Traitement par cidofovir topique d’infections cutanées à papillomavirus humain, poxvirus et Herpes simplex virus chez des malades séropositifs pour le VIH

Topical cidofovir for benign human papillomavirus–associated skin lesions

Cidofovir is a broad-spectrum antiviral agent that has shown efficacy against skin lesions caused by human papillomavirus (HPV). We present a case of extensive verruca vulgaris lesions refractory to imiquimod that was responsive to topical cidofovir therapy, and analyze other case series in the literature of successful treatment of benign HPV-associated skin lesions with topical cidofovir. Topical cidofovir’s favorable response rate and tolerability make it a useful treatment option for patients of differing ages and immune status who have nonmalignant HPV-associated skin lesions and desire topical therapy.

Molluscum contagiosum in pediatric patients: to treat or not to treat? Could a personalized imiquimod regimen be the answer to the dilemma?

Background: Although molluscum contagiosum virus (MCV) infection is a common disease widespread among children and young adults, there is no shared opinion on treatment that can be divided into physical, chemical, medical (immunomodulating or anti-viral). According to some authors, MCV is best left to clear by itself.Objectives: To assess the clearance of MCV lesions in a sample of pediatric patients. It compares outcomes in treated with Imiquimod cream, compared with non-treated patients.Methods: The sample consits of 48 pediatric patients affected by MVC clinically diagnosed. It was divided into two groups: Group I, treated with Imiquimod 5% cream once/day until the onset of a visible inflammatory reaction. Once the reaction was illicited, application was suspended until the irritation resolved. If the lesion was still present, drug was administered again using the same regimen. The cycle was repeated until complete clinical resolution. Group II, control, comprises non-treated patients. Follow up visits were carried out 12, 16, 20, 48, and 52 weeks from the beginning of treatment.Results: At week 20, all patients except one in the treated group were lesion free. Persistence of MCV lesions was documented in one patient only until week 48. In the control group all patients were still affected by MCV lesions during the follow-up period. Spontaneous clinical resolution of the infection was observed in only 2 patients at week 52. The results of the study show Imiquimod's significant efficacy.Conclusions: Our study is one of the few case-control studies in pediatric population carried out with such long-term follow-up. Efficacy of this personalized treatment, scarce recurrence, absence of cicatricial sequelae and lack of necessity for deep sedation, in the case of children with disseminated lesions, makes the use of Imiquimod the first line of treatment compared with other destructive treatments or with no-treatment at all.

BRAF inhibitor-associated cutaneous squamous cell carcinoma: new mechanistic insight, emerging evidence for viral involvement and perspectives on clinical management

Mutations in the BRAF proto-oncogene occur in the majority of cutaneous melanomas. The commonly detected valine (V) to glutamate (E) mutation (V600E) is known to drive melanomagenesis and has thus been the target of two highly selective chemotherapeutic agents: vemurafenib and dabrafenib. While BRAF inhibitor therapy has revolutionized the treatment of metastatic melanoma, unanticipated cutaneous toxicities, including the development of cutaneous squamous cell carcinomas (cSCCs), are frequently reported and hinder therapeutic durability. However, the mechanisms by which BRAF inhibitors induce cutaneous neoplasms are poorly understood, thus posing a challenge for specific therapies. In this review, we summarize the clinical and molecular profiles of BRAF inhibitor-associated cSCCs, with a focus on factors that may contribute to disease pathogenesis. In particular, we discuss the emerging evidence pointing towards viral involvement in BRAF inhibitor-induced cutaneous neoplasms and offer new perspectives on future therapeutic interventions. Continued clinical and mechanistic studies along this line will not only allow for better understanding of the pathogenic progression of BRAF inhibitor-induced cSCCs, but will also lead to development of new therapeutic and preventative options for patients receiving targeted cancer therapy.

