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Imiquimod-Associated Localized Skin Ulceration in a Patient With Uncontrolled Diabetes. Obstet Gynecol 2022; 140:316-319. [DOI: 10.1097/aog.0000000000004851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 04/21/2022] [Indexed: 11/26/2022]
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Hammerl V, Parlar B, Navarini A, Gantenbein L, Väth H, Mueller SM. Mucosal side effects in patients treated with topical imiquimod-A scoping review of the literature. Dermatol Ther 2020; 34:e14355. [PMID: 32990395 DOI: 10.1111/dth.14355] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/05/2020] [Accepted: 09/23/2020] [Indexed: 11/28/2022]
Abstract
Imiquimod 5% is approved for topical treatment of actinic keratosis (AKs), superficial basal cell carcinoma and condylomata acuminata, the 3.75% formulation for the treatment of AKs and genital warts. Imiquimod has also been used off-label in various other skin conditions (eg, Bowen's disease, lentigo maligna, vulvar intraepithelial neoplasia). As a toll-like receptor 7/8 (TLR7/8) agonist imiquimod induces a local inflammatory response by increased production of cytokines, co-stimulatory molecules, activation of Nk-cells and antigen-specific T-cells. In addition to imiquimod-associated adverse effects at non-application sites such as fever, vertigo or myalgia there have been anecdotal reports of distant inflammatory mucosal reactions-a side effect not declared in the medicinal product information. In this scoping review we collected a total of seven cases of patients with lesions of the oral mucosa and lips and summarized pathophysiological hypotheses to explain this type of side effect. The review is complemented with an illustrated report of a 87-year-old female patient of ours suffering from chronic lymphocytic leukemia (CLL) who developed severe oral mucosal and labial reactions following application of imiquimod 3.75% for treatment of AKs. She denied accidental transfer of imiquimod and was tested negative for herpes simplex virus (PCR) and bacteria (culture) from lesional swabs.
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Affiliation(s)
- Veronika Hammerl
- Department of Dermatology, University Hospital Basel, Basel, Switzerland
| | - Betül Parlar
- Department of Dermatology, University Hospital Basel, Basel, Switzerland
| | - Alexander Navarini
- Department of Dermatology, University Hospital Basel, Basel, Switzerland
| | - Lorena Gantenbein
- Department of Dermatology, University Hospital Basel, Basel, Switzerland
| | - Helga Väth
- Private Dermatology Practice, Binningen, Switzerland
| | - Simon M Mueller
- Department of Dermatology, University Hospital Basel, Basel, Switzerland
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Maroñas-Jiménez L, Morales-Raya C, Burillo-Martínez S, Velasco-Tamariz V, Rodríguez-Peralto JL, Vanaclocha-Sebastián F. Aphthous vulvar ulcers: a paradoxal adverse effect at distance of topical imiquimod? Eur J Obstet Gynecol Reprod Biol 2015; 198:156-157. [PMID: 26330283 DOI: 10.1016/j.ejogrb.2015.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 08/07/2015] [Accepted: 08/13/2015] [Indexed: 10/23/2022]
Affiliation(s)
| | - Carlos Morales-Raya
- Department of Dermatology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | - Jose Luis Rodríguez-Peralto
- Department of Pathology, Hospital Universitario 12 de Octubre, Universidad Complutense, Instituto de Investigación I+12, Madrid, Spain
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Smith WA, Siegel D, Lyon VB, Holland KE. Psoriasiform eruption and oral ulcerations as adverse effects of topical 5% imiquimod treatment in children: a report of four cases. Pediatr Dermatol 2013; 30:e157-60. [PMID: 22612595 DOI: 10.1111/j.1525-1470.2012.01780.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Imiquimod 5% cream is a topical immune-response modifier indicated in the treatment of multiple cutaneous conditions including actinic keratoses, superficial basal cell carcinoma, and condylomata acuminata. In children, it has been approved only for ages 12 and older in the treatment of external genital and perianal warts. It has also been used off label for a variety of pediatric skin disorders, including molluscum contagiosum (MC), trichoepitheliomas, verrucae plana, and verrucae vulgaris. Local and systemic adverse reactions have been reported, with the most frequently reported events being application site reactions including itching, burning, erythema, and erosion. Although these local reactions are well known, other rare local and systemic reactions can occur. There have been multiple case reports in adults of rare adverse cutaneous reactions occurring with imiquimod, but few have been reported in children. We present four cases of rare adverse cutaneous reactions. In all cases, the children were being treated with imiquimod 5% cream for verrucae or MC. Two of these patients developed a localized psoriasiform eruption, and two developed mucosal ulcerations.
