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Zhang X, Xie Y, Wang L. Rare Cutaneous Side Effects of Imiquimod: A Review on Its Mechanisms, Diagnosis, and Management. Dermatol Ther (Heidelb) 2023; 13:1909-1934. [PMID: 37528289 PMCID: PMC10442311 DOI: 10.1007/s13555-023-00978-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 07/05/2023] [Indexed: 08/03/2023] Open
Abstract
As an immune-response modifier, imiquimod can bind to Toll-like receptors on immune cells and enhance innate and adaptive immune responses, exerting potential antitumor and antiviral effects, which led to its approval by the US Food and Drug Administration for the treatment of actinic keratosis, superficial basal cell carcinomas, and anogenital warts, and to its off-label use in treating many other benign and malignant dermatoses. Although topical administration of imiquimod has been considered well tolerated, an increasing number of cutaneous and noncutaneous side effects are being reported as its clinical applications expand. This review primarily focuses on rare cutaneous side effects. To the best of our knowledge, this is the first article to summarize the mechanism, diagnosis, and management of rare cutaneous side effects of imiquimod, which may help to heighten awareness among physicians, especially dermatologists, about potential imiquimod-induced cutaneous side effects.
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Affiliation(s)
- Xiaoyan Zhang
- Department of Dermatovenereology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yao Xie
- Department of Dermatovenereology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Lin Wang
- Department of Dermatovenereology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
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2
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Leeyaphan C, Nanchaipruek Y, Phinyo P. Therapeutic outcomes and prognostic factors in patients with hypertrophic herpes simplex infection treated with imiquimod: A systematic review and meta-analysis of individual patient data from case reports and case series. J Dermatol 2022; 49:879-886. [PMID: 35632986 DOI: 10.1111/1346-8138.16446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/22/2022] [Accepted: 05/05/2022] [Indexed: 11/26/2022]
Abstract
Hypertrophic herpes simplex (HHS) often has atypical presentations, such as a hypertrophic mass or ulcers, with chronic courses. This situation poses a diagnostic challenge and results in delayed treatment. Imiquimod was used as a treatment for HHS by several studies, but the therapeutic outcomes varied. This systematic review and meta-analysis of individual patient data was conducted to investigate the therapeutic outcomes and prognostic factors of imiquimod treatment for patients with HHS. Biomedical databases (Embase, PubMed, Medline, Cochrane Controlled Trials Register, and ClinicalTrials.gov) were searched for all types of clinical studies reporting the complete cure rate and the time to complete response to imiquimod therapy between 1926 and 2021. Quantitative analysis of individual patient data was performed using multivariable flexible parametric survival regression with cluster variance correction. A total of 12 019 articles were identified and screened for eligibility. Twenty-five studies (21 case reports and four case series) with a combined total of 42 patients were included. The complete cure rate for imiquimod treatment was estimated at 88.1%. The median time to complete response was 60 days (95% confidence interval 35-70). Combined treatment, male sex, and an age less than 50 years were identified as significant prognostic factors for a shorter time to complete cure. A severe local reaction was reported in 2.3%. Imiquimod therapy has high effectiveness and safety in curing HHS. Patients who were male or younger than 50 years or whose treatments were combined with thymidine kinase-dependent antivirals had the best prognoses and were more likely to respond to treatment.
