1
|
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.
Collapse
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.
| |
Collapse
|
2
|
Yu H, Cen J, Lin X, Cheng H, Seifert O. Imiquimod induced vitiligo-like lesions-A consequence of modified melanocyte function. IMMUNITY INFLAMMATION AND DISEASE 2021; 10:70-77. [PMID: 34614305 PMCID: PMC8669695 DOI: 10.1002/iid3.543] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/10/2021] [Accepted: 09/22/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Imiquimod plays an important role in the management of condyloma and premalignant lesions. Successively, an increase of hypopigmented lesions following imiquimod application has been reported. However, the mechanisms of imiquimod on melanocytes remain unclear. This study was designed to assess the effect of Imiquimod on the functions of melanocytes in vitro. METHODS Primary cultured melanocytes were isolated from normal control skin tissue. After incubation with imiquimod for 48 h in vitro, cell viability was analyzed by cell counting kit-8 assay. Apoptosis was detected using the Annexin V-fluorescein-5-isothiocyanate flow cytometry assay. Melanin content and tyrosinase activity in melanocytes were measured by colorimetric method and the modified dopachrome method. The production of inflammatory cytokine interleukin 8 (IL-8), IL-6, and soluble ICAM-1 (soluble Intercellular Adhesion Molecule-1[sICAM-1]) in melanocytes were measured by enzyme-linked immunosorbent assay (ELISA). Toll-like receptor 7 (TLR7), toll-like receptor 9 (TLR9) protein, and autophagy-related proteins microtubule-associated protein 1A/1B-light chain 3 (LC3-II), p62, mechanistic target of rapamycin (mTOR), and Atg5 were assessed using western blot analysis. RESULTS Imiquimod significantly inhibited the activity of tyrosinase activity and decreased melanin content in melanocytes and significantly increased apoptosis and IL-6, IL-8, and sICAM-1 production in melanocytes. Moreover, the expression of TLR7 and TLR9 proteins were significantly increased, and the expression of mTOR, p62 protein were markedly decreased, but the expression of LC3II/I and Atg5 protein were significantly increased in melanocytes after incubating with imiquimod. CONCLUSIONS This study shows that imiquimod directly inhibits melanogenesis and increases melanocyte apoptosis rates. These effects combined with the upregulation of TLR7 and TLR9 together with increased autophagy activity and inflammatory cytokines production, might be the main reasons leading to hypopigmented lesions after imiquimod application.
Collapse
Affiliation(s)
- Haiyan Yu
- Department of Dermatology, Sir Run Run Shaw Hospital, Zhejiang University Medical College, Hangzhou, Zhejiang, China
| | - Jianping Cen
- Department of Dermatology, Sir Run Run Shaw Hospital, Zhejiang University Medical College, Hangzhou, Zhejiang, China
| | - Xiaoxia Lin
- Department of Dermatology, Sir Run Run Shaw Hospital, Zhejiang University Medical College, Hangzhou, Zhejiang, China
| | - Hao Cheng
- Department of Dermatology, Sir Run Run Shaw Hospital, Zhejiang University Medical College, Hangzhou, Zhejiang, China
| | - Oliver Seifert
- Division of Dermatology and Venereology, Ryhov Hospital, Jönköping, Sweden.,Division of Cell Biology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| |
Collapse
|
3
|
Anthony N, Bourneau-Martin D, Ghamrawi S, Lagarce L, Babin M, Briet M. Drug-induced vitiligo: a case/non-case study in Vigibase ® , the WHO pharmacovigilance database. Fundam Clin Pharmacol 2020; 34:736-742. [PMID: 32246859 DOI: 10.1111/fcp.12558] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 03/26/2020] [Accepted: 03/29/2020] [Indexed: 02/06/2023]
Abstract
