LETTER TO EDITOR
|Year : 2008 | Volume
| Issue : 2 | Page : 102-104
Augmented effect of five percent imiquimod cream and antiretroviral therapy in resolution of giant molluscum contagiosum
Sanjiv V Choudhary, Adarshlata Singh, Sumit Gupta, Sankha Koley
Department of Dermatology, Jawaharlal Nehru Medical College, Sawangi, Maharashtra, India
Sanjiv V Choudhary
28, Modern Nagpur Society, Chhatrapati Nagar, Nagpur-15 (M.S)
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Choudhary SV, Singh A, Gupta S, Koley S. Augmented effect of five percent imiquimod cream and antiretroviral therapy in resolution of giant molluscum contagiosum. Indian J Sex Transm Dis 2008;29:102-4
|How to cite this URL:|
Choudhary SV, Singh A, Gupta S, Koley S. Augmented effect of five percent imiquimod cream and antiretroviral therapy in resolution of giant molluscum contagiosum. Indian J Sex Transm Dis [serial online] 2008 [cited 2020 Aug 13];29:102-4. Available from: http://www.ijstd.org/text.asp?2008/29/2/102/48737
Molluscum contagiosum is a benign self-limiting viral infection caused by the molluscum contagiosum virus of the pox virus family. In adults with genital lesions, the infection is usually sexually transmitted. Atypical (giant, warty, multiple, and extensive) and recalcitrant lesions have been described in patients with HIV infection. In most of the patients with AIDS, Molluscum contagiosum lesions are found to be extragenital. The various sites affected are neck, axillae, groin and buttocks.  Molluscum contagiosum occurring in HIV-infected patients are resistant to conventional treatment modalities. Imiquimod, a heterocyclic imidazoquinoline amide, is an immune response modifying drug that has potent antiviral and antitumor activities.  We report a case of giant Molluscum contagiosum in an HIV +ve patient showing marked regression of lesions in a short duration, with combined use of 5% imiquimod cream and antiretroviral therapy (ART).
A 25-year-old male, unmarried, patient presented with multiple asymptomatic raised solid lesions involving the right groin since the past one year. History of multiple unprotected heterosexual exposures was present with commercial sex workers. Cutaneous examination revealed multiple small dome-shaped umbilicated papules and giant nodules (0.5 to 2.5 cm) involving the right groin region [Figure 1]. The Enzyme-Linked Immunosorbent Assay (ELISA) test was positive for HIV antibodies. His CD4 T-cell count was 36/mm 3 . Blood Veneral Disease Research Laboratory (VDRL) was negative, the Giemsa stain of the material from a papule demonstrated squamous cells with round basophilic molluscum contagiosum inclusion bodies [Figure 2]. The histopathology of skin biopsy from the lesion was consistent with molluscum contagiosum. The patient was already on ART with stavudine 40 mg, lamivudine 150 mg, and nevirapine 200 mg, all were given twice daily since the past three months. Cryotherapy was tried to destroy the molluscum lesions. But the patient was not tolerating the pain due to cryotherapy. We applied topical KOH 10% once daily for two weeks, but the response was not satisfactory and patient developed superficial erosions. After healing of the erosions, the patient was put on topical 5% imiquimod cream for overnight application, five days in a week. After six weeks of topical treatment the lesions on his right groin regressed by 90% [Figure 3]. Complete resolution of lesions was seen at the end of eight weeks of topical treatment [Figure 4]. His CD4 T-cell count was 68/mm 3 after six months of ART.
Molluscum contagiosum lesions in immunocompromised patients will be mostly atypical and extragenital, as seen in our patient. Therapies targeted at boosting the immune system in the immunocompromised have proven to be most effective in such cases.  Imiquimod is the first member of a new class of immunomodulator drugs, which modulate and upregulate the immune system by inducing the production of cytokines like IFN-gamma, IFN-alpha, and IL-12.
Imiquimod is currently not approved by the Food and Drug Administration (FDA) for the treatment of molluscum contagiosum. However, studies and reports evaluating the role of imiquimod cream in treating molluscum revealed a high clearance rate. , Sen S and Bhaumik P, in their report, revealed that there was a good response to ART when treating giant molluscum contagiosum in immunocompromised patients.  However, it took nine months to clear the lesions of molluscum with ART. Hengge, Esser, Schultewolter, et al ., in a study of 15 patients with molluscum, using an overnight application of 5% imiquimod cream, five days per week, for 16 consecutive weeks, revealed only 53% total clearance. 
In our case the patient was already on ART for the past three months, when he was presented to us with giant molluscum lesions. After six weeks of treatment with 5% imiquimod cream, the patient revealed 90% clearance in lesions and a complete resolution of lesions was seen at the end of eight weeks of topical treatment. The marked regression of lesions in a short duration could be explained by the combined effect of ART and 5% imiquimod cream in augmenting the immune response both systemically and locally. Such marked regression of lesions in a short duration was not observed when ART or imiquimod cream was used alone. Ronald Buckley and Kathleen Smith in their report also revealed a marked regression of molluscum lesions in an HIV positive patient, with three months combined use of 5% imiquimod cream and ART.  Imiquimod has the added benefit of a self-application topical therapy, which tends to be preferred by the patients, thus reducing the number of hospital visits. However, it cannot be used extensively in our day-to-day practice due to its high cost.
This case is reported to highlight the augmented effect of 5% imiquimod cream and antiretroviral therapy in resolution of giant molluscum contagiosum in an HIV infected patient.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]