Sie sind auf Seite 1von 7

Efficacy of imiquimod 5% cream in the treatment

of equine sarcoids: a pilot study


Blackwell Publishing Ltd

Sandra A. F. Nogueira*, Sheila M. F. Torres*,


Erin D. Malone, Sandra F. Diaz*, Carl Jessen*
and Sophie Gilbert*
*Veterinary Clinical Sciences Department, University of Minnesota,
Saint Paul, Minnesota, USA
Veterinary Population Medicine Department, University of
Minnesota, Saint Paul, Minnesota, USA
Correspondence: Dr Sandra A. F. Nogueira, Veterinary Clinical
Sciences Department, College of Veterinary Medicine, University
of Minnesota, C339 Veterinary Medical Center, 1453 Boyd Avenue,
St. Paul, MN 55108, USA. Tel.: +1-612-624-3218;
E-mail: nogu0005@umn.edu.

Abstract
Imiquimod is an immune response modifier with
potent antiviral and antitumour activity. The objective
of this pilot study was to evaluate the efficacy of an
imiquimod 5% cream (Aldara: 3M, Saint Paul, MN,
USA) as a topical treatment for equine sarcoids. Fifteen horses with a total of 19 tumours were enrolled,
including mixed (7), fibroblastic (5), flat (3), verrucous
(2), and nodular (2) types. Baseline data included
history, physical examination, tumour location, measurement and digital photography. Imiquimod was
applied by the owners three times a week until
complete resolution of the tumour or 32 weeks,
whichever occurred first. Tumours were measured
and photographed every 4 weeks. Treatment efficacy
was defined as 75% or greater reduction of tumour
size by the end of the trial. Four sarcoids were withdrawn from the study. Twelve of the remaining 15
tumours (80%) showed more than 75% reduction in
size and nine (60%) totally resolved between 8 and
32 weeks. The most common adverse effects of
exudation, erythema, erosions, depigmentation and
alopecia were limited to the tumour and adjacent
areas. The results suggest that topical imiquimod is
a therapeutic option for the treatment of equine
sarcoids, although more detailed studies are required
to corroborate these initial findings.
Accepted 19 April 2006

evidence that bovine papillomavirus is implicated in the


aetiology.1,5 8
There is no single universally effective treatment and
the rate of recurrence is high.1,3,4,9 Successful management
remains a challenge, with a wide variety of treatment options,
which include: complete surgical excision, cryosurgery,
immunotherapy (e.g. autogenous vaccines and mycobacterial products), laser therapy, radiotherapy, hyperthermia,
photodynamic therapy, intratumoral chemotherapy (e.g.
5-fluorouracil and cisplatin), topical agents (e.g. AW3(4)LUDES, podophyllum, XXTERRA and Animex) or a
combination of these modalities.1 4,913 Many of these
treatments are only available at selected referral centres
and may require repeated administrations.
Imiquimod, an imidazoquinolinamine, is the first representative of a new class of immune response modifiers
with potent antiviral and antitumour activity in animal models and humans. Successful topical treatment of human
genital warts has been reported,14,15 as well as anecdotal
use of the cream in equine sarcoids.1 Although the exact
mechanism of action of imiquimod is not clearly understood,
in vitro studies have shown potent immunoregulatory
effects on innate and cell-mediated immune responses.15,16
The association of equine sarcoids with papilloma virus
and the antiviral and antitumour effects of imiquimod
justify investigating this drug as a treatment for sarcoids.
The aim of this pilot clinical trial was therefore to evaluate
the efficacy of 5% imiquimod cream in the management
of different types of equine sarcoids.

Materials and methods


Inclusion criteria
Client-owned horses of any age, sex and breed diagnosed with
sarcoid, but otherwise clinically healthy, were included in the study.
The diagnosis of sarcoid was based on the clinical characteristic of the
tumour and confirmatory histopathology. Tumour types were classified as previously reported.3 Horses were not included in the study if
they had received treatment with imiquimod, interferon, glucocorticoids, cytotoxic drugs, chemical and/or surgical therapy or any topical
medications used to treat sarcoids within the previous 4 weeks. Owners were required to sign a written informed consent before enrolling
their horses in the study and were advised of their right to withdraw
from the trial at any time.