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Affiliation(s)
- Charussri Leeyaphan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yanisorn Nanchaipruek
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Musculoskeletal Science and Translational Research, Chiang Mai University, Chiang Mai, Thailand
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3
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Oliveira SRD, Assoni AS, Vargas TJDS, Daxbacher E. Acyclovir-resistant chronic mucocutaneous herpes with good response to the association with imiquimod in an AIDS patient: case report. An Bras Dermatol 2022; 97:264-266. [PMID: 35039209 PMCID: PMC9073243 DOI: 10.1016/j.abd.2020.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/01/2020] [Accepted: 10/13/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
| | | | | | - Egon Daxbacher
- Hospital Federal de Bonsucesso, Rio de Janeiro, RJ, Brazil
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4
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Bhagchandani S, Johnson JA, Irvine DJ. Evolution of Toll-like receptor 7/8 agonist therapeutics and their delivery approaches: From antiviral formulations to vaccine adjuvants. Adv Drug Deliv Rev 2021; 175:113803. [PMID: 34058283 PMCID: PMC9003539 DOI: 10.1016/j.addr.2021.05.013] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 05/04/2021] [Accepted: 05/15/2021] [Indexed: 02/07/2023]
Abstract
Imidazoquinoline derivatives (IMDs) and related compounds function as synthetic agonists of Toll-like receptors 7 and 8 (TLR7/8) and one is FDA approved for topical antiviral and skin cancer treatments. Nevertheless, these innate immune system-activating drugs have potentially much broader therapeutic utility; they have been pursued as antitumor immunomodulatory agents and more recently as candidate vaccine adjuvants for cancer and infectious disease. The broad expression profiles of TLR7/8, poor pharmacokinetic properties of IMDs, and toxicities associated with systemic administration, however, are formidable barriers to successful clinical translation. Herein, we review IMD formulations that have advanced to the clinic and discuss issues related to biodistribution and toxicity that have hampered the further development of these compounds. Recent strategies aimed at enhancing safety and efficacy, particularly through the use of bioconjugates and nanoparticle formulations that alter pharmacokinetics, biodistribution, and cellular targeting, are described. Finally, key aspects of the biology of TLR7 signaling, such as TLR7 tolerance, that may need to be considered in the development of new IMD therapeutics are discussed.
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Affiliation(s)
- Sachin Bhagchandani
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Department of Chemistry, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
| | - Jeremiah A Johnson
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Department of Chemistry, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02139, USA.
| | - Darrell J Irvine
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Department of Materials Science and Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Howard Hughes Medical Institute, Chevy Chase, MD 20815, USA; Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA.
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5
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Rodríguez DN, Cudós ES, Carnero JR, Pinto PH. Atypical Presentation of Herpes Simplex Virus Type 2 Infection Refractory to Treatment With Aciclovir in 2 Hematologic Patients. ACTAS DERMO-SIFILIOGRAFICAS 2019. [DOI: 10.1016/j.adengl.2019.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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6
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Tognarelli EI, Palomino TF, Corrales N, Bueno SM, Kalergis AM, González PA. Herpes Simplex Virus Evasion of Early Host Antiviral Responses. Front Cell Infect Microbiol 2019; 9:127. [PMID: 31114761 PMCID: PMC6503643 DOI: 10.3389/fcimb.2019.00127] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/10/2019] [Indexed: 12/21/2022] Open
Abstract
Herpes simplex viruses type 1 (HSV-1) and type 2 (HSV-2) have co-evolved with humans for thousands of years and are present at a high prevalence in the population worldwide. HSV infections are responsible for several illnesses including skin and mucosal lesions, blindness and even life-threatening encephalitis in both, immunocompetent and immunocompromised individuals of all ages. Therefore, diseases caused by HSVs represent significant public health burdens. Similar to other herpesviruses, HSV-1 and HSV-2 produce lifelong infections in the host by establishing latency in neurons and sporadically reactivating from these cells, eliciting recurrences that are accompanied by viral shedding in both, symptomatic and asymptomatic individuals. The ability of HSVs to persist and recur in otherwise healthy individuals is likely given by the numerous virulence factors that these viruses have evolved to evade host antiviral responses. Here, we review and discuss molecular mechanisms used by HSVs to evade early innate antiviral responses, which are the first lines of defense against these viruses. A comprehensive understanding of how HSVs evade host early antiviral responses could contribute to the development of novel therapies and vaccines to counteract these viruses.
