Off-Label Human Papillomavirus Vaccination and Shortened, Low-Dose Topical Imiquimod in an Elderly Patient with Multiple Actinic Keratoses

Abstract 

Human papillomavirus (HPV) is associated with skin dysplasia development. This case report describes a clinical response observed following combined HPV vaccination and low-dose topical imiquimod in an elderly patient with multiple actinic keratoses (AK). A 95-year-old immunocompetent man was evaluated for AK at an office-based dermatological practice. Due to the patient’s age and disease burden, prolonged or invasive treatments were deemed inappropriate. Consequently, the patient was offered off-label 9-valent HPV vaccination at 0- and 2 months as a potential adjunct to low-dose imiquimod. Short, low dose imiquimod therapy consisted of 3,75% cream applied 3 x weekly for two weeks. Over three months later, a significant lesional reduction was noted. Local skin reactions were uncharacteristically marked, with oozing erosions in treated skin areas. No systemic side effects were observed. Our case may reflect a particularly strong response to imiquimod alone despite shortened and low-dose therapy or alternatively, a combined effect with HPV vaccination. Given the case findings’ limited  generalizability, larger controlled trials are warranted to investigate the utility of HPV vaccination and difficult-to-treat AK patients.