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Imiquimod treatment of vulvitis circumscripta plasmacellularis
International Journal of Gynecology and Obstetrics (2006) 95, 161 — 162
www.elsevier.com/locate/ijgo
BRIEF COMMUNICATION
Imiquimod treatment of vulvitis circumscripta plasmacellularis A. Frega a,*, F. Rech a, D. French b a b
Department of Gynecology, Perinatology and Child Health, University bLa SapienzaQ, Rome, Italy Department of Experimental Medicine and Pathology, University bLa SapienzaQ, Rome, Italy
Received 2 March 2006; received in revised form 12 April 2006; accepted 3 May 2006
KEYWORDS Vulvitis circumscripta plasmacellularis; Imiquimod; Human papillomavirus
Vulvitis circumscripta plasmacellularis (VCP) is a rare but well-described condition affecting women of any age [1]. A biopsy is mandatory for VCP diagnosis because its clinical aspect is similar to that of several other conditions [2,3]. The present report describes 2 cases of VCP successfully treated with topical imiquimod (Aldara; 3-M Pharmaceuticals, Saint Paul, MN, USA). In March 1997, a 40-year-old woman underwent carbon dioxide laser vaporization of a vulvar wart caused by human papillomavirus (HPV). The results of an HPV test, performed by polymerase chain reaction, were positive for virus types 6 and 11. Follow-up tests results were negative. In November 2002 the patient complained that she had been experiencing vaginal discharge, vulvar erythema, pruritus, burning, and dyspareunia over * Corresponding author. E-mail address: [email protected] (A. Frega).
the previous 6 months. On clinical examination she had a reddish, eroded, circumscribed lesion on the inner aspects of both labia minora. A direct biopsy was performed and VCP detected (Figs. 1 and 2). The results of an HPV test were positive for viral types 6 and 11 although histologic signs of viral infection were absent. In the previous months, the patient had been treated with antibiotics as well as
Figure 1 Vulvar mucosa revealing flattened epidermis with erythrocytic permeation. Epithelium shows diamond shaped keratinocytes with intercellular edema. Submucosa reveals band-like plasmacytic inflammation.
0020-7292/$ - see front matter D 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2006.05.005
162
Figure 2 Epithelial—dermal interface. Band-like plasmacytic inflammation with capillary dilatation and deposits of hemosiderin.
oral and topical corticosteroids, without significant improvement. In April 1995 a 51-year-old woman underwent carbon dioxide laser vaporization of vulvar and perineal HPV lesions. The results of an HPV test and follow-up examination were the same as in the previous case. In September 2003, the patient complained of having experienced vulvar pruritus and burning, dysuria, and dryness over the previous 7 to 8 months. A vulvar examination revealed 2 well-defined, ulcerated, and hemorrhagic lesions. In the recent past, the patient had not received any treatment. A direct biopsy revealed changes similar to those described in the previous case, and the results of an HPV test were positive for viral types 6 and 11. Both patients were instructed to apply 5% imiquimod twice per week for 2 weeks, and 3 times
A. Frega et al. per week for another 8 weeks. The patients completed the entire treatment. Complete resolution was observed at the ninth and eighth week, respectively. The only adverse effect was irritation at the application site. To date, neither patient had lesion recurrence. An immune response modifier able to induce the production of interferon a, imiquimod is known to be effective in the topical treatment of external genital warts; 5% imiquimod fully resolved clinical VCP lesions that had been recalcitrant to various therapies [1]. The etiology of VCP remains unclear, but constant rubbing and chronic infection may predispose to the onset of the disease [4]. It can also be postulated that HPV may be an etiologic factor of VCP.
References [1] Ee HL, Yosipovitch G, Chan R, Ong BH. Resolution of vulvitis circumscripta plasmacellularis with topical imiquimod: two case reports. Br J Dermatol 2003;149:638 – 43. [2] Woodruff JD, Sussman J, Shakfeh S. Vulvitis circumscripta plasmacellularis: a report of four cases. J Reprod Med 1990;34:369 – 72. [3] Yoganathan J, Bohl TG, Mason G. Plasma cell balanitis and vulvitis (of Zoon): a study of 10 cases. J Reprod Med 1994;39:939 – 44. [4] Kuniyuki S, Asada T, Yasumoto R. A case of vulvitis circumscripta plasmacellularis positive for herpes simplex type II antigen. Clin Exp Dermatol 1998;23:230 – 1.
