Effects of psoriasis treatment on genital warts: a case report

Manuscript text

Generally speaking, the use of immunosuppressive drugs predisposes to infections, as they block the most important stage in antiviral defense, which is the cytotoxic T-lymphocyte HLA-dependent response. ¹ We report a case of extensive genital warts in a young woman on therapy with cyclosporine, afterwards successfully treated with an anti-tumor necrosis factor alpha (TNF-α) agent.

An 18-year-old woman came to our department for moderate psoriasis previously treated with topical therapy and phototherapy. In recent months, despite the therapy, the patient had observed a significant aggravation of the disease. On this basis, we prescribed cyclosporine 3 mg/kg/day. After three months from the start of treatment, the patient returned because of the appearance of verrucous plaques and papules on the genital area (Figure 1a). Similar lesions were present also in the perianal region (Figure 1b). Histological examination confirmed our clinical diagnosis of condylomata acuminata (Figure 1c). Multiplex real-time polymerase chain reaction revealed human papillomavirus (HPV) type 11. Notably, the patient had undergone HPV 16 and 18 vaccination one year before. On this basis, we decided to stop cyclosporine. After only two months, spontaneous regression of the genital warts was observed (Figure 2a). However, desquamative erythematous plaques appeared on the entire body surface, consistent with recurrence of psoriasis (Figure 2a-2b). We decided to start adalimumab, an anti-TNF-α agent. After 12 months, the cutaneous manifestations of psoriasis were completely healed and we did not observe any new lesions in the genital or perianal area (Figure 2c-2d).

The use of immunosuppressive drugs enhances viral replication and favors the reactivation of latent viruses and the development of new infections. ² It has also been reported that cyclosporine may predispose to the reactivation of latent infections and may favor the development of clinical HPV-related diseases, due to the inhibition of cell-mediated immunity, which plays a crucial role in controlling HPV infections.^3–6 In the present case, treatment with cyclosporine was withdrawn due to profuse genital wart development and this choice led to the complete resolution of the lesions. In the literature, the relationship between HPV and TNF-blockers has not yet been clearly defined. TNF-α plays a critical role in the control of viral infections and the depletion of TNF-α by its inhibitors may facilitate the risk of reactivation of these diseases. ⁷ However, in the literature there are only few cases of florid onset of warts under anti-TNF-α therapy.^7,8 Moreover, most of these patients had been previously treated with other immunosuppressive drugs. Notably, a recent study that reviewed 50 patients with rheumatoid arthritis on treatment with anti-TNF-α drugs did not show an increased short-term risk of exacerbation or progression of HPV. ⁹

Our case underlines that the prompt interruption of cyclosporine can induce a complete regression of warts without any additional treatment and adds evidence to the possible use of anti-TNF-α therapy in patients with psoriasis and genital warts. Further studies are needed to establish a clear relation between HPV infection and TNF-α antagonists.