Patient treated 2 weeks ago with imiquimod 5% cream for genital verruca vulgaris now has a raw, red, painful penis after hours—what is the appropriate management?

Management of Severe Local Skin Reaction to Imiquimod

Instruct the patient to immediately stop imiquimod application and wash the affected area thoroughly with mild soap and water to remove any residual cream. 1

Immediate Management

• Discontinue imiquimod immediately and have the patient wash the treatment area with mild soap and water to remove any remaining cream 1
• This presentation represents a severe local skin reaction, which is a known and expected adverse effect of imiquimod therapy 2, 3, 1
• The FDA label explicitly states: "Should severe local skin reaction occur, the cream should be removed by washing the treatment area with mild soap and water" 1

Expected Local Reactions with Genital Imiquimod Use

• Local inflammatory reactions including erythema, erosion, excoriation/flaking, and edema are common and expected with imiquimod treatment for genital warts 3, 1
• Most reactions are mild to moderate, but severe reactions can occur requiring treatment cessation 3, 1
• The FDA label specifically warns that "local skin reactions on the delicate moist surfaces can result in pain or swelling" in genital areas 1

After-Hours Guidance

• Provide symptomatic relief measures: cool compresses, gentle cleansing with mild soap and water, and over-the-counter topical emollients or barrier creams to protect the raw skin 1
• Advise the patient to avoid any further application of imiquimod until evaluated by their provider 1
• Instruct the patient to avoid sexual contact while the skin is healing 1

Follow-Up Plan

• Schedule urgent follow-up within 24-48 hours to assess the severity of the reaction and determine whether to resume treatment at a reduced frequency or switch to an alternative therapy 2, 3
• If treatment is to be resumed, consider reducing application frequency or implementing rest periods, though the CDC guidelines recommend the standard three-times-weekly dosing for genital warts 2, 3
• If no substantial improvement in wart clearance had occurred after 8 weeks of treatment prior to this reaction, consider switching to an alternative treatment modality rather than resuming imiquimod 2, 3

Common Pitfall to Avoid

• Do not advise the patient to "push through" severe local reactions—the FDA label explicitly instructs removal of cream when severe reactions occur 1
• Male patients treating genital warts have lower complete clearance rates (approximately 35%) compared to females (approximately 67%), so alternative therapies may be more appropriate if this reaction occurred early in the treatment course 4