Effect of imiquimod in anogenital warts from HIV-positive men

Viral Venereal Diseases of the Skin

Viral venereal diseases remain difficult to treat. Human papilloma virus (HPV) and herpes simplex virus (HSV) are two common viral venereal diseases. HPV infections are characterized by anogenital warts and less commonly by premalignant or malignant lesions. HSV infections classically present as grouped vesicles on an erythematous base with associated burning or pain; however, immunosuppressed patients may have atypical presentations with nodular or ulcerative lesions. This review discusses the epidemiology, diagnosis, and management of anogenital HPV and HSV infections with an emphasis on treatment modalities for the practicing dermatologist. Diagnosis of these diseases typically relies on clinical assessment, although multiple diagnostic techniques can be utilized and are recommended when diagnosis is uncertain or evaluating an individual with increased risk of malignancy. Management of HPV and HSV infections involves appropriate counseling, screening, and multiple treatment techniques. Particularly for HPV infections, a practitioner may need to use a combination of techniques to achieve the desired outcome.

Treatment of intra-anal warts with imiquimod 5% cream: A single-center prospective open study

Intra-anal warts are frequently recalcitrant to surgical removal, but imiquimod 5% cream is not formulated to use in clinical practice due to the risk of mucosal inflammation. In the present, prospective, open study examining the efficacy and safety of imiquimod 5% cream, the drug was applied to the entire inner surface of the anal canal with a cotton swab under anoscopy three times weekly for 16 weeks. If complete remission was not achieved, the treatment was continued until week 28. Electrocautery was applied once in a poorly responsive case. In total, 21 patients with intra-anal warts, of whom 16 were HIV-positive, were enrolled. Two patients withdrew before week 16, and nine more patients withdrew before week 28. The complete clearance rate was 36.8% (7/19) at week 16 and 70% (7/10) at week 28. Four patients achieved complete clearance at week 16 and maintained clearance at week 28 without further treatment. Three of four patients resistant to previous electrocautery achieved clearance with imiquimod 5% cream treatment. Adverse events occurred in 81% (17/21) of the patients mainly at the application site, but serious or previously unencountered adverse events were not observed. Imiquimod 5% cream applied to intra-anal warts was nearly as efficacious and safe as when applied to external anogenital warts. Since treatment modalities for intra-anal warts are very limited, application of imiquimod 5% cream alone with careful and frequent observation or in combination with electrocautery is a useful option for refractory cases of intra-anal wart.

Human papillomavirus-related genital disease in the immunocompromised host: Part II

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.

Topical treatment of anogenital human papillomavirus infection in male patients

Background: Human papillomavirus (HPV)-associated anogenital warts have a prevalence of up to 78% in sexually active men. Some HPV subtypes bear a considerable oncogenic potential. Materials & methods: Original papers on the treatment of external anogenital warts were included in a meta-analysis to assess the most effective topical treatment. Results: Clearance rates were 0–6.5% for placebo treatment, 76.6% for podophyllotoxin 0.15% cream administered for 4 weeks, 61.5% for podophyllotoxin 0.5% solution (2–6 weeks) and 53.7% for imiquimod 5% cream (12–16 weeks). For male patients, the intent-to-treat analysis demonstrated statistically significant superiority of podophyllotoxin preparations versus imiquimod (p < 0.0001 and p < 0.005, respectively). Clearance rates of locally ablative treatments, such as surgery, cryotherapy, electrocautery and carbon dioxide laser, differed widely without clear superiority of a specific ablative technique. In HIV-positive patients, all treatment options yielded lower clearance rates and higher recurrence rates. Conclusion: While preventive vaccines might reduce HPV-associated morbidity for future generations, those with active HPV disease still need to be treated with customary treatment options. In male patients, podophyllotoxin preparations yielded higher response rates than imiquimod.