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Affiliation(s)
- Wallace A Smith
- Medical College of WisconsinDepartment of Dermatology, Medical College of Wisconsin Milwaukee, Wisconsin
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Gormley RH, Kovarik CL. Human papillomavirus-related genital disease in the immunocompromised host: Part II. J Am Acad Dermatol 2012; 66:883.e1-17; quiz 899-900. [PMID: 22583721 DOI: 10.1016/j.jaad.2010.12.049] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 12/19/2010] [Indexed: 12/17/2022]
Abstract
Human papillomavirus is responsible for common condyloma acuminata and a number of premalignant and malignant anogenital lesions. The immunocompromised population is at particular risk because of a higher incidence of malignant transformation. Lesions in this population may prove refractory to standard treatment. This is part II of a two-part review that will discuss the treatment of condyloma acuminata and vaginal, vulvar, penile, and anal intraepithelial neoplasias. This article will provide an updated review of available treatments, with a focus on recent advances and the challenges faced in successfully treating human papillomavirus lesions in the immunocompromised host.
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Affiliation(s)
- Rachel H Gormley
- Department of Dermatology, Division of Infectious Diseases, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
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Abstract
Cytokine dermatitis is a well-known and common clinical adverse effect of imiquimod 5% cream (Aldara, 3M). Data from initial Phase III clinical trials reveal a minority of study drug patients experience systemic adverse effects, including fever, arthralgia, headache, myalgia, and lymphadenopathy. These adverse effects are caused, presumably, from increased absorption of study drug over the area of dermatitis, leading to systemic cytokine release. Furthermore, the incidence of systemic reactions was rarely statistically increased above control patients. We describe herein a case of severe cytokine dermatitis in a 2-year-old female patient treated with daily imiquimod for molluscum contagiosum who subsequently developed febrile seizure. We believe this to be the first reported case of seizure associated with imiquimod 5% cream (Aldara, 3M) in a pediatric setting.
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Lacarrubba F, Nasca MR, Micali G. Advances in the use of topical imiquimod to treat dermatologic disorders. Ther Clin Risk Manag 2011; 4:87-97. [PMID: 18728724 PMCID: PMC2503670 DOI: 10.2147/tcrm.s1109] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Imiquimod (IQ) is an immune-response modifying agent, first approved by FDA for the topical treatment of external genital and perianal warts in 1997. It induces, through stimulation of Toll-like receptors (TLRs) localized on the surface of antigen-presenting cells, synthesis and release of several endogenous pro-inflammatory cytokines such as interferon-α (IFN-α), tumor necrosis factor-α (TNF-α) and interleukins (IL) 6 and 12, which in turn stimulate both the innate and acquired immune pathways, resulting in upregulation of natural antiviral and antitumor activity. IQ 5% cream has been used for the treatment of a wide variety of dermatologic conditions in which the immune system is thought to play a role in regression of the disease. In some disorders, such as genital and perianal warts, actinic keratoses, basal cell carcinomas, Bowen’s disease and molluscum contagiosum, relative safety and efficacy are supported by randomized controlled trials of IQ. However, it is common for patients to experience local skin reactions, which can range from mild to severe in intensity, but usually resolve 1–2 weeks after interrupting treatment. Additional randomized trials are encouraged to assess safety and efficacy of IQ in the treatment of an even wider range of cutaneous disorders.
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Santos-Juanes J, Esteve A, Mas-Vidal A, Coto-Segura P, Salgueiro E, Gómez E, Galache Osuna C. Acute Renal Failure Caused by Imiquimod 5% Cream in a Renal Transplant Patient: Review of the Literature on Side Effects of Imiquimod. Dermatology 2011; 222:109-12. [DOI: 10.1159/000323737] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 12/19/2010] [Indexed: 11/19/2022] Open
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Possible Association between Th1 Immune Polarization and Epithelial Permeability with Toll-Like Receptors 2 Dysfunction in the Pathogenesis of the Recurrent Aphthous Ulceration. ACTA ACUST UNITED AC 2010. [DOI: 10.1155/2010/163804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Recurrent Aphthous Ulceration (RAU) is a chronic oral inflammatory disease that affects approximately 25% of the general population. The etiology of the disease is unknown; however, factors that favor the onset of RAU have been correlated with a Th1 immune polarization, while factors that reduce RAU episodes have been associated with down regulation of immune reaction or stimulation of the peripheral tolerance. In this context, the integrity of the epithelial barrier is also fundamental for the prevention of the disease and conditions that augment its permeability or produce disruption are considered potential triggers. The key factor responsible for increased susceptibility is unclear, though a deficiency of Toll-like receptor (TLR) activity seems to be a good candidate. TLRs are a group of membrane proteins that recognize conserved molecules derived from bacterial, virus, fungal, or host tissues. Particularly, the TLR2 is involved in both immune regulation and control of epithelial barrier integrity. Thus, based on literature review, we showed evidences that correlate the TLR2 dysfunction and the diverse predisposing factors with the elements considered critical for disease pathogenesis: the Th1 immune reaction and the increased epithelial permeability.