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Affiliation(s)
- Eduardo I Tognarelli
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Tomás F Palomino
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Nicolás Corrales
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Susan M Bueno
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alexis M Kalergis
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile.,Departamento de Endocrinología, Facultad de Medicina, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo A González
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
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Dua P, Shinder R, Laskar DB, Lazzaro DR, Rizzuti AE. A case of hypertrophic herpes simplex virus affecting the eyelid and cornea masquerading as IgG4-related disease. Am J Ophthalmol Case Rep 2017; 9:68-71. [PMID: 29468223 PMCID: PMC5786855 DOI: 10.1016/j.ajoc.2017.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 12/07/2017] [Accepted: 12/11/2017] [Indexed: 11/22/2022] Open
Abstract
Purpose To report a case of hypertrophic herpes simplex virus (HSV) of the eyelid and cornea masquerading as IgG4-related disease. Observations A 37-year old African American female with a past medical history of human immunodeficiency virus (HIV) on highly active antiretroviral therapy (HAART) and a recent history of treated genital herpes, presented with an ulcerative lesion of the left upper and lower eyelids, and severe ocular inflammation with symblepharon. Initially, eyelid biopsy revealed findings consistent with IgG4-related disease, and the patient was treated with high dose oral prednisone. After one week of therapy, there was no improvement in the patient's symptoms, and she subsequently developed a corneal epithelial defect which progressed to chronic ulceration. Repeat biopsy and corneal cultures revealed herpes simplex virus type 2. The patient was treated with high dose acyclovir, and the lid lesion improved. The conjunctival inflammation and corneal epithelial defect resolved but symblepharon restricting her eye movement remained. She also developed corneal vascularization and opacification causing severe vision loss. Conclusions and importance Chronic hypertrophic herpes simplex virus infection is a rare condition reported in patients with HIV. While there have been few reports of hypertrophic HSV affecting the eyelid, this is the first reported case of hypertrophic HSV affecting the eye, resulting in severe vision loss.
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Affiliation(s)
- Prachi Dua
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Roman Shinder
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Derek B Laskar
- Department of Pathology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Douglas R Lazzaro
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Allison E Rizzuti
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, USA
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Atypical Presentation of Herpes Simplex Virus Type 2 Infection Refractory to Treatment With Aciclovir in 2 Hematologic Patients. ACTAS DERMO-SIFILIOGRAFICAS 2017; 110:393-397. [PMID: 29203034 DOI: 10.1016/j.ad.2017.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 09/07/2017] [Accepted: 09/10/2017] [Indexed: 11/20/2022] Open
Abstract
Herpesvirus infections are not uncommon in hematologic patients. Our first patient, diagnosed with chronic lymphatic leukemia, presented extensive genital herpes infection refractory to treatment with aciclovir and with a partial response to foscarnet, which had to be withdrawn due to systemic adverse effects. The second patient, diagnosed with follicular Hodgkin lymphoma, presented hypertrophic herpes infection refractory to treatment with aciclovir but that responded to intralesional cidofovir and topical imiquimod. As in other immunocompromised patients, herpesvirus infection in hematologic patients can present atypical manifestations, as well as resistance to treatments that are activated by the viral thymidine kinase. A high level of clinical suspicion is therefore needed to make an early diagnosis, together with extensive knowledge of the different treatments available.
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9
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Ogawa Y, Higuchi T, Koyamada R, Arai S, Okada S. Hypertrophic Herpes Simplex Virus Type 1 Infection in a Patient With Acute Myeloid Leukemia. J Hematol 2017; 6:68-71. [PMID: 32300396 PMCID: PMC7155823 DOI: 10.14740/jh333w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 06/29/2017] [Indexed: 12/18/2022] Open
Abstract
A 64-year-old woman had a transformation from polycythemia vera to acute myeloid leukemia. While she was treated with azacitidine and prednisolone, a nodule at the left angle of the mouth developed, which was biopsied and diagnosed with hypertrophic herpes simplex virus type 1 (HSV-1) infection. The nodule resolved completely with aciclovir. While HSV type 2 virus occasionally forms mass or tumoral lesions in immunocompromised, especially acquired immunodeficiency syndrome, patients, it is extremely rare that HSV-1 infection leads to similar lesions. The hematological conditions and the therapies given may have contributed to the rare manifestation of HSV-1 infection.