Vitiligo is a common depigmenting disorder ensuing the loss of epidermal melanocytes. It is a multifactorial disease with immunological, genetic and environmental factors including drug exposure. The purpose of the study was to investigate the drugs and therapeutic subclasses associated with vitiligo occurrence reported in VigiBase® , the WHO pharmacovigilance database. A case/non-case study was carried out by defining cases as vitiligo reports and non-cases as all other reports. The reporting odds ratio (ROR) was calculated for the 'suspected' drugs and drug classes according to ATC level 4. During the study period, 741 cases of vitiligo were registered. Mean age was 49 ± 20 years. The disproportionality analysis showed an association between vitiligo and pembrolizumab (ROR 116.9, 95% Confidence Interval (CI) 94.8, 144.3), nivolumab (ROR 22.6, 95% CI 15.8, 32.4), ipilimumab (ROR 41.7, 95% CI 25.0, 69.7), imiquimod (ROR 152.8, 95% CI 103.0, 226.7), adalimumab (ROR 3.8, 95% CI 2.5,5.8), infliximab (ROR 2.6, 95% CI 1.65, 4.01), alemtuzumab (ROR 27.8, 95% CI 17.6, 43.9), and ustekinumab (ROR 9.3, 95% CI 5.6, 15.6). Concerning the pharmacological classes ATC level 4, a significant association was found with monoclonal antibodies, interferons, selective immunosuppressants, TNF-alpha inhibitors, interleukin inhibitors, and topical antivirals. This study confirmed the expected associations between vitiligo and immune checkpoint inhibitors and strengthened the emerging signal about the association between vitiligo and imiquimod, TNF-alpha inhibitors and interferons. New signals were shown with selective immunosuppressants including alemtuzumab and interleukin inhibitors.
Collapse
Affiliation(s)
- Norah Anthony
- Service de Pharmacologie-Toxicologie et Pharmacovigilance, Centre hospitalo-Universitaire d'Angers, 4 rue larrey, 49100, Angers, France
| | - Delphine Bourneau-Martin
- Service de Pharmacologie-Toxicologie et Pharmacovigilance, Centre hospitalo-Universitaire d'Angers, 4 rue larrey, 49100, Angers, France
| | - Sarah Ghamrawi
- Service de Pharmacologie-Toxicologie et Pharmacovigilance, Centre hospitalo-Universitaire d'Angers, 4 rue larrey, 49100, Angers, France
| | - Laurence Lagarce
- Service de Pharmacologie-Toxicologie et Pharmacovigilance, Centre hospitalo-Universitaire d'Angers, 4 rue larrey, 49100, Angers, France
| | - Marina Babin
- Service de Pharmacologie-Toxicologie et Pharmacovigilance, Centre hospitalo-Universitaire d'Angers, 4 rue larrey, 49100, Angers, France
| | - Marie Briet
- Service de Pharmacologie-Toxicologie et Pharmacovigilance, Centre hospitalo-Universitaire d'Angers, 4 rue larrey, 49100, Angers, France.,Université d'Angers, Angers, France.,Laboratoire MitoVasc, UMR CNRS 6214 INSERM 1083, Angers, France
| |
Collapse
|
4
|
Kim NH, Lee JB, Yun SJ. Development of Vitiligo-Like Depigmentation after Treatment of Lentigo Maligna Melanoma with 5% Imiquimod Cream. Ann Dermatol 2018; 30:454-457. [PMID: 30065586 PMCID: PMC6029957 DOI: 10.5021/ad.2018.30.4.454] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/24/2017] [Accepted: 08/28/2017] [Indexed: 11/08/2022] Open
Abstract
A 69-year-old man presented with a black irregular patch on his left cheek. Skin biopsy revealed lentigo maligna melanoma in situ. He was treated via partial excision of the melanoma, followed by the application of 5% imiquimod cream every other night for 6 to 8 hours. The patient experienced severe local inflammation accompanied by burning, edema, and erythema, as well as oozing and crusting. The patient discontinued using the imiquimod cream after 15 applications because of the inflammation. Depigmentation was noted in the treated area 3 months after the initiation of treatment with imiquimod cream. Histological examination using Melan-A staining of the depigmented area revealed an absence of melanocytes, which is consistent with vitiligo. The depigmented lesions improved considerably after a 5-year follow-up, and there was no recurrence of melanoma.