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Micali G, Lacarrubba F, Dinotta F, Massimino D, Nasca MR. Treating skin cancer with topical cream. Expert Opin Pharmacother 2010; 11:1515-27. [DOI: 10.1517/14656566.2010.481284] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Diluvio L, Campione E, Jasmine Paternò E, Orlandi A, Terrinoni A, Chimenti S. Peculiar clinical and dermoscopic remission pattern following imiquimod therapy of basal cell carcinoma in seborrhoeic areas of the face. J DERMATOL TREAT 2009; 20:124-9. [DOI: 10.1080/09546630802441226] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Borra RC, De Mesquita Barros F, De Andrade Lotufo M, Villanova FE, Andrade PM. Toll-like receptor activity in Recurrent Aphthous Ulceration. J Oral Pathol Med 2009; 38:289-98. [DOI: 10.1111/j.1600-0714.2008.00743.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Kaya TI, Tursen U, Ikizoglu G. Large genital ulcers in a patient with Behçet’s disease associated with imiquimod cream treatment for external genital warts. Clin Exp Dermatol 2008; 33:783-4. [DOI: 10.1111/j.1365-2230.2008.02839.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Corticoides tópicos en la estomatitis aftosa recurrente. Revisión sistemática. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2008. [DOI: 10.1016/s0001-6519(08)73314-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Wagstaff AJ, Perry CM. Topical imiquimod: a review of its use in the management of anogenital warts, actinic keratoses, basal cell carcinoma and other skin lesions. Drugs 2008; 67:2187-210. [PMID: 17927284 DOI: 10.2165/00003495-200767150-00006] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Topical imiquimod 5% cream (Aldara) is an immune response modulator that is indicated for the treatment of external anogenital warts, superficial basal cell carcinoma and actinic keratoses. The cream is applied two to five times per week for varying periods, depending on the indication. Topical imiquimod cream has also been evaluated in the treatment of several other skin conditions. Immunomodulatory therapy with topical imiquimod 5% is an effective option for the approved indications. The drug appears to be relatively well tolerated, with the option of breaks from treatment as required for local skin reactions (which are common). Systemic reactions have been reported. Treatment of human papillomavirus- and UV-associated skin lesions with topical imiquimod offers a noninvasive, tissue-sparing alternative to ablative treatment options. However, well designed trials of the sustained, long-term efficacy and tolerability of topical imiquimod versus those of common treatment approaches including surgery and other topical alternatives are required before the place of the drug in the management of these lesions can be finalised. Nonetheless, while other treatments for anogenital warts, superficial basal cell carcinoma or actinic keratoses are available, the advantages of self treatment linked with the demonstrated efficacy of topical imiquimod offer an attractive alternative for many patients.
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Quijano D, Rodríguez M. Topical Corticosteroids in Recurrent Aphthous Stomatitis. Systematic Review. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2008. [DOI: 10.1016/s2173-5735(08)70242-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Campanelli A, Lübbe J. Erosive cheilitis after facial application of imiquimod 5% cream. J Eur Acad Dermatol Venereol 2007; 21:1429-30. [DOI: 10.1111/j.1468-3083.2007.02238.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Nasca MR, De Pasquale R, Micali G. Multiple and clustered eruptive epidermoid cysts following treatment with topical imiquimod. Dermatology 2007; 215:352-3. [PMID: 17911995 DOI: 10.1159/000107630] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Accepted: 04/02/2007] [Indexed: 11/19/2022] Open
Abstract
A 61-year-old woman developed multiple and clustered eruptive epidermoid cysts at the site of treatment of a basal cell carcinoma located on her nose with imiquimod 5% cream (5 times/week for 6 weeks). Clearing was achieved after topical treatment with tretinoin 0.025% cream (1 application/day for 1 month).
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