Population and tumour characteristics

Introduction
Sarcoids, which vary clinically from benign flat to locally
aggressive ulcerative fibroblastic tumours,1 4 are very common neoplasms of horses worldwide, representing up to
90% of skin tumours and 20% of all tumours.1 3 Although
the cause is currently unknown, there is considerable

Fifteen horses diagnosed with sarcoids presented at the Veterinary


Medical Center of the University of Minnesota between April 2004
and August 2005 were included in the study. There were seven mares
and eight geldings represented by seven breeds, including Quarter
horse (6), American Paint horse (2), Arabian (2), Thoroughbred (2),
Andalusian (1), Appaloosa (1) and Thoroughbred/Hanoverian (1). The
mean ages of the horses at tumour onset and at first visit were
9.4 years (range: 1.5 24 years) and 12.2 years (range: 3 29 years),
respectively (Table 1).

2006 The Authors. Journal compilation 2006 European Society of Veterinary Dermatology. 17; 259265

259

Nogueira et al.

260
Table 1. Characteristics of 19 sarcoids from 15 horses included in the study

2006 The Authors. Journal compilation 2006 European Society of Veterinary Dermatology.

Tumours

Horse sex

Horse breed

Tumour types

Location of tumour

Age at onset
of tumour (years)

Age at first
visit (years)

Gelding

Quarter horse

Fibroblastic

Perineal region

16

20

2
3a
4a
5
6
7
8b
9b
10
11
12
13
14c
15c
16c
17
18
19

Mare
Mare

Quarter horse
Andalusian

Mare
Mare
Gelding
Gelding

Quarter horse
Appaloosa
Quarter horse
American Paint horse

Gelding
Gelding
Gelding
Gelding
Mare

Quarter horse
Arabian horse
Thoroughbred
Thoroughbred/Hanoverian
American Paint horse

Mare
Mare
Gelding

Thoroughbred
Arabian horse
Quarter horse

Fibroblastic
Verrucous
Mixed (flat + verrucous)
Flat
Verrucous
Flat
Mixed (flat + nodular)
Mixed (verrucous + nodular)
Nodular
Mixed (flat + nodular)
Fibroblastic
Fibroblastic
Mixed (flat + verrucous + nodular)
Nodular
Fibroblastic
Mixed (flat + nodular)
Flat
Mixed (flat + nodular)

Proximal limb
Thorax
Proximal limb
Neck
Pinna
Temporal region
Neck
Neck
Perineal region
Upper eyelid
Muzzle
Distal limb
Upper eyelid
Thorax
Distal limb
Neck
Proximal limb
Upper eyelid

5
18
18
19
24
10
4
4
11
2.5
13
1.5
4
4
4
2
15
4

7
23
23
24
29
15
6
6
13
4.5
15
3
6
6
6
4
16
5

Letters a, b and c identify the three horses with more than one treated tumours.

Previous therapies
Cryotherapy, laser, XXTERRA,
5-fluorouracil, cisplatin injection
Surgical removal twice
XXTERRA, surgical removal
None
None
XXTERRA, IV Eq-Stim
Nonspecific topical products
Antifungal oral therapy
Antifungal therapy
None
Surgical removal, XXTERRA
XXTERRA, nonspecific topical products
5-fluorouracil, surgical removal
Laser, cryotherapy
Laser, cryotherapy
Laser, cryotherapy
XXTERRA
None
None

Response to
previous therapies
Reoccurred
Reoccurred
Reoccurred

Reoccurred
No response
No response
No response

Reoccurred
No response
Reoccurred
No response
No response
Reoccurred
No response

Imiquimod 5% cream for equine sarcoid

Figure 1. Tumour 1. Fibroblastic equine


sarcoid on the perineal region. (a) Prior to
imiquimod therapy; (b) same tumour at
16 weeks of therapy.

A total of 19 sarcoids were studied on the 15 horses. Twelve had


a single tumour, two had two tumours and one had three tumours.
The tumour types included mixed (7), fibroblastic (5), flat (3), verrucous (2), and nodular (2). Mixed types were comprised of flat and
nodular (4), verrucous and nodular (1), flat and verrucous (1), and flat,
verrucous and nodular (1). Five tumours were untreated prior to
enrolment, while 14 had received at least one treatment modality
(Table 1).

Treatment protocol
A thin layer of imiquimod 5% cream (Aldara, 3M Pharmaceuticals,
Saint Paul, MN, USA) was applied to the tumour surface three times
a week on nonconsecutive days. Prior to application, the tumour was
cleaned with soap and water to remove exudate and improve drug
penetration. The first five horses were treated for 16 weeks, independent of treatment outcome, according to a human protocol.14
Based on the observations of these horses, duration of treatment was
extended for subsequent tumours until complete resolution or up to
32 weeks, whichever occurred first. The study protocol was approved
by the Animal Care and Use Committee of the University of Minnesota.