Molluscum Contagiosum Viral Infection Treated With a Dilute Povidone-Iodine/Dimethylsulfoxide Preparation

Introduction

Molluscum contagiosum is a viral infection of the skin that is spread from direct contact, either via person to person by touching affected lesions or innocuously via fomites. The condition is often socially stigmatizing, motivating patients to seek treatment. There are many anecdotal remedies, but none have been overwhelmingly effective in controlled clinical trials.

Case Report

A 16-year-old girl presented with approximately 75 lesions on her inner thighs as a result of friction from an athletic uniform. She tried over-the-counter antibiotic ointment and topical steroids for several weeks without improvement, and was concerned at the rate of spread of the lesions, along with the social implications.

Conclusion

The topical povidone-iodine/dimethylsulfoxide system is very effective in eradicating molluscum contagiosum. This novel combination warrants further investigation in randomized, controlled trials to further elucidate its clinical utility.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-015-0091-4) contains supplementary material, which is available to authorized users.

Molluscum contagiosum virus infection

Molluscum contagiosum virus is an important human skin pathogen: it can cause disfigurement and suffering in children, in adults it is less common and often sexually transmitted. Extensive and persistent skin infection with the virus can indicate underlying immunodeficiency. Traditional ablative therapies have not been compared directly with newer immune-modulating and specific antiviral therapies. Advances in research raise the prospect of new approaches to treatment informed by the biology of the virus; in human skin, the infection is localised in the epidermal layers, where it induces a typical, complex hyperproliferative lesion with an abundance of virus particles but a conspicuous absence of immune effectors. Functional studies of the viral genome have revealed effects on cellular pathways involved in the cell cycle, innate immunity, inflammation, and cell death. Extensive lesions caused by molluscum contagiosum can occur in patients with DOCK8 deficiency-a genetic disorder affecting migration of dendritic and specialised T cells in skin. Sudden disappearance of lesions is the consequence of a vigorous immune response in healthy people. Further study of the unique features of infection with molluscum contagiosum virus could give fundamental insight into the nature of skin immunity.

[Usefulness of topical cidofovir treatment for recalcitrant molluscum contagiosum in immunocompromised children]

Molluscum contagiosum (MC) is common and often numerous and recalcitrant in immunocompromised children. The response to available treatments is frequently unsatisfactory. Cidofovir is a nucleoside analog of the deoxycytidine antiviral drug approved for the intravenous treatment of cytomegalovirus retinitis in AIDS patients. We report four cases of children, 5-8 years old, who developed extensive MC in the context of chemotherapy for acute lymphoid leukemia and who were treated with a cream containing cidofovir 1%. In all patients, the lesions began to regress within 2 to 4 months. For three patients, complete regression was observed in 7 to 9 months, and the children remained clear of recurrence. For one patient, partial regression was obtained after 17 months of treatment. No side effects have been observed. Treatment of MC in immunocompromised children is difficult because the usual treatments are inappropriate. Successful use of either topically or intralesionally administered cidofovir in several virally induced cutaneous diseases has been demonstrated and recently documented in the treatment of MC in immunocompromised adults. Conversely, its use in children is not documented. Although intravenous use of cidofovir may lead to severe adverse effects, one single case of a systemic side effect has been reported after topical use at a greater concentration, but no changes in laboratory data were observed. Topical cidofovir offers an effective and well-tolerated therapeutic alternative option for the treatment of MC in immunosuppressed children.

Zoonotic Brazilian Vaccinia virus: from field to therapy

Vaccinia virus (VACV), the prototype species of the Orthopoxvirus (OPV) genus, causes an occupational zoonotic disease in Brazil that is primarily associated with the handling of infected dairy cattle. Cattle and human outbreaks have been described in southeastern Brazil since 1999 and have now occurred in almost half of the territory. Phylogenetic studies have shown high levels of polymorphisms among isolated VACVs, which indicate the existence of at least two genetically divergent clades; this has also been proven in virulence assays in a mouse model system. In humans, VACV infection is characterized by skin lesions, primarily on the hands, accompanied by systemic symptoms such as fever, myalgia, headache and lymphadenopathy. In this review, we will discuss the virological, epidemiological, ecological and clinical aspects of VACV infection, its diagnosis and compounds that potentially could be used for the treatment of severe cases.

