Sustained Clinical Resolution of Acquired Epidermodysplasia Verruciformis in an Immunocompromised Patient After Discontinuation of Oral Acitretin With Topical Imiquimod

Increased cases of acquired epidermodysplasia verruciformis (EDV) in patients with human immunodeficiency virus (HIV) have been reported in the literature.^1-5 With regard to management, there are no randomized controlled trials in either immunocompetent or immunocompromised patients, and only a limited number of anecdotal treatment options, such as topical imiquimod, oral retinoids, and oral cimetidine.^1-5 Though remission of EDV has been noted with highly active antiretroviral therapy (HAART),⁴ the overall consensus is that HAART has little to no effect on the improvement of these lesions.^5,6 Systemic retinoids, either independently or in combination with other treatment modalities, such as acitretin plus interferon alfa-2a,⁷ etretinate,⁸ and isotretinoin⁹ have been used with limited success, demonstrating transient clinical response and recurrence of lesions after cessation of therapy. Low-dose maintenance retinoids may prevent recurrence,^2,9 though this may not be an option for all patients. More recently, a case series reported clinical improvement with topical 1% cidofovir in 2 patients.¹⁰

We report the case of a 46-year-old Hispanic male with long-standing HIV (CD4 lymphocyte count approximately 250 cells/mm³ and viral load undetectable) compliant with HAART. He presented with a 1-year history of pink to hypopigmented, slightly verrucous, flat-topped papules and plaques on the neck (Figure 1a) and circumferentially around his penis (Figure 1b). A biopsy of a lesion on his neck confirmed the diagnosis of EDV. Trials of once-daily application of topical tretinoin 0.025% cream, topical tazarotene 0.05% cream, and topical imiquimod 5% cream were all separately attempted for approximately 2 months each without any clinical improvement. Because of the patient’s frustration with the lack of response to these topical agents and his heightened cosmetic awareness of these lesions, additional treatment options were sought.

Once-daily acitretin 10 mg was initiated in addition to the application of imiquimod 5% cream 3 times per week at nighttime. At his 2-week follow-up appointment, the patient reported an improvement in the appearance of the lesions. At this same visit, acitretin was increased to 25 mg orally once daily with maintenance of imiquimod 5% cream 3 times per week. After 3 months of concurrent treatment, near resolution of all EDV lesions was also noted on his neck (Figure 2a) and penis (Figure 2b). However, he reported a recent onset of recurrent headaches with the oral acitretin, so this systemic retinoid was discontinued altogether. Imiquimod 5% cream was continued 3 times per week for maintenance in order to prevent recurrence.^2,9 Approximately 4 months later, the patient self-tapered imiquimod therapy to once or twice weekly. Fifteen months after completing this short course of acitretin, the patient continued to have no evidence of recurrence (Figure 3), with a most recent CD4 count of 237 cells/mm3 and an undetectable viral load.