Medical treatment for VIN and Extramammary Pagets Disease

What is imiquimod, and how does it work?

Imiquimod (Aldara)

Imiquimod is an immune response modifier cream that when applied to the skin activates the immune system to recognise abnormal cells and causes inflammation which removes them. Imiquimod 5% cream (trade name Aldara)  is being used for treatment of certain Vulval skin conditions like VIN and Extra-mammary Paget’s disease.

How should the cream be applied?

In order for the Imiquimod cream to work, it should be applied regularly, ideally 3 times a week, for up to 16 weeks.

You would aim to start using the cream once a week and if tolerated increase to three times a week.

The best way to apply the cream is to look at the vulval area in a mirror, apply a simple barrier ointment (e.g. Vaseline, Cetraben, Hydramol, Epaderm) to the surrounding normal skin to give some protection.  Then apply the Imiquimod cream to the abnormal areas.It is best to rub the Imiquimod cream until it vanishes.

The cream should be left on for 8-10 hours and is therefore best applied at bedtime. It should be washed off with water and an emollient soap substitute e.g. aqueous cream, Dermol 500, Epaderm or Hydramol the next morning. You should avoid sexual contact on the nights the cream is applied. 

Advice for vulval care while using Imiquimod

As the cream works, it causes blistering of the skin and this can be very painful (like a burn) until healthy skin grows back. When this happens, it is important you keep the area clean and dry. Antibiotics are not usually required but your GP will be able to prescribe a variety of painkillers which should help.  This may include 5% Lidocaine ointment which is a local anaesthetic which can be applied to the skin to numb the area up to three times a day. It can be useful to apply an emollient to the vulva regularly to help soothe and protect the vulval skin.

What are the common side effects of imiquimod cream?

Within 3 to 5 days, the skin treated with imiquimod cream can get red and sore. Even normal looking skin around the treated area may be affected, because it may contain invisible abnormal cells. The skin may weep, peel, crack or even blister and then scab over. The area may be itchy or sore, painful and burn. This is caused by the abnormal cells dying and a sign that the treatment is working. The skin reaction tends to be worst in week 2 to 3 of application.

For most people, the more sore and red the skin becomes, the better the treatment works.  It is normal for redness and some crusting to persist for around 2 weeks after the treatment course has finished.
Some patients develop flu-like symptoms such as swollen lymph nodes, aches and pains, mild fever and generally feeling unwell. Taking paracetamol can be helpful.

If the skin or general reaction becomes too severe to tolerate, it is helpful to stop the cream for a week or so before restarting it again once the skin is more comfortable.

As the abnormal cells die, the skin barrier becomes damaged and therefore susceptible to wound infection. If you are not sure whether you have a normal treatment reaction or a wound infection, you should see your doctor.

What are the rare side effects of imiquimod cream?

If you have a severe reaction to imiquimod cream, the treated area may become ulcerated. The skin colour may become darker or lighter following severe inflammation. Very rarely, a patient can be allergic to Imiquimod cream and develop a severe allergic skin rash.

Questions and help

If you have any queries and would like to speak to a specialist nurse on telephone: 

Queen Margaret Hospital (Outpatient's Services)

Queen Margaret Hospital,
Whitefield Road,
Dunfermline,
KY12 0SU
01383 623623 (switchboard)

Victoria Hospital

Victoria Hospital,
Hayfield Road,
Kirkcaldy,
KY2 5AH
01592 643355 (switchboard)

Reference https://www.bad.org.uk/Imiquimod cream

NHS Fife kindly reproduces this information based on accurate information about the subject compiled from a consensus of the views held by representatives of the British Association of Dermatologists: individual patient circumstances may differ, which might alter both the advice and course of therapy given to you by your doctor.