Novel treatment of atypical human papillomavirus-associated epithelial hyperplasia with cidofovir

PURPOSE

We report a severe case of human papillomavirus-associated epithelial hyperplasia in a man infected with human immunodeficiency virus. These lesions were recalcitrant to treatment with surgical modalities and were eventually controlled with the daily application of a topical cidofovir gel.

PATIENT AND METHODS

A single case is presented, along with a relevant review of the published data.

RESULTS

Before the initiation of cidofovir treatment, the patient had approximately 80% of his gingiva and buccal mucosa engrossed by confluent papillomatous lesions. At 2 weeks after cidofovir treatment, the lesions had markedly regressed, and by 4 weeks, they were almost fully resolved. No untoward adverse reactions occurred.

CONCLUSIONS

Cidofovir formulated as a gel can be safe and effective for the treatment of epithelial hyperplasia in those with human immunodeficiency virus infection.

Chronic mucocutaneous herpes simplex virus and varicella zoster virus infections

Chronic herpes simplex virus (CHSV) and chronic varicella zoster virus (CVZV) are defined as atypical mucocutaneous wart-like and/or ulcerative HSV or VZV infections, persisting for at least 1 month. Both are commonly associated with HIV infection and may occasionally present with other types of immunosuppression. CHSV and CVZV occur despite the immune restoration effect of highly active antiretroviral therapy for HIV. The clinical polymorphism of CHSV and CVZV makes recognition difficult. Histology, immunohistology, PCR and viral culture all help to confirm the diagnosis. Treatment is frequently complicated by resistance to thymidine kinase (TK)-dependent antivirals, including acyclovir, valacyclovir and famciclovir. Viral culture remains an essential tool for antiviral drug susceptibility testing. Therapeutic alternatives include non-TK-dependent antivirals, such as foscarnet or cidofovir, which directly target viral DNA polymerase. With few exceptions, CHSV and CVZV infections do not constitute significant risk factors for disseminated cutaneous or systemic infection. This review compares the similarities of and differences between CHSV and CVZV infections.

[Extensive oral condylomas treated by in situ cidofovir injection in an HIV patient]

BACKGROUND

Human papillomavirus infections are difficult to treat and have a high rate of recurrence, especially in a setting of human immunodeficiency (HIV) infection. Moreover, there is no standard treatment for oral condylomas.

PATIENTS AND METHODS

We report the partial success of in situ injections of cidofovir in an HIV patient, presenting extensive oral condylomas. The injections were well tolerated and the response was still present at one year while the immune status of the patient was unchanged.

DISCUSSION

The efficacy of topical cidofovir against condyloma acuminata has been reported and the value of in situ cidofovir injections for the treatment of laryngeal papillomatosis is well established. This case report shows the need for further investigation of in situ cidofovir injections as an alternative treatment for human papillomavirus lesions that are difficult to treat because of both site and extension.

Oral topical cidofovir: novel route of drug delivery in a severely immunosuppressed patient with refractory multidrug-resistant herpes simplex virus infection

We present a case of serious treatment-refractory acyclovir- and foscarnet-resistant herpes simplex virus (HSV) type-1 orolingual infection that responded to oral cidofovir rinses after failure of acyclovir and foscarnet therapy. The use of 3% cidofovir in a saline rinse for refractory mucosal HSV infection appears promising but needs prospective evaluation.

Molluscum contagiosum profus au cours d’une dermatite atopique traitée par tacrolimus : intérêt du cidofovir

BACKGROUND

Tacrolimus applied locally is a non-steroid anti-inflammatory drug with proven efficacy in atopic dermatitis. Skin infections can occur, especially viral infections.

CASE-REPORT

A 35-year-old male patient had been treated for extensive atopic dermatitis for several months with tacrolimus (Protopic). After six months of treatment, he presented a large eruption of molluscum contagiosum, in particular on the zones that had received a substantial amount of tacrolimus. The treatment was discontinued and application of a preparation containing cidofovir led to the patient's quick complete recovery, without recurrence in the ensuing months.

