[Question #9586] Tacrolimus HPV reactivation
31 months ago
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I was diagnosed with genital warts in June 2019.Had them removed but had a few recurrences between June 2019 and December 2020.Have not had recurrence since.Have also had persistent redness and inflammation on head of penis.My doctor has given me tacrolimus ointment to apply twice daily for the next 6 weeks to treat this.Does tacrolimus ointment reactivate HPV infection? Or am I safe to use this medication? Thank you.
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H. Hunter Handsfield, MD
31 months ago
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Welcome back to the forum. Thanks for your confidence in our services.
My answer is there may be risk of HPV reactivation, perhaps especially for warts. However, data are very limited.
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As you likely know, tacrolimus is a potent immunosuppressant, and it is logical that it might increase the chance of HPV reactivation. In searching the medical literature, I find a two publications, reporting a total of 3 patients, that suggest this may happen from time to time -- one of facial warts in a child and another report of two cases of genital HPV reactivation with development of warts, documented in those two cases as caused by HPV6 and 11. Neither patient had previously diagnosed genital warts. In all three patients, the warts appeared in exactly (and only) in areas to which the ointment had been applied. Both publications were over 15 years ago (2007). Rare case reports don't mean very much -- any single occurrence could be coincidental -- and there are no systematic data, such as published research on the topic. On the other hand, both reports are well written by seemingly competent clinicians, and the association of reactivated HPV with warts in these three patients doesn't seem coincidental. So my reply must be that this it might be a problem, but I cannot cannot judge the actual risk, i.e. its likelihood in any particular patient.
I'm a little surprised by use of tacrolimus in this situation. It is used (and I understand is quite effective) for atopic dermatitis (eczema), lichen planus and lichen sclerosis, all three of which can occur on the penis. (The two reported patients with genital warts were being treated for lichen sclerosis and the child for eczema.) However, your description doesn't sound typical for any of these -- unless maybe you have the same condition elsewhere on your body. Is the prescribing doctor a dermatologist? Is there reason to suspect any of these conditions as the cause of your penile skin inflammation? You might raise these questions with your doctor, or perhaps see a dermatologist if your doc isn't one.
I hope this information helps a little bit. Let me know if anything isn't clear.
HHH, MD
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31 months ago
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Thank you for your detailed response Dr.My doctor is not a dermatologist.I have had several fungal/yeast infections on my penis over the years and always treated these with oral and topical antifungals that generally cleared the infection.The persistent patch of redness on my penis head did not respond to antifungal treatment so my doctor suggested tacrolimus instead.I have patches of dermatitis on my arms and legs.I have decided to stop using tacrolimus and make another appointment with my doctor.The risk of reactivated HPV warts is just not worth it.Could you suggest any course that treatment that has no risk of reactivating HPV? Thank you
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H. Hunter Handsfield, MD
31 months ago
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Thanks for the additional detail. I agree with your decision to not use tacrolimus ointment. However, I cannot judge the cause of your penile rash nor, therefore, what other treatment(s) to consider. Clearly it is no STI and we do not address non-STI genital rashes, lesions, etc. I strongly urge you to see a dermatologist. Some non dermatologists have excellent understanding and skills in skin problems, but it seems to me that your doctor is not among them.---
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