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A case report and literature review of delayed telogen effluvium after topical imiquimod use in treating a cervical high-grade squamous intraepithelial lesion

  • Andrej Cokan1,*,
  • Maja Pakiž1

1Department for gynaecological and breast oncology, Clinic for Gynaecology and Obstetrics, University Medical Centre Maribor, 2000 Maribor, Slovenia

DOI: 10.22514/ejgo.2022.048 Vol.43,Issue 5,October 2022 pp.104-106

Submitted: 04 July 2022 Accepted: 29 August 2022

Published: 15 October 2022

*Corresponding Author(s): Andrej Cokan E-mail:


The use of imiquimod in cervical intraepithelial lesions has been evaluated in different trials and was found associated with various and numerous adverse events. Telogen effluvium is an infrequent systemic adverse event observed mainly in patients experiencing severe systemic adverse reactions. This paper presents the case of a young woman who developed telogen effluvium after intravaginal imiquimod use that was not preceded by other systemic adverse events and resolved gradually after nine months. Telogen effluvium after intravaginal imiquimod use is rare, may appear without any preceding severe adverse event, and may persist for an extended period.


Imiquimod; Intravaginal administration; Adverse effect; Telogen effluvium

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Andrej Cokan,Maja Pakiž. A case report and literature review of delayed telogen effluvium after topical imiquimod use in treating a cervical high-grade squamous intraepithelial lesion. European Journal of Gynaecological Oncology. 2022. 43(5);104-106.


[1] Kyrgiou M, Athanasios A, Kalliala IEJ, Paraskevaidi M, Mitra A, Martin-Hirsch PP, et al. Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease. The Cochrane Database of Systematic Reviews. 2017; 11: CD012847.

[2] van de Sande AJM, Koeneman MM, Gerestein CG, Kruse AJ, van Kemenade FJ, van Beekhuizen HJ. TOPical Imiquimod treatment of residual or recurrent cervical intraepithelial neoplasia (TOPIC-2 trial): a study protocol for a randomized controlled trial. BMC Cancer. 2018; 18: 655.

[3] Cokan A, Pakiž M, Serdinšek T, Dovnik A, Kodrič T, Repše Fokter A, et al. Comparison of conservative treatment of cervical intraepithelial lesions with imiquimod with standard excisional technique using LLETZ: a randomized controlled trial. Journal of Clinical Medicine. 2021; 10: 5777.

[4] Fonseca BO, Possati-Resende JC, Salcedo MP, Schmeler KM, Accorsi GS, Fregnani JHTG, et al. Topical imiquimod for the treatment of high-grade squamous intraepithelial lesions of the cervix. Obstetrics & Gynecology. 2021; 137: 1043–1053.

[5] Grimm C, Polterauer S, Natter C, Rahhal J, Hefler L, Tempfer CB, et al. Treatment of cervical intraepithelial neoplasia with topical imiquimod: a randomized controlled trial. Obstetrics and Gynecology. 2012; 120: 152–159.

[6] Jung PS, Kim JH, Kim D. Application of topical imiquimod for treatment of cervical intraepithelial neoplasia in young women: a preliminary result of a pilot study. Gynecologic Oncology. 2016; 141: 103–104.

[7] Hendriks N, Koeneman M, van de Sande M, Penders CGJ, Piek JMJ, Kooreman LFS, et al. EP1245 topical imiquimod treatment of high-grade cervical intraepithelial neoplasia (TOPIC-3) study: a multicentre, non-randomized controlled study. International Journal of Gynecologic Cancer. 2019; 29: A625–A625.

[8] Wouters T, Hendriks N, Koeneman M, Kruse A, van de Sande A, van Beekhuizen HJ, et al. Systemic adverse events in imiquimod use for cervical intraepithelial neoplasia—a case series. Case Reports in Women’S Health. 2019; 21: e00105.

[9] Headington JT. Telogen effluvium. Archives of Dermatology. 1993; 129: 356.

[10] Rasheed H, Mahgoub D, Hegazy R, El-Komy M, Abdel Hay R, Hamid MA, et al. Serum ferritin and vitamin D in female hair loss: do they play a role? Skin Pharmacology and Physiology. 2013; 26: 101–107.

[11] Cassano N, Amerio P, D’Ovidio R, Vena GA. Hair disorders associated with autoimmune connective tissue diseases. Italian Journal of Dermatology and Venereology. 2014; 149: 555–565.

[12] Yu V, Juhász M, Chiang A, Atanaskova Mesinkovska N. Alopecia and associated toxic agents: a systematic review. Skin Appendage Disorders. 2018; 4: 245–260.

[13] Conde J, Davis K, Ntuen E, Balmer N, Jones D, McMichael A. A case of imiquimod-induced alopecia. Journal of Dermatological Treatment. 2010; 21: 122–124.

[14] Borst C, Grimm C, Tanew A, Radakovic S. Imiquimod-induced effluvium after intravaginal application for treatment of cervical intraepithelial neoplasia. JAAD Case Reports. 2019; 5: 602–604.

[15] Diaz-Arrastia C, Arany I, Robazetti SC, Dinh TV, Gatalica Z, Tyring SK, et al. Clinical and molecular responses in high-grade intraepithelial neoplasia treated with topical imiquimod 5%. Clinical Cancer Research. 2001; 7: 3031–3033.

