Alexandra Monastirli

Dionysios Tsambaos

Efstathia Pasmatzi

George Badavanis

Sophia Georgiou

English

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ACTA DERMATOVENEROLOGICA CROATICA164Dear Editor, Molluscum contagiosum (MC) is a very common skin infection caused by a molluscipox virus gene of the poxvirus family. It usually occurs in young chil-dren, sexually active adults, and immunocompro-mised individuals. The typical clinical picture of this infection is characterized by asymptomatic flesh-col-ored, single or multiple papules, measuring 2-6 mm in diameter with a central umbilication that occur on the skin and the mucous membranes. In adults, the skin lesions are predominantly located in the geni-Acta Dermatovenerol Croat                              2017;25(2):164-166                             LETTEr To ThE EDITorTopical Imiquimod is an Effective and Safe Drug for Molluscum Contagiosum in Childrental region, whereas in children they are found on the trunk, the extremities, and the face. MC is generally regarded as a self-limited disease; however, its treatment is usually advisable consider-ing its potentially protracted course and the risk of superinfection, scarring, autoinoculation, and trans-mission to other members of the community. A large number of approaches to the treatment of MC have been used so far (none of them approved by the Food and Drug Administration (FDA)) includ-No Gender Age (years) Location of the lesions response (%) Duration of treatment (weeks)1 M 8 Face 100 62 F 10 Trunk 82.35 103 F 12 Face 100 64 M 7 Extremities 84.61 105 M 5 Trunk 100 76 M 8 Extremities 100 57 M 8 Trunk 100 48 F 11 Face 100 59 M 8 Face 61.13 1210 F 7 Trunk 100 511 F 4 Extremities 100 512 F 3 Extremities, trunk* 100 313 F 7 Trunk 100 514 F 12 Face 100 615 M 13 Face 100 616 M 10 Trunk 100 517 M 8 Extremities 100 418 F 9 Trunk 100 819 M 6 Face 55.55 1120 M 5 Face 63.63 1221 F 9 Face 100 522 F 12 Extremities 100 623 F 11 Trunk 58.33 10M = male; F = female;  * = disseminated lesionsTable 1. Demographic data and therapeutic response of the children with molluscum contagiosum which were  treated  with topical imiquimod under occlusion      165ACTA DERMATOVENEROLOGICA CROATICA  Acta Dermatovenerol CroatLetter to the editor   2017;25(2):164-166ing ablative regimens (curettage, electrodessication, cryotherapy, laser therapy) and topical or systemic pharmacologic agents (tretinoin, cantharidin, trichlo-roacetic and salicylic acid, potassium hydroxide, in-terferon-alfa, and cimetidine). Imiquimod is a topically applicable Toll-like recep-tor (TLr)-7/8 agonist, which is capable of stimulating the innate cutaneous immunity and the cellular arm of the adaptive immune response and of exerting potent anti-viral, anti-tumor and immunoregulatory effects (1). originally approved for the treatment of external genital and perianal warts in adults, imiqui-mod was later approved for the therapy of basal cell carcinomas and actinic keratoses and has also been used in the management of several off-label indica-tions including cutaneous infections and neoplasms. our group has successfully used topical imiqui-mod in the treatment of a variety of dermatoses in-cluding granuloma annulare, pyogenic granuloma, herpes labialis, and lichen striatus (2-6). Moreover, we have examined the topical application of imiquimod over the last twelve years in the treatment of 23 chil-dren with MC, the demographic data and the thera-peutic response of which are summarized in Table 1. Seventeen out of 23 children (73.91%) treated with topical imiquimod once daily under occlusion (in-cluding two cases with disseminated lesions) showed a complete remission within 3 to 8 weeks of treat-ment. Furthermore, 6 other children who switched to other forms of treatment showed a partial remission (55.55%-84.61%) after 10 to 12 weeks of therapy. The only cutaneous adverse reaction to topical imiqui-mod was a mild to moderate irritation in the appli-cation area that was observed in all treated children, whereas no systemic side effects could be seen. our findings are compatible with those of other groups, who also demonstrated the therapeutic