www.elsevier.com/locate/ijgo
BRIEF COMMUNICATION
Imiquimod treatment of vulvitis circumscripta plasmacellularis A. Frega a,*, F. Rech a, D. French b a b
Department of Gynecology, Perinatology and Child Health, University bLa SapienzaQ, Rome, Italy Department of Experimental Medicine and Pathology, University bLa SapienzaQ, Rome, Italy
Received 2 March 2006; received in revised form 12 April 2006; accepted 3 May 2006
KEYWORDS Vulvitis circumscripta plasmacellularis; Imiquimod; Human papillomavirus
Vulvitis circumscripta plasmacellularis (VCP) is a rare but well-described condition affecting women of any age [1]. A biopsy is mandatory for VCP diagnosis because its clinical aspect is similar to that of several other conditions [2,3]. The present report describes 2 cases of VCP successfully treated with topical imiquimod (Aldara; 3-M Pharmaceuticals, Saint Paul, MN, USA). In March 1997, a 40-year-old woman underwent carbon dioxide laser vaporization of a vulvar wart caused by human papillomavirus (HPV). The results of an HPV test, performed by polymerase chain reaction, were positive for virus types 6 and 11. Follow-up tests results were negative. In November 2002 the patient complained that she had been experiencing vaginal discharge, vulvar erythema, pruritus, burning, and dyspareunia over * Corresponding author. E-mail address: [email protected] (A. Frega).
the previous 6 months. On clinical examination she had a reddish, eroded, circumscribed lesion on the inner aspects of both labia minora. A direct biopsy was performed and VCP detected (Figs. 1 and 2). The results of an HPV test were positive for viral types 6 and 11 although histologic signs of viral infection were absent. In the previous months, the patient had been treated with antibiotics as well as
Figure 1 Vulvar mucosa revealing flattened epidermis with erythrocytic permeation. Epithelium shows diamond shaped keratinocytes with intercellular edema. Submucosa reveals band-like plasmacytic inflammation.
0020-7292/$ - see front matter D 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2006.05.005
162
Figure 2 Epithelial—dermal interface. Band-like plasmacytic inflammation with capillary dilatation and deposits of hemosiderin.
oral and topical corticosteroids, without significant improvement. In April 1995 a 51-year-old woman underwent carbon dioxide laser vaporization of vulvar and perineal HPV lesions. The results of an HPV test and follow-up examination were the same as in the previous case. In September 2003, the patient complained of having experienced vulvar pruritus and burning, dysuria, and dryness over the previous 7 to 8 months. A vulvar examination revealed 2 well-defined, ulcerated, and hemorrhagic lesions. In the recent past, the patient had not received any treatment. A direct biopsy revealed changes similar to those described in the previous case, and the results of an HPV test were positive for viral types 6 and 11. Both patients were instructed to apply 5% imiquimod twice per week for 2 weeks, and 3 times
A. Frega et al. per week for another 8 weeks. The patients completed the entire treatment. Complete resolution was observed at the ninth and eighth week, respectively. The only adverse effect was irritation at the application site. To date, neither patient had lesion recurrence. An immune response modifier able to induce the production of interferon a, imiquimod is known to be effective in the topical treatment of external genital warts; 5% imiquimod fully resolved clinical VCP lesions that had been recalcitrant to various therapies [1]. The etiology of VCP remains unclear, but constant rubbing and chronic infection may predispose to the onset of the disease [4]. It can also be postulated that HPV may be an etiologic factor of VCP.
References [1] Ee HL, Yosipovitch G, Chan R, Ong BH. Resolution of vulvitis circumscripta plasmacellularis with topical imiquimod: two case reports. Br J Dermatol 2003;149:638 – 43. [2] Woodruff JD, Sussman J, Shakfeh S. Vulvitis circumscripta plasmacellularis: a report of four cases. J Reprod Med 1990;34:369 – 72. [3] Yoganathan J, Bohl TG, Mason G. Plasma cell balanitis and vulvitis (of Zoon): a study of 10 cases. J Reprod Med 1994;39:939 – 44. [4] Kuniyuki S, Asada T, Yasumoto R. A case of vulvitis circumscripta plasmacellularis positive for herpes simplex type II antigen. Clin Exp Dermatol 1998;23:230 – 1.