Assessment of therapeutic efficacy


At the first visit, a thorough history including signalment, age at time
of tumour development, type, number and location of the tumour(s),
previous therapy, response to therapy and findings of a thorough dermatological examination was recorded for each horse. Horses were
evaluated by one of the investigators (SN) at the first visit and every
4 weeks thereafter for the treatment period.
At each visit, tumours were measured in centimetres at their greatest length, width and height using a ruler. Volume measurement was
not an option for the flat tumours as their heights were close to zero;
therefore, tumour size was characterized as the greatest crosssectional area, calculated as the product of the two greatest dimensions (length, width or height).14,17 Treatment efficacy was defined as
75% or greater reduction of the original tumour size by the end of the
trial. Digital photographs taken before treatment and at each subsequent visit were used as supporting evidence. Efficacy was evaluated
for individual tumours instead of horses as different tumours on the
same horse exhibited different treatment outcomes. At the end of
treatment, owners subjectively rated their perception of treatment
efficacy as none, poor, good or excellent for each tumour.

Compliance and assessment of adverse drug effects


Compliance with treatment protocol was determined by comparing
the number of imiquimod packets returned by the owners with the
number of packets dispensed. Compliance was considered satisfactory
if at least 90% of the doses were administered.
Skin reactions at treatment sites including alopecia, erythema,
depigmentation, oedema, erosion, ulceration, scaling and exudation
were recorded by the investigator at each visit and by the owners on
treatment days. If the owner and/or the investigator felt that local skin
reactions were causing significant discomfort to the horse, treatment

interruption of 2 weeks or reduction in treatment frequency was


allowed. If deemed necessary, horses were treated by the owners
with 24 mg kg1 of phenylbutazone (Butasone, Jaapharm Canada
Inc., Woodbridge, Canada) orally every 24 h as required to minimize
discomfort.

Withdrawal criteria
Horses were withdrawn from the study if there were intolerable
adverse effects that did not subside after 2 weeks of imiquimod
discontinuation or reduction in treatment frequency, lack of owner
compliance with treatment protocol or follow-up visits, concurrent
diseases that could interfere with treatment application or evaluation,
or owners desire to withdraw their horses.

Follow-up after dosing


Follow-up information was obtained by telephone for tumours
reported by owners to have no or partial resolution and by investigator
re-evaluation of tumours that showed complete resolution.

Statistical analysis
Assuming that tumours are independent, a 95% confidence interval
(CI) for the success rate was estimated based on binomial distribution.
Statistical analysis was carried out using the SPSS statistical package
(SPSS version 11.5.1, Chicago, IL, USA).

Results
Treatment outcome
Four (21%) sarcoids were withdrawn from the trial upon
owners request: two after 4 weeks of therapy; one because
of inability to attend follow-up (tumour 6) and the other
because of winter treatment difficulty (tumour 7), and
two after 8 and 16 weeks of therapy (tumours 16c and 13,
respectively), because of lack of treatment response
(Table 2). Treatment was completed for 15 of the 19 (79%)
sarcoids. Twelve of the 15 sarcoids had more than 75%
reduction in size (Fig. 1a,b; Table 2), resulting in 80%
success rate (95% CI 60100%). Of these 12 sarcoids,
nine (60%) completely resolved (Fig. 2a,b; Table 2). The
time to achieve at least 75% reduction in size ranged from
8 to 32 weeks (Table 2). One flat, one verrucous and one
fibroblastic sarcoid (tumours 3a, 5 and 12; Table 2) failed
to respond to treatment. Upon completion of the study,
owners rated treatment efficacy as excellent in 11,
good in 3 and poor in 1 tumour. If the four withdrawn
sarcoids were included in the statistical analysis, it would
have resulted in a success rate of 68% (95% CI 58.8
79.1%).

2006 The Authors. Journal compilation 2006 European Society of Veterinary Dermatology.

261

Nogueira et al.