efficacy and safety of topical imiquimod in MC.Interestingly, in two very similar subsequent pa-pers Katz and Swetman (7) and Katz (8,9) expressed the view that “imiquimod is neither efficacious nor safe in the treatment of MC in children”. This view was not the result of the author’s clinical experience but was exclusively based on the findings of two random-ized clinical trials (rCTs). These were carried out in 2006 upon request of the FDA from the drug’s origi-nal manufacturer (3M) and “definitely showed that imiquimod does not effectively treat MC in children”. Surprisingly, today, 10 years after their completion, these rCTs still remain unpublished, whereas the cor-responding FDA site provides no information with regard to the researchers, the centers in which these trials were conducted, their research protocol, and the demographic data of the enrolled patients. In a very recent review on childhood skin infec-tions, rush and Dinulos (10), exclusively based on Dr. Katz’s paper, fully adopted this view and stated that “imiquimod is neither efficacious nor safe in the treatment of MC”, although they admit that the rCTs cited by the latter still remain unpublished. In con-trast to these authors, we reject Dr Katz’s inexplicable request to the medical community to fully ignore all articles published in peer-reviewed journals that demonstrate the efficacy and safety of imiquimod in MC. We do not claim that imiquimod is a panacea. however, based on our clinical experience and that of other groups, we are convinced that this compound represents a very useful and painless tool in the der-matologic arsenal for the treatment of MC, an other-wise difficult to manage dermatosis, particularly in children.References:1. Pasmatzi E, Chaidaroglou A, Sakkis Th, Monastirli A, Georgiou S, Sagriotis A, et al. Topical applica-tion of imiquimod induces alterations in periphe-ral blood lymphocytes in healthy individuals. Acta Derm Venereol 2009;89:134-9.2. Badavanis G, Monastirli A, Pasmatzi E, Tsambaos D. Successful treatment of granuloma annulare with imiquimod cream 5%: a report of four cases. Acta Dermato-Venereologica 2005;85:547-8.3. Tsambaos D, Chaidaroglou A, Sakkis Th, Sagriotis A, Georgiou S, Badavanis G, et al. Topical toll-like receptor agonists: a new era in cutaneous immu-notherapy. rev Clin Pharmacol and Pharmacokin 2006;20:341-3.4. Georgiou S, Monastirli A, Pasmatzi E, Tsambaos D. Pyogenic granuloma: complete remission under occlusive imiquimod 5% cream. Clin Exp Derm 2008;33:454-6.5. Monastirli A, Melachrinou M, Pasmatzi E, Georgiou S, Tsambaos D. Successful treatment of lichen stri-atus with occlusive imiquimod 5% cream. hosp Chron 2010;5:33-5.6. Tsambaos D, rodi M, Pasmatzi E, Monastirli A, Papadaki h, Mouzaki A. Long-term remission of recurrent herpes labialis following topical imi-quimod application on distant healthy skin: a clinical and immunological study. Antiviral Ther 2011;16:863-9.7. Katz KA, Swetman GL. Imiquimod, molluscum, and the need for a better “best pharmaceuticals for children” act. Pediatrics 2013;132:1-3.8. Katz KA. Imiquimod is not an effective drug 166 ACTA DERMATOVENEROLOGICA CROATICAfor molluscum contagiosum. Lancet Infect Dis 2014;14:372-3.9. Katz KA. Dermatologists, imiquimod, and treat-ment of molluscum contagiosum in children: righting wrongs. JAMA Dermatol 2015;151:125-6. 10. rush J, Dinulos JD. Childhood skin and soft tissue infections: new discoveries and guidelines re-garding the management of bacterial soft tissue infections, molluscum contagiosum, and warts. Curr opin Pediatr 2016;28:2.George Badavanis, Efstathia Pasmatzi, Alexandra Monastirli, Sophia Georgiou, Dionysios TsambaosDepartment of Dermatology, School of Medicine, University of Patras, GreeceCorresponding author:Efstathia Pasmatzi, MDDepartment of DermatologySchool of MedicineUniversity of Patras26504 rio-PatrasGreece pasmatzi@med.upatras.grreceived: July 5, 2016Accepted: May 25, 2017  Acta Dermatovenerol CroatLetter to the editor   2017;25(2):164-166

Topical imiquimod is and effective and safe drug for molluscum contagiosum in children

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