Collapse
Affiliation(s)
- Na Hee Kim
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea
| | - Jee Bum Lee
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea
| | - Sook Jung Yun
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea
| |
Collapse
|
5
|
Long FQ, Zhao LS, Qian YH. Vitiligo or Vitiligo-like Hypopigmentation Associated with Imiquimod Treatment of Condyloma Acuminatum: Not a Casual Event. Chin Med J (Engl) 2017; 130:503-504. [PMID: 28218231 PMCID: PMC5324394 DOI: 10.4103/0366-6999.199846] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Fu-Quan Long
- STD Institute, Shanghai Dermatology Hospital, Shanghai 200443, China
| | - Li-Shi Zhao
- STD Institute, Shanghai Dermatology Hospital, Shanghai 200443, China
| | - Yi-Hong Qian
- STD Institute, Shanghai Dermatology Hospital, Shanghai 200443, China
| |
Collapse
|
6
|
Serra MC, Menicanti C, Pennacchioli E, Tosti G. Vulvar vitiligo-like depigmentation and multiple halos of hypomelanosis at the trunk following treatment with imiquimod 5% cream for vulvar condylomata: casual or related events? An Bras Dermatol 2015; 89:806-7. [PMID: 25184923 PMCID: PMC4155962 DOI: 10.1590/abd1806-4841.20143058] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 09/20/2013] [Indexed: 11/22/2022] Open
Abstract
A 25-year-old Caucasian female with multiple genital warts involving the vulvar area
was treated with imiquimod 5% cream. During follow-up the patient developed areas of
hypopigmentation at the site of application of imiquimod cream and areas of
hypomelanosis around multiple preexisting nevi of the trunk. At 18 months follow-up
genital depigmentation persisted and halo nevi of the trunk were still present.
Different mechanisms of imiquimod-induced depigmentation have been reported. Halo
nevi are considered expression of an autoimmune response. In the case presented here,
it might be conceivable that both vitiligo-like depigmentation at the site of
application and halo of hypomelanosis around melanocytic nevi have been induced by
the same immunologic mechanism elicited by topical application of imiquimod.
Collapse
Affiliation(s)
| | - Claudia Menicanti
- Dipartimento di Fisiopatologia Medico-Chirurgica, Ospedale Maggiore Policlinico, Fondazione IRCSS Ca' Granda, Milano, Italia
| | | | - Giulio Tosti
- Divisione Melanoma, Istituto Europeo di Oncologia, Milano, Italia
| |
Collapse
|
7
|
Reusser NM, Downing C, Guidry J, Tyring SK. HPV Carcinomas in Immunocompromised Patients. J Clin Med 2015; 4:260-81. [PMID: 26239127 PMCID: PMC4470124 DOI: 10.3390/jcm4020260] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 12/13/2014] [Accepted: 12/19/2014] [Indexed: 12/20/2022] Open
Abstract
Human papillomavirus (HPV) infection is the most common sexually transmitted disease worldwide and can result in pre-malignancies or overt malignancies of the skin and mucosal surfaces. HPV-related illnesses are an important personal and public health problem causing physical, mental, sexual and financial detriments. Moreover, this set of malignancies severely affects the immunosuppressed population, particularly HIV-positive patients and organ-transplant recipients. There is growing incidence of HPV-associated anogenital malignancies as well as a decrease in the average age of affected patients, likely related to the rising number of high-risk individuals. Squamous cell carcinoma is the most common type of HPV-related malignancy. Current treatment options for HPV infection and subsequent disease manifestations include imiquimod, retinoids, intralesional bleomycin, and cidofovir; however, primary prevention with HPV vaccination remains the most effective strategy. This review will discuss anogenital lesions in immunocompromised patients, cutaneous warts at nongenital sites, the association of HPV with skin cancer in immunocompromised patients, warts and carcinomas in organ-transplant patients, HIV-positive patients with HPV infections, and the management of cutaneous disease in the immunocompromised patient.
