observed.
Investigator’s clinical scores (Fig. 3)
The azithromycin-treated group showed significant
improvement in scores at all time points from day 5
(P < 0.05) to day 45 (P < 0.001) compared to baseline.
There were no significant changes in clinical score in the
Figure 1. Papillomatosis showing severe acanthosis, with the affected
epidermis three to four times thicker than neighbouring normal
epidermis, and finger-like projections into the dermis. Haematoxylin
and eosin, ×120.
195
Ya©cı et al.
Figure 2. Pigmented papilloma with dense melanin pigmentation in
basal cells in addition to typical papillomatous epithelial proliferation.
Haematoxylin and eosin, ×120.
Figure 3. Investigator’s clinical scores between days 0 and 45. Ten
dogs were included in azithromycin treatment group, while seven
dogs were enrolled in placebo group. Comparison of the two groups
revealed that the clinical scores did not significantly differ between
the groups on day 0, while the azithromycin treatment group showed
a significantly lower clinical score than placebo group on days 5
(P < 0.05), 10, 15, 20, 25, 30 and 45 (all P < 0.001). *Indicates the
time at which the two groups were significantly different.
placebo group at all time points. Comparison of the two
groups revealed that the clinical scores did not differ
between the groups on day 0, whereas the azithromycin
group showed a significantly lower clinical score than the
placebo group on day 5 (P < 0.05), and days 10, 15, 20, 25,
30 and 45 (P < 0.001).
Discussion
In this study, azithromycin was found to be effective in
decreasing clinical lesion scores in dogs with papillomato-
sis. The beneficial effect of azithromycin in this study is in
keeping with the therapeutic inflammatory potential effect
of azithromycin reported on human papillomatosis.6–10 In
an attempt to mimic clinical practice, clinical evaluations
including lesion scores were the main outcome measures
in this trial. The scoring system used in this study had not
been previously validated, to the authors’ knowledge,
because there are no other detailed clinical trials on dogs
with papillomatosis. This scoring system, however, was
purposely designed to evaluate both the extent and the
196
severity of the disease as in other accepted scoring
systems used in veterinary and human medicine.14–21
Canine oral papillomavirus (COPV) is an important
model for mucosal human papillomavirus infection.1 Dogs
are usually infected with at least four variants of papilloma-
viruses,3 with oral papillomatosis caused by a specific
papillomavirus recognized as COPV.1,4 COPV causes papillo-
matosis on the oral mucosa, the conjunctiva and external
nares.3 Canine oral papillomas induced by COPV are
common in younger puppies and are characterized by
multiple, invasive, cauliflower-like hyperkeratotic masses
evident on the tongue, lips, palate gingiva, buccal mucosa
and pharynx.5 The biopsy samples collected prior to
treatment; exhibited characteristic features of papillomatosis.
Although COPV is an important aetiological factor in
canine papillomatosis, no characteristic pox virus inclusion
bodies in keratinocytes were observed on histopathology.
In one case, a cross-breed dog, pigmented papilloma was
identified. In pugs, genetic factors rather than viruses are
thought to be primarily responsible for pigmented papillomas.22
There are reports identifying viral antigen in papillomas
using immunoperoxidase-stained anti-COPV antibody.22,23
In the present study, we were unable to demonstrate the
possible presence of viral antigen because of the lack of a
commercially available anti-COPV antibody.
Papillomatosis in dogs may be a self-limiting disease,
requiring no treatment. However, persistent lesions may
be associated with defective cell-mediated immunization.
Papillomaviruses are very resistant within the environment
and are difficult to eliminate with disinfectants.3 Many
therapeutic trials for the treatment of papillomatosis have
been reported, including live papilloma virus vaccine.14
However, side-effects including squamous cell carcinomas
at the vaccine injection site were observed in the latter
study.14 Other reported treatment options include specific
vaccinations,24 Propionibacterium acnes25 and cimetidine;26
however, no single treatment has been shown to be superior.
Live papillomavirus vaccines have been associated with
squamous cell carcinomas at the injection site following
vaccination,14,24 but no adverse effects were noticed
following azithromycin treatment in this study.
Macrolide antibiotics have been widely used in human
medicine and there has been great interest shown in their
therapeutic potential for various infectious and noninfectious
diseases.27 It is unclear whether they modulate the host
inflammatory responses or whether they eliminate latent
pathogens that could possibly trigger chronic inflammation.27
The efficacy of azithromycin, one of the azalide subclass
of macrolide antibiotics, in human papillomatosis has well
been documented in various studies and case series.6–10
In the present study, the lesions disappeared following
azithromycin therapy in all treated cases, suggesting that
azithromycin therapy is a safe and effective therapy for
canine papillomatosis. It is unknown whether azithromycin
has any antiviral activity or whether its efficacy is due to
other mechanisms. Further studies on the mode of action
are therefore required.
Acknowledgements
The authors would like to thank Oguz Kul for his kind help
with interpreting the histopathology.
© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.
 Azithromycin therapy of canine papillomatosis