Table 2. Treatment outcome and follow-up of 19 sarcoids of various types treated with 5% imiquimod cream applied three times a week for up
to 32 weeks

Tumours

Tumour types

Baseline
A (cm2)

1*

Fibroblastic

252

2*
3a*
4a*
5*
6**
7**
8b
9b
10
11
12
13**
14c
15c
16c**

Fibroblastic
Verrucous
Mixed (flat + verrucous)
Flat
Verrucous
Flat
Mixed (flat + nodular)
Mixed (verrucous + nodular)
Nodular
Mixed (flat + nodular)
Fibroblastic
Fibroblastic
Mixed (flat + verrucous + nodular)
Nodular
Fibroblastic

17
18
19

Mixed (flat + nodular)


Flat
Mixed (flat + nodular)

Final
A (cm2)

Outcome
(% change
in size)

Duration of
treatment
(weeks)

Follow-up
time
(weeks)

97.62

16

28

8.75
24.5
36
266
4
78
12
45
2.38
10
6
22.5
3
12
10.5

0
15.75
8
104
1
91
0
0
0
0.2
9
34
0
0
12

100.00
35.71
77.78
60.90
75.00
16.67
100.00
100.00
100.00
98.00
50.00
51.11
100.00
100.00
14.29

16
16
16
16
4
4
16
16
16
32
32
16
12
16
8

60
28
28
24
45
60
32
32
36
23.2
8
0
8
8
4

15
27.5
1.8

0
0
0

100.00
100.00
100.00

12
8
8

4
4
12

Follow-up outcome
Restarted treatment
with imiquimod, stable
No recurrence
No change
No change
No change
No change
No change
No recurrence
No recurrence
No recurrence
No change
No change
Other therapy
No recurrence
No recurrence
Imiquimod after
debulking, reoccurred
No recurrence
No recurrence
No recurrence

A, cross-sectional area; , letters a, b and c identify the three horses with more than one treated tumours; , negative values indicate decrease in
size and positive signs indicate increase in size; *, tumours treated for 16 weeks independent of treatment outcome; **, withdrawn tumours.

Figure 2. Tumour 2. Fibroblastic equine


sarcoid on the proximal limb. (a) Prior to
imiquimod therapy; (b) same tumour at
60 weeks after therapy.

Compliance and adverse drug effects


Compliance with treatment protocol was satisfactory for
all horses in the study.
The most common side-effects of imiquimod noted by
the investigator and owners were alopecia, erythema,
exudation, erosion and depigmentation limited to tumour
and adjacent skin areas (Fig. 3a). In most cases, side-effects
started within the first 2 weeks of therapy, subsided after
8 weeks and almost completely resolved within about
30 days after cessation of treatment with acceptable
cosmetic outcome (Fig. 3b). Treatment of periorbital areas
did not injure the eye structures. In addition, two mares 3
and 4 months pregnant at initiation of the trial produced
healthy foals. Two horses required a maximum of four
doses of oral phenylbutazone during treatment due to discomfort and another two were sedated with 0.5 mg kg1
of 2% xylazine hydrochloride (Rompun, Bayer, Leverkusen,
Germany) intravenously to allow tumour cleaning and
examination at follow-up visits. One of the latter required
a week of rest because of tumour discomfort associated
262

with treatment and cleaning. Two other horses required


reduction in treatment frequency to twice weekly for 1
week; one because of severe fly infestation and the other
because of discomfort during cleaning. The side-effects
subsided after the week of reduction in treatment frequency and treatment was reinstituted without further
rest periods.
Follow-up
Fifteen sarcoids were followed after the end of the dosing
period. Of the nine tumours that completely resolved,
none recurred during follow-up of 460 weeks (mean
= 21.8 weeks) (Table 2). Treatment sequela included
partial alopecia (7/9), depigmentation (6/9), scarring (3/9),
hyperpigmentation (3/9) and leukotrichia (1/9). Of the
three tumours that had partial response (more than 75%,
but less than 100% reduction in size), two did not show
any further changes after 23.228 weeks (mean = 26.4
weeks). However, one (tumour 1) had increased in size
8 weeks later and imiquimod was restarted using the

2006 The Authors. Journal compilation 2006 European Society of Veterinary Dermatology.

Imiquimod 5% cream for equine sarcoid

Figure 3. Tumour 19. Mixed (flat and nodular) periorbital equine sarcoid. (a) At 4 weeks of imiquimod therapy showing severe exudate at
the tumour area, and alopecia and depigmentation on clinically normal
skin; (b) 4 weeks after imiquimod therapy showing almost complete
resolution of the side-effects with acceptable cosmetic outcome.

same protocol (Table 2). Tumour size was reduced on


treatment; therefore, twice weekly application was
maintained, preventing further growth for the following
20 weeks. Two sarcoids (tumours 3a and 5) with less than
75% reduction in size and one (tumour 12) that did not
respond to imiquimod therapy did not show change in an
828 week follow-up (mean = 20 weeks) (Table 2).