Collapse
Affiliation(s)
- Nicole M Reusser
- Medical School, the University of Texas Health Science Center at Houston, 6431 Fannin, Houston, TX 77030, USA.
| | | | - Jacqueline Guidry
- Center for Clinical Studies, 1401 Binz, Suite 200, Houston, TX 77004, USA.
| | - Stephen K Tyring
- Medical School, the University of Texas Health Science Center at Houston, 1401 Binz, Suite 200, Houston, TX 77004, USA.
| |
Collapse
|
8
|
Husain S, Abdul Y, Webster C, Chatterjee S, Kesarwani P, Mehrotra S. Interferon-gamma (IFN-γ)-mediated retinal ganglion cell death in human tyrosinase T cell receptor transgenic mouse. PLoS One 2014; 9:e89392. [PMID: 24586745 PMCID: PMC3938457 DOI: 10.1371/journal.pone.0089392] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 01/20/2014] [Indexed: 02/04/2023] Open
Abstract
We have recently demonstrated the characterization of human tyrosinase TCR bearing h3T-A2 transgenic mouse model, which exhibits spontaneous autoimmune vitiligo and retinal dysfunction. The purpose of current study was to determine the role of T cells and IFN-γ in retina dysfunction and retinal ganglion cell (RGC) death using this model. RGC function was measured by pattern electroretinograms (ERGs) in response to contrast reversal of patterned visual stimuli. RGCs were visualized by fluorogold retrograde-labeling. Expression of CD3, IFN-γ, GFAP, and caspases was measured by immunohistochemistry and Western blotting. All functional and structural changes were measured in 12-month-old h3T-A2 mice and compared with age-matched HLA-A2 wild-type mice. Both pattern-ERGs (42%, p = 0.03) and RGC numbers (37%, p = 0.0001) were reduced in h3T-A2 mice when compared with wild-type mice. The level of CD3 expression was increased in h3T-A2 mice (h3T-A2: 174 ± 27% vs. HLA-A2: 100%; p = 0.04). The levels of effector cytokine IFN-γ were also increased significantly in h3T-A2 mice (h3T-A2: 189 ± 11% vs. HLA-A2: 100%; p = 0.023). Both CD3 and IFN-γ immunostaining were increased in nerve fiber (NF) and RGC layers of h3T-A2 mice. In addition, we have seen a robust increase in GFAP staining in h3T-A2 mice (mainly localized to NF layer), which was substantially reduced in IFN-γ ((-/-)) knockout h3T-A2 mice. We also have seen an up-regulation of caspase-3 and -9 in h3T-A2 mice. Based on our data we conclude that h3T-A2 transgenic mice exhibit visual defects that are mostly associated with the inner retinal layers and RGC function. This novel h3T-A2 transgenic mouse model provides opportunity to understand RGC pathology and test neuroprotective strategies to rescue RGCs.
