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IImiquimod
Mechanism of action: An immune enhancer that stimulates production of interferon and
other cytokines. It appears to have an advantage of reduced recurrence rate.
Suitable for: Women, and some men with foreskin-associated warts. Particularly useful for
‘carpet warts’, e.g. female introitus and perianal area.
Contraindications: Not currently recommended in pregnancy. A register of imiquimod use
in pregnancy has been established.*
Application: Careful application of imiquimod cream is important.
Applied onto fingertip and rubbed onto clean dry, wart area until cream vanishes once daily,
three times per week, prior to normal sleeping hours and after sexual activity (imiqimod
weakens condoms and vaginal diaphragms). Wash off next morning or after 6-10 hours.
The manufacturer recommends that a sachet be used for single use to cover an area of up to
20cm2. However, it has been demonstrated that one sachet will cover up to 386cm2 and
although, not recommended by the manufacturer, one sachet is commonly used for multiple
applications.64 It is recommended that treatment should be continued until the warts have
resolved, or up to a maximum of 16 weeks per course.
A preliminary study involving a small number of largely pre-treated women showed that a
four week course of imiquimod was as effective as longer courses of 8, 12 and 16 weeks with
fewer adverse reactions and reduced cost.65 The majority of women who cleared their warts
did so by eight weeks regardless of the duration of treatment, suggesting that imiquimod
prompts a cell-mediated response with specific T-cell immune memory within the first four
weeks.
Side effects: Localised erythema, swelling and/or rarely superficial ulceration of the treated
area can be expected from two to six weeks as part of the immune response and will probably
be related to the direct therapeutic action of the agent, i.e. switching on the immune
response rather than to hypersensitivity. If indicated, the clinician may advise the patient to
miss the next two applications, use salt water baths as well as drying with a hairdryer before
recommencing treatment. These local skin reactions cause discontinuation of the treatment in
less than 2% of patients