[16] Lin C, Qiu J, Wang C, Chang S, Tang Y, Wu P, et al. Topical imiquimod treatment for human papillomavirus infection in patients with and without cervical/vaginal intraepithelial neoplasia. Taiwanese Journal of Obstetrics and Gynecology. 2012; 51: 533–538.

[17] Chen F. Efficacy of imiquimod 5% cream for persistent human papillomavirus in genital intraepithelial neoplasm. Taiwanese Journal of Obstetrics and Gynecology. 2013; 52: 475–478.

[18] Pachman DR, Barton DL, Clayton AC, McGovern RM, Jefferies JA, Novotny PJ, et al. Randomized clinical trial of imiquimod: an adjunct to treating cervical dysplasia. American Journal of Obstetrics and Gynecology. 2012; 206: 42.e1–42.e7.

[19] Tapilskaya NI, Vorobtsova IN, Gaidukov SN, Proshin SN. Efficacy and safety of imiquimod in the treatment of subclinical and clinical forms of persistent cervical papillomavirus infection in patients of early reproductive age. Gynecology. 2015; 17: 14–17.

[20] Kim JH, Kim DY. Imiquimod as an alternative option for young women with high-grade cervical intraepithelial neoplasia. European Journal of Gynaecological Oncology. 2019; 40: 943–947.

[21] Park J, Lee S, Hur S, Kim T, Hong S, Lee J, et al. 27 GX-188E, a therapeutic HPV vaccine, in combination with imiquimod or IL-7-HYFC for treatment of HPV-16 or HPV-18 related cin 3: results from phase 2 study. Plenary Sessions. 2019; 29: A16.

[22] Sande AJMVD, Koeneman MM, Baars RV, Gerestein CG, Kruse AJ, Kemenade FJV, et al. Treatment of residual or recurrent CIN with topical imiquimod: a retrospective study. Archives of Microbiology & Immunology. 2020; 4: 95–109.

[23] Hendriks N, Koeneman M, Slangen B, Krüse A. EPV237/#541 two-year effectiveness of topical imiquimod treatment of high-grade cervical intraepithelial neoplasia (TOPIC-3). E-Posters. 2021; 31: A122–A123.

[24] Diakomanolis E, Haidopoulos D, Stefanidis K. Treatment of high-grade vaginal intraepithelial neoplasia with imiquimod cream. New England Journal of Medicine. 2002; 347: 374–374.

[25] Buck HW, Guth KJ. Treatment of vaginal intraepithelial neoplasia (primarily low grade) with imiquimod 5% cream. Journal of Lower Genital Tract Disease. 2003; 7: 290–293.

[26] Haidopoulos D, Diakomanolis E, Rodolakis A, Voulgaris Z, Vlachos G, Intsaklis A. Can local application of imiquimod cream be an alternative mode of therapy for patients with high-grade intraepithelial lesions of the vagina? International Journal of Gynecological Cancer. 2005; 15: 898–902.

[27] Tainio K, Jakobsson M, Louvanto K, Kalliala I, Paavonen J, Nieminen P, et al. Randomised trial on treatment of vaginal intraepithelial neoplasia-Imiquimod, laser vaporisation and expectant management. International Journal of Cancer. 2016; 139: 2353–2358.

[28] Policiano ACF, Lopes JPM, Barata SAM, Colaço AM, Calhaz-Jorge C. Topical therapy with imiquimod for vaginal intraepithelial neoplasia: a case series. Journal of Lower Genital Tract Disease. 2016; 20: e34–e36.

[29] Sasagasako N, Kosaka K, Sagae Y, Itoh K, Aratake J, Yamada K, et al. Recurrent vaginal intraepithelial neoplasia successfully treated with topical imiquimod: a case report. Molecular and Clinical Oncology. 2020; 13: 19.

[30] Inayama Y, Yamanishi Y, Nakatani E, Aratake J, Sasagasako N, Yamada K, et al. Imiquimod for vaginal intraepithelial neoplasia 2–3: a systematic review and meta-analysis. Gynecologic Oncology. 2021; 160: 140–147.

[31] Walter A, Schäfer M, Cecconi V, Matter C, Urosevic-Maiwald M, Belloni B, et al. Aldara activates TLR7-independent immune defence. Nature Communications. 2013; 4: 1560.

[32] Schön MP, Schön M. Imiquimod: mode of action. British Journal of Dermatology. 2007; 157: 8–13.

[33] Amberg N, Holcmann M, Stulnig G, Sibilia M. Effects of imiquimod on hair follicle stem cells and hair cycle progression. Journal of Investigative Dermatology. 2016; 136: 2140–2149.

[34] Harrison L, Skinner S, Marbury T, Owens M, Kurup S, McKane S, et al. Pharmacokinetics and safety of imiquimod 5% cream in the treatment of actinic keratoses of the face, scalp, or hands and arms. Archives of Dermatological Research. 2004; 296: 6–11.

[35] Kuhl H. Pharmacology of estrogens and progestogens: influence of different routes of administration. Climacteric. 2005; 8: 3–63.

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