DISCUSSION

Viral skin infections, in particular poxvirus infections, are prompted by topical immunosuppressant treatments such as tacrolimus, usually in dose-dependent fashion. Paradoxically, they provide protection against bacterial infections by restoring the integrity of the cutaneous barrier. Application of cidofovir successfully treated a severe form of molluscum contagiosum rapidly without any noticeable adverse effects. This confirms several observations about the efficacy and the good safety of this drug in the treatment of infections by DNA viruses. It provides an additional therapeutic prospect for immunodepressed patients who often present extensive and resistant forms of infections that are usually common.

A prospective randomized trial comparing the efficacy and adverse effects of four recognized treatments of molluscum contagiosum in children

Molluscum contagiosum is a common viral disease of childhood presenting as small, firm, dome-shaped umbilicated papules. Although benign and generally self-limited, this condition is contagious and can lead to complications such as inflammation, pruritus, dermatitis, bacterial superinfection, and scars. No consensus has been established concerning the management of this condition. We conducted a prospective randomized study comparing four common treatments for molluscum contagiosum in 124 children aged 1 to 18 years. One group was treated with curettage, a second with cantharidin, a third with a combination of salicylic acid and lactic acid, and a fourth with imiquimod. Patients needing, respectively, one, two, or three visits for treatment of their mollusca were: 80.6%, 16.1%, and 3.2% for curettage, 36.7%, 43.3%, and 20.0% for cantharidin, 53.6%, 46.4%, and 0% for salicylic acid and glycolic acid, and 55.2%, 41.4%, and 3.4% for imiquimod. The rate of side effects was 4.7% for group 1, 18.6% for group 2, 53.5% for group 3, and 23.3% for group 4. Curettage was found to be the most efficacious treatment and had the lowest rate of side effects. It must be performed with adequate anesthesia and is a time-consuming procedure. Cantharidin is a useful bloodless alternative particularly in the office setting, but has moderate complications due to blisters and necessitated more visits in our experience. The topical keratolytic used was too irritating for children. Topical imiquimod holds promise but the optimum treatment schedule has yet to be determined. Finally, we believe that the ideal treatment for mollusca depends on the individual patient preference, fear, and financial status, distance from the office, and whether they have dermatitis or blood-borne infections.

Detection of Molluscum contagiosum Virus (MCV) Subtype I as a Single Dominant Virus Subtype in Molluscum Lesions from a Turkish Population

BACKGROUND

Molluscum contagiosum has a worldwide occurrence and its primary mode of transmission is via direct human contact including sexual means. The aim of the study was to implement a polymerase chain reaction-based assay for detection and subtyping of Molluscum contagiosum virus (MCV) in skin lesions diagnosed with molluscum contagiosum in a large regional teaching hospital in Turkey.

METHODS

For this purpose, a total of 61 patients were included in the study. Randomly selected single lesion from each patient was used to extract DNA material and a specific PCR reaction amplifying 393-bp- and 575-bp-long regions from MCV genome was used in the detection. Subtyping was carried out by digestion of the amplified 575-bp product with restriction endonuclease enzyme BamHI. Both amplified and restriction enzyme digested products visualized on agarose gel electrophoresis.

RESULTS

All 61 molluscum cases (100%) included in the study contained MCV genetic material as demonstrated by the presence of 393- and 575-bp-long PCR amplified products. Restriction enzyme BamHI digestion of the 575-bp-long amplicon indicated that the infecting subtype in all the cases (100%) was MCV subtype I.

CONCLUSIONS

Results of this study demonstrate that subtype I is the only infecting strain dominant in our region. Because the only consecutive molluscum patients admitted to our hospital were included in the study, our data do not rule out the possibility that other genotypes might be present in the Turkish population. However, it is not unreasonable to conclude that similar trends exist in the rest of the country. Results also show that a molecular-based diagnostic assay would be feasible in cases where diagnosis was deemed necessary.