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Affiliation(s)
- Yusuke Ogawa
- Internal Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Takakazu Higuchi
- Division of Hematology, St. Luke's International Hospital, Tokyo, Japan
| | - Ryosuke Koyamada
- Division of Hematology, St. Luke's International Hospital, Tokyo, Japan
| | - Satoru Arai
- Department of Dermatology, St. Luke's International Hospital, Tokyo, Japan
| | - Sadamu Okada
- Division of Hematology, St. Luke's International Hospital, Tokyo, Japan
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10
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Leflunomide in the Treatment of a Pseudotumoral Genital Herpes Simplex Virus Infection in an HIV Patient. Case Rep Infect Dis 2017; 2017:1589356. [PMID: 28373917 PMCID: PMC5360951 DOI: 10.1155/2017/1589356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 01/18/2017] [Accepted: 01/31/2017] [Indexed: 12/03/2022] Open
Abstract
The patient is a 52-year-old African American man with a past medical history of HIV infection (on antiretroviral therapy, CD4 count 399 cells/µL, and undetectable HIV viral load) and recurrent genital herpes. While on valacyclovir, the patient presented with four tumorous lesions on the perineum and scrotum. A biopsy specimen stained positively with HSV-1 and HSV-2 immunostains and displayed a lymphoplasmacytic infiltrate. The patient received foscarnet and imiquimod for two weeks with minimal improvement. Based on the previous activity of leflunomide, which has both antiviral and immunomodulatory properties, in cytomegalovirus and herpes simplex infections, leflunomide 20 mg orally twice daily was started. The patient received 23 days of foscarnet, 14 days of topical imiquimod, and 11 days of leflunomide with approximately 80% reduction in the size of the perineal lesion. After nine months on leflunomide there was complete regression of the large perineal lesion and only two small ulcerations remained on the scrotum. Pseudotumoral herpes lesions in HIV patients represent an immune reconstitution event and are poorly responsive to the usual anti-herpes agents. This report demonstrates the successful use of leflunomide in the treatment of an HIV patient with pseudotumoral herpes. Thalidomide has also been used with some success.
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Tandon S, Singh J, Sinha S, Sharma DP. Recalcitrant hypertrophic herpes genitalis in HIV-infected patient successfully treated with topical imiquimod. Dermatol Ther 2017; 30. [PMID: 28261899 DOI: 10.1111/dth.12479] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 01/27/2017] [Accepted: 02/01/2017] [Indexed: 11/28/2022]
Abstract
Herpes Simplex Virus type 2 is the primary cause of genital ulceration worldwide. The presence of atypical features like deep ulcerations, hypertrophic, or pseudotumoural lesions or unusual location can be a marker for co-infection with HIV. These immunocompromised patients are usually resistant to the conventional antiviral treatment. We present a case of an HIV-infected patient with hypertrophic herpes genitalis, refractory to conventional oral antiviral therapy, who was successfully treated with a combination of oral valcyclovir and topical application of 5% imiquimod.
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Affiliation(s)
- Sidharth Tandon
- Department of Dermatology, Venereology and Leprosy, Post Graduate Institute of Medical Education and Research and Dr. Ram Manohar Lohia Hospital, New Delhi, 110001, India
| | - Jasmeet Singh
- Department of Dermatology, Venereology and Leprosy, Post Graduate Institute of Medical Education and Research and Dr. Ram Manohar Lohia Hospital, New Delhi, 110001, India
| | - Surabhi Sinha
- Department of Dermatology, Venereology and Leprosy, Post Graduate Institute of Medical Education and Research and Dr. Ram Manohar Lohia Hospital, New Delhi, 110001, India
| | - Dr Preeti Sharma
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India
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Parsons BF, Ryder N. Pseudoepitheliomatous hyperplasia causing a painful plaque in a HIV-infected female. Int J STD AIDS 2016; 28:723-725. [PMID: 28470128 DOI: 10.1177/0956462416676020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Dermatological conditions are more common and can present atypically, in human immunodeficiency virus-infected individuals. This case report describes a 22-year-old human immunodeficiency virus-positive Caucasian female who presented with a vulval lesion eight weeks after starting antiretroviral treatment. Clinical examination revealed a 2 cm well-demarcated plaque on the outer aspect of the left labium minus. The lesion was tender, no contact bleeding or ulceration present. She was presumptively treated for chancroid and herpes simplex with 500 mg ceftriaxone IM stat, 1 g azithromycin PO stat, and valacyclovir 500 mg BD for five days. The lesion persisted despite treatment, and during follow-up, a punch biopsy was carried out. She was diagnosed with pseudoepitheliomatous hyperplasia of the epidermis. In addition to highlighting this condition that has been previously reported in human immunodeficiency virus/herpes simplex virus co-infection, this case demonstrates that unusual skin presentations must be considered in human immunodeficiency virus-infected individuals and illustrates the importance of biopsy for any non-healing lesions.
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Affiliation(s)
- Bianca F Parsons
- 1 Pacific Clinic Newcastle, HNE Sexual Health, Newcastle, NSW, Australia
| | - N Ryder
- 1 Pacific Clinic Newcastle, HNE Sexual Health, Newcastle, NSW, Australia.,2 The Kirby Institute, University of New South Wales, Kensington, NSW, Australia.,3 School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia
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