Discussion
In this pilot study, application of 5% imiquimod cream
(Aldara) once daily three times a week to equine sarcoids resulted in more than 75% reduction in tumour size
in 80% of the sarcoids. More frequent applications are
unlikely to have resulted in a higher or faster response

rate; however, more frequent dosing in humans resulted


in more severe local side-effects and did not improve the
success rate.15
Tumours that completely resolved on treatment did so
within 16 weeks. However, a periocular sarcoid showed
incomplete resolution at 32 weeks, suggesting that some
tumours may take longer to cure. Clients may need to be
informed of possible long-term treatment and of lower
chances of complete tumour regression if no significant
improvement is observed after 16 weeks of therapy.
The treatment-related reaction at tumour site was
probably associated to the pharmacological properties of
imiquimod, as reported in humans.14,15,1821 This reaction
extended to the surrounding clinically normal skin, which
could either reflect a high susceptibility of horses to an
immunological or irritant response of imiquimod or indicate
the presence of subclinical sarcoid at the inflammatory
sites, as has been observed in human actinic keratoses.20,21
Advantages of imiquimod therapy include convenient
application by owners without special equipment and facilities, a noninvasive treatment protocol, and a satisfactory
cosmetic outcome. It may be the first therapy choice for
tumours in certain locations, such as the limbs, perineal
and periorbital areas where other treatments may be
inappropriate.1,11,12 Disadvantages include long treatment
duration and inflammation on adjacent skin, but these
were insufficient to deter therapy recommendation.
The cost of treatment is important in the choice of
therapy for equine sarcoids. In this study, tumours required
an average of one packet of imiquimod (0.25 g) per application, resulting in an average of 12 packets (one box) per
tumour for 4 weeks of therapy. Therefore, the cost of treating a medium size sarcoid (approximately 80 cm2) with the
protocol described was estimated to be US$150.00 to
US$200.00 for 4 weeks. Consequently, the cost for 16
weeks of imiquimod therapy (US$600800) is comparable
to that for most other efficacious treatments for equine
sarcoids performed at the University of Minnesota, for
example conventional surgery (US$370.00 620.00),
laser (US$422.00) and cryosurgery (US$660.00). These
treatments are often combined and repeated over time,
increasing their cost.
A limitation of this study was the relatively short posttreatment evaluation. While none of the nine tumours
that completely resolved recurred during a follow-up
period of 460 weeks, a period of at least 1 year would
have improved confidence of a complete cure.9 However,
recurrence rates for tumours treated with imiquimod in
humans are reportedly low and considered to result from
a cell-mediated immunological memory induced by the
drug.2022 Another limitation was the lack of a placebo
group, as spontaneous regression has been reported in
horses with sarcoids. However, spontaneous regression
occurs in 10% or less of affected horses and typically
within the first 6 months after initial diagnosis.1,2,8 The
tumours in this study had been present for at least 1 year
at time of inclusion, and resolution occurred within 16 weeks
of therapy, indicating that the observed outcome was most
likely associated with the therapeutic intervention. Finally,
the small sample population of this pilot study limited
accurate evaluation of whether tumour type, size, location
and previous therapies had an effect on treatment outcome.

2006 The Authors. Journal compilation 2006 European Society of Veterinary Dermatology.

263

Nogueira et al.

This therapeutic efficacy of imiquimod seems to compare favourably with reported effects of intratumoural
administration of IL-2 and cisplatin, which showed partial
or complete regression in 80% of the sarcoids.2 On the
other hand, the percentage of completely resolved tumours
(60%) was somewhat lower than the rates reported for
local bacilli CalmetteGurin vaccination (64%), CO2 laser
(71%), cryosurgery (79%) and conventional surgical
excision (82%).9 This diversity may be a consequence of
differences in case selection and tumour location, size and
type. Possible insufficient treatment duration in this study
for the first four tumours treated for only 16 weeks could
have hindered a better final outcome. The results of this
study cannot be compared with topical therapies such as
XXTERRA, Animex, 5-fluorouracil and AW-3(4)-Ludes
where only anecdotal evidence of their efficacy has been
reported.1,6,12,13
In conclusion, results of this pilot study indicate that
imiquimod 5% cream is a convenient and safe option for
treatment of equine sarcoids. However, a prospective
randomized, double-blinded, placebo-controlled study
including larger number of different types of sarcoids is
needed.

