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Lack of efficacy in treating condyloma acuminata and preventing recurrences with the recombinant quadrivalent human papillomavirus vaccine in a case series of immunocompetent patients

      To the Editor: With great interest we read the article by Lee et al
      • Lee H.J.
      • Kim J.K.
      • Kim D.H.
      • Yoon M.S.
      Condyloma accuminatum treated with recombinant quadrivalent human papillomavirus vaccine (types 6, 11, 16, 18).
      published in the journal in June 2011. The authors report on a 46-year-old man with extensive perianal condylomata acuminata that showed a dramatic improvement after a single injection of the recombinant quadrivalent human papillomavirus (HPV) vaccine (against the HPV types 6, 11, 16, and 18). In contrast, our experiences with the prophylactic HPV vaccine for treating condylomata acuminata are less promising.
      Six immunocompetent patients (1 female and 5 male) with anogenital warts who had received the prophylactic HPV vaccine presented at our institution between 2009 and 2011. The mean age of the patients was 26 years (range, 12-42 years). Patients’ clinical characteristics are shown in Table I. In all of them, HPV vaccination (3 doses of Gardasil [Sanofi Pasteur MSD, Leimen, Germany] within 6 months) was initiated after the first clinical visit at our department, where ablation of the warts was performed with electrocautery. All patients experienced recurrences (mean number of recurrences: 4.8; range, 1-11) of at least 1 condyloma after electrocautery and HPV vaccination. HPV typing of the condyloma performed at first presentation and at time of recurrence showed that the respective HPV types had probably persisted in the patients (Table I).
      Table IPatient clinical characteristics, lesional human papillomavirus types, and number of recurrences after human papillomavirus vaccination
      Patient no.Age, y/sexLocalization of condylomata acuminataMode of transmissionPretreatmentLesional HPV type(s) before and after vaccinationNo. of recurrences after vaccination
      113/FPerianalUnknownNoneHPV573
      219/MPerianal and intra-analMSMNoneHPV67
      312/MPerianalUnknownCurettageHPV611
      434/MGenital and perianalHeterosexualNoneHPV61
      542/MGenital and perianalHeterosexualNoneHPV65
      637/MGenitalHeterosexualCO2 laser, imiquimod, podophyllotoxinHPV6+ HPV552
      CO2, Carbon-dioxide; F, female; HPV, human papillomavirus; M, male; MSM, men who have sex with men.
      Some years ago, a large randomized trial in women with existing high-risk HPV infection showed that HPV vaccination does not accelerate clearance of the virus and therefore should not be used to treat prevalent infections.
      • Hildesheim A.
      • Herrero R.
      • Wacholder S.
      • Rodriguez A.C.
      • Solomon D.
      • Bratti M.C.
      • et al.
      Effect of human papillomavirus 16/18 L1 viruslike particle vaccine among young women with preexisting infection: a randomized trial.
      This observation was confirmed by a recent trial.
      • Haupt R.M.
      • Wheeler C.M.
      • Brown D.R.
      • Garland S.M.
      • Ferris D.G.
      • Paavonen J.A.
      • et al.
      Impact of an HPV6/11/16/18 L1 virus-like particle vaccine on progression to cervical intraepithelial neoplasia in seropositive women with HPV16/18 infection.
      In contrast, it was hypothesized that prophylactic HPV vaccination could have a therapeutic effect in recurrent (HPV6- of HPV11-induced) respiratory papillomatosis by preventing new papilloma formation.
      • Pawlita M.
      • Gissmann L.
      Recurrent respiratory papillomatosis: indication for HPV vaccination?.
      In our case series, prophylactic HPV vaccination did not prevent condyloma recurrences, whereas in the report of Lee et al,
      • Lee H.J.
      • Kim J.K.
      • Kim D.H.
      • Yoon M.S.
      Condyloma accuminatum treated with recombinant quadrivalent human papillomavirus vaccine (types 6, 11, 16, 18).
      perianal warts started to regress after a single application of the vaccine. Importantly, the patient of Lee et al
      • Lee H.J.
      • Kim J.K.
      • Kim D.H.
      • Yoon M.S.
      Condyloma accuminatum treated with recombinant quadrivalent human papillomavirus vaccine (types 6, 11, 16, 18).
      was previously treated with 5% imiquimod cream for a total of 4 weeks. Thus, the regression of condyloma could be a delayed effect of imiquimod, which has also been observed in imiquimod treatment of anal dysplasia.
      • Wieland U.
      • Brockmeyer N.H.
      • Weissenborn S.J.
      • Hochdorfer B.
      • Stücker M.
      • Swoboda J.
      • et al.
      Imiquimod treatment of anal intraepithelial neoplasia in HIV-positive men.
      Moreover, it should be considered that spontaneous clearance of condyloma might occur. We fully agree with Lee et al
      • Lee H.J.
      • Kim J.K.
      • Kim D.H.
      • Yoon M.S.
      Condyloma accuminatum treated with recombinant quadrivalent human papillomavirus vaccine (types 6, 11, 16, 18).
      that the only way to elucidate the role of a prophylactic HPV vaccine in treating prevalent anogenital warts would be the initiation of a randomized controlled trial.

      References

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        • Kim J.K.
        • Kim D.H.
        • Yoon M.S.
        Condyloma accuminatum treated with recombinant quadrivalent human papillomavirus vaccine (types 6, 11, 16, 18).
        J Am Acad Dermatol. 2011; 64: e130-e132
        • Hildesheim A.
        • Herrero R.
        • Wacholder S.
        • Rodriguez A.C.
        • Solomon D.
        • Bratti M.C.
        • et al.
        Effect of human papillomavirus 16/18 L1 viruslike particle vaccine among young women with preexisting infection: a randomized trial.
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        • Haupt R.M.
        • Wheeler C.M.
        • Brown D.R.
        • Garland S.M.
        • Ferris D.G.
        • Paavonen J.A.
        • et al.
        Impact of an HPV6/11/16/18 L1 virus-like particle vaccine on progression to cervical intraepithelial neoplasia in seropositive women with HPV16/18 infection.
        Int J Cancer. 2011; 129: 2632-2642
        • Pawlita M.
        • Gissmann L.
        Recurrent respiratory papillomatosis: indication for HPV vaccination?.
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        • Brockmeyer N.H.
        • Weissenborn S.J.
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        • Stücker M.
        • Swoboda J.
        • et al.
        Imiquimod treatment of anal intraepithelial neoplasia in HIV-positive men.
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