A staging system for assessing severity of disease and response

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Résumé L’azithromycine, un antibiotique azalide de la sous classe des macrolides, est efficace, bien
toléré et sûr pour le traitement de la papillomatose de l’homme. Cette étude rapporte les résultats cliniques
et histopathologiques d’une étude randomisée, prospective, en double aveugle contrôlée par placebo, de
17 chiens de races variées souffrant de papillomatose orale (n = 12) ou cutanée (n = 5) traitée avec l’azithromycine.
Les papillomes apparaissaient comme des papules blanchâtres, verruqueusesn hyperkératosiques, d’une
taille de 1–2.7 mm. les chiens ont été traités soit par l’azithromycine (n = 10) ou par le placebo (n = 7).
Les propriétaires comme le vétérinaire ne savaient pas le traitement administré. L’azithromycine (10 mg/kg)
a été administrée par voie orale tous les jours pendant 10 jours. Les évaluations cliniques étaient réalisées
par le même investigateur pendant toute l’étude. Le traitement avec l’azithromycine a permis une diminution
significative des scores cliniques (P < 0.001), alors qu’aucune modification n’a été observée dans le groupe
placebo. Dans le groupe azithromycine les lésions ont disparu en 10–15 jours. Un cas du groupe placebo
a présenté une régression spontanée des lésions à J41, mais des lésions étaient toujours évidentes à J50
pour les 6 autres cas. Aucune récurrence n’a été observée dans le groupe azithromycine après un suivi de
8 mois. aucun effet secondaire n’a été observé. En conclusion, l’azithromycine apparait comme un
traitement efficace et sûr de la papillomatose canine.

© 2008 The Authors. Journal compilation © 2008 ESVD and ACVD. 197
Ya©cı et al.

Resumen La azitromicina, un antibiótico macrólido en la subclase de las azalidas, es una terapia efectiva,
bien tolerada y segura para el tratamiento de la papilomatosis en seres humanos. Este estudio presenta los
resultados clínicos e histopatológicos de un estudio prospectivo, al azar, doble ciego y controlado por
placebo en 17 perros de varias razas con diagnóstico previo de papilomatosis oral (n = 12) y cutánea (n = 5)
tratados con azitromicina. Los papilomas se presentaban en forma de pápulas hiperqueratóticas blanquecinas y
verrugosas de 1–2.7 mm de tamaño. Los casos se asignaron al azar al grupo de tratamiento con azitromicina
(n = 10) o al grupo placebo (n = 7). Tanto los dueños como los investigadores desconocían la distribución
de los animales en los grupos. La azitromicina (10 mg/kg) se administró por vía oral cada 24 horas durante
10 días. La evaluación clínica fue hecha por el mismo investigador durante la prueba. El tratamiento
con azitromicina redujo de forma significativa los valores clínicos (P < 0.001), mientras que no hubo cambios
en el grupo placebo. En el grupo tratado con azitromicina las lesiones desaparecieron en 10–15 días. Un
caso placebo presentó regresión espontánea de los papilomas en el día 41, pero las lesiones eran aun
evidentes en los seis perros restantes en el día 50. No hubo recurrencia de la papilomatosis en los animales
tratados con azitromicina (seguimiento durante 8 meses). No se observaron efectos adversos en
ninguno de los grupos. En resumen, concluimos que la azitromicina parece ser un tratamiento seguro y
efectivo frente a la papilomatosis canina.

Zusammenfassung Azithromycin, ein Azalid-Antibiotikum der Untergruppe Makrolidantibiotika, ist eine

effektive, gut verträgliche und sichere therapeutische Behandlungsmöglichkeit für die Papillomatose
des Menschen. Dieser Bericht beschreibt die klinischen und histopathologischen Ergebnisse einer
prospektiven, randomisierten, doppel-geblindeten, Plazebo-kontrollierten Studie bei 17 Hunden
unterschiedlicher Rasse mit einer Diagnose von oraler (n = 12) und kutaner Papillomatose (n = 5), die mit
Azithromycin behandelt worden war. Die Papillome traten als weißliche, warzenartige, hyperkeratotische
Papeln mit einer Größe von 1–2.7 mm auf. Die Fälle wurden zufällig der Azithromycin (n = 10) und der
Plazebo-Gruppe (n = 7) zugeordnet. Beide, BesitzerInnen und InvestigatorInnen, waren bezüglich der
Gruppenzuordnung geblindet. Azithromycin (10 mg/kg) wurde 10 Tage lang alle 24 Stunden per os verabreicht.
Die klinische Evaluierung wurde von derselben untersuchenden Person während der gesamten Studie
durchgeführt. Durch die Behandlung mit Azithromycin wurden die klinischen Werte signifikant vermindert
(P < 0.001), während in der Plazebo-Gruppe keine Veränderung zu beobachten war. In der Azithromycin-
Gruppe verschwanden die Hautläsionen innerhalb von 10–15 Tagen. Ein Fall in der Plazebo-Gruppe zeigte
bis zum 41. Tag eine spontane Remission der Papillome, während die Läsionen bei den übrigen 6 Fällen
am Tag 50 nach wie vor vorhanden waren. Bei den Hunden, die mit Azithromycin behandelt worden waren,
kam es zu keinem erneuten Auftreten der Papillomatose (Nachuntersuchungen bis zu 8 Monate später). In
keiner der beiden Gruppen wurden Nebenwirkungen festgestellt. Zusammenfassend scheint Azithromycin
eine sichere und effektive Behandlung für die canine Papillomatose zu sein.

198 © 2008 The Authors. Journal compilation © 2008 ESVD and ACVD.