Acknowledgements
The authors thank 3M Pharmaceuticals for drug supply,
Joan Lucas for motivation to pursue the study, Kathy
Stuebner for research coordination and Derek Knottenbelt
and Robert Koch for valuable manuscript review. They are
also grateful to both referring veterinarians and owners for
their contribution. This project was supported by the University of Minnesota Equine Center, College of Veterinary
Medicine, University of Minnesota, with funds provided
by the Minnesota Racing Commission, Minnesota Agricultural Experimental Station, and contributions from private
donors.

References
1. Scott DW, Miller WH. Neoplastic and non-neoplastic tumors. In:
Scott DW, Miller WH, eds. Equine Dermatology. Philadelphia, PA:
WB Saunders, 2003: 71931.
2. Spoormakers TJP, Klein WR, Jacobs JJL et al. Comparison of the
efficacy of local treatment of equine sarcoids with IL-2 or cisplatin/
IL-2. Cancer Immunology and Immunotherapy 2003; 52: 17984.
3. McConaghy FF, Davis RE, Hodgson DR. Equine sarcoid: a persistent therapeutic challenge. Compendium on Continuing Education
for the Practicing Veterinarian 1994; 16: 10229.
4. Foy JM, Rashmir-Raven AM, Brashier MK. Common equine skin
tumors. Compendium on Continuing Education for the Practicing
Veterinarian 2002; 24: 24254.

5. Carr EA, Theon AP, Madewell BR et al. Bovine papillomavirus


DNA in neoplastic and nonneoplastic tissues obtained from
horses with and without sarcoids in the western United States.
American Journal of Veterinary Research 2001; 62: 7414.
6. Chambers G, Ellsmore VA, OBrien PM et al. Association of
bovine papillomavirus with the equine sarcoid. Journal of General
Virology 2003; 84: 105562.
7. Martens A, De Moor A, Demeulemeester J et al. Polymerase
chain reaction analysis of the surgical margins of equine sarcoids
for bovine papilloma virus DNA. Veterinary Journal 2001; 30: 460
7.
8. Brostrom H. Equine sarcoids: a clinical and epidemiological study
in relation to equine leucocyte antigens (ELA). Acta Veterinaria
Scandinavica 1995; 36: 22336.
9. Martens A, De Moor A, Vlaminck L et al. Evaluation of excision,
cryosurgery and local BCG vaccination for the treatment of equine
sarcoids. Veterinary Record 2001; 149: 6659.
10. Genetzky RM, Biwer RD, Myers RK. Equine sarcoids: causes,
diagnosis and treatment. The Compendium 1998; 5: 625.
11. Bertone AL, McClure JJ. Update on equine therapeutics: therapy
for sarcoids. The Compendium 1996: 2624.
12. Knottenbelt DC, Walker JA. Topical treatment of the equine sarcoid. Equine Veterinary Education 1994; 6: 725.
13. Knottenbelt DC, Kelly DF. The diagnosis of periorbital sarcoid in
the horse: 445 cases from 1974 to 1999. Veterinary Ophthalmology 1974; 3: 16991.
14. Beutner KR, Tyring SK, Trofatter KF Jr et al. Imiquimod, a patientapplied immune-response modifier for treatment of external
genital warts. Antimicrobial Agents of Chemotherapy 1998; 42:
78994.
15. Gollnick H, Barasso R, Jappe U et al. Safety and efficacy of imiquimod 5% cream in the treatment of penile genital warts in uncircumcised men when applied three times weekly or once per day.
International Journal of STD and AIDS 2001; 12: 228.
16. Sauder DN. Immunomodulatory and pharmacologic properties of
imiquimod. Journal of the American Academy of Dermatology
2000; 43: S611.
17. Mackenzie-Wood A, Kossard S, de Launey J et al. Imiquimod 5%
cream in the treatment of Bowens disease. Journal of the American Academy of Dermatology 2001; 44: 46270.
18. Edwards L, Ferenczy A, Eron L et al. Self-administered topical 5%
imiquimod cream for external anogenital warts. Archives of
Dermatology 1998; 134: 2530.
19. Marks R, Gebauer K, Shumack S et al. Imiquimod 5% cream in
the treatment of superficial basal cell carcinoma: results of a
multicenter 6-week dose-response trial. Journal of the American
Academy of Dermatology 2001; 44: 80713.
20. Salasche SJ, Levine N, Morrison