Collapse
Affiliation(s)
- Shahid Husain
- Hewitt Laboratory of the Ola B. Williams Glaucoma Center, Department of Ophthalmology, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Yasir Abdul
- Hewitt Laboratory of the Ola B. Williams Glaucoma Center, Department of Ophthalmology, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Christine Webster
- Department of Surgery, Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Shilpak Chatterjee
- Department of Surgery, Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Pravin Kesarwani
- Department of Surgery, Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Shikhar Mehrotra
- Department of Surgery, Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, United States of America
| |
Collapse
|
9
|
Chatterjee S, Eby JM, Al-Khami AA, Soloshchenko M, Kang HK, Kaur N, Naga OS, Murali A, Nishimura MI, Caroline Le Poole I, Mehrotra S. A quantitative increase in regulatory T cells controls development of vitiligo. J Invest Dermatol 2013; 134:1285-1294. [PMID: 24366614 PMCID: PMC3989443 DOI: 10.1038/jid.2013.540] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 11/11/2013] [Accepted: 11/14/2013] [Indexed: 12/14/2022]
Abstract
T cell cytolytic activity targeting epidermal melanocyte is shown to cause progressive depigmentation and autoimmune vitiligo. Using the recently developed transgenic mice h3TA2 that carry T cell with a HLA-A2 restricted human tyrosinase reactive TCR and develop spontaneous vitiligo from an early age, we addressed the mechanism regulating autoimmune vitiligo. Depigmentation was significantly impaired only in IFN-γ knockout h3TA2 mice but not in TNF-α or perforin knockout h3TA2 mouse strains, confirming a central role for IFN-γ in vitiligo development. Additionally, the regulatory T cells (Treg) were relatively abundant in h3TA2-IFN-γ−/− mice, and depletion of Treg employing anti-CD25 antibody fully restored the depigmentation phenotype in h3TA2-IFN-γ−/− mice mediated in part through upregulation of pro-inflammatory cytokines as IL-17and IL-22. Further therapeutic potential of Treg abundance in preventing progressive depigmentation was evaluated by adoptively transferring purified Treg or using rapamycin. Both adoptive transfer of Treg and rapamycin induced lasting remission of vitiligo in mice treated at the onset of disease, or in mice with established disease. This leads us to conclude that reduced regulatory responses are pivotal to the development of vitiligo in disease-prone mice, and that a quantitative increase in the Treg population may be therapeutic for vitiligo patients with active disease.
Collapse
Affiliation(s)
- Shilpak Chatterjee
- Department of Surgery, Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jonathan M Eby
- Department of Pathology, Microbiology and Immunology, Oncology Research Institute, Loyola University, Maywood, Illinois, USA
| | - Amir A Al-Khami
- Department of Surgery, Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Myroslawa Soloshchenko
- Department of Surgery, Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Hee-Kap Kang
- Department of Pathology, Microbiology and Immunology, Oncology Research Institute, Loyola University, Maywood, Illinois, USA
| | - Navtej Kaur
- Department of Surgery, Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Osama S Naga
- Department of Surgery, Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Anuradha Murali
- Department of Surgery, Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - I Caroline Le Poole
- Department of Pathology, Microbiology and Immunology, Oncology Research Institute, Loyola University, Maywood, Illinois, USA
| | - Shikhar Mehrotra
- Department of Surgery, Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA.
| |
Collapse
|
10
|
Kwon HH, Cho KH. Induction of Vitiligo-Like Hypopigmentation after Imiquimod Treatment of Extramammary Paget's Disease. Ann Dermatol 2012. [PMID: 23197922 PMCID: PMC3505787 DOI: 10.5021/ad.2012.24.4.482] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Hyuck Hoon Kwon
- Department of Dermatology, College of Medicine, Seoul National University, Seoul, Korea
| | | |
Collapse
|
11
|
Abstract
Imiquimod is a small molecule with adjuvant pro-inflammatory effects that can be topically delivered as a cream for treating external genital and perianal warts. In our report, two Chinese males at the ages of 25 and 22 years were treated with imiquimod 5% cream for recurrent condyloma accuminatum, three times per week for 18 and 12. weeks, respectively. Depigmentation were noted and gradually enlarged in the treated areas after the two patients discontinued imiquimod. Therefore, clinicians should be made aware of the possible pigmentary changes associated with application of this cream.
Collapse
Affiliation(s)
- Ruzhi Zhang
- Department of Dermatology, The First Affiliated Hospital of Bengbu Medical College, Anhui, China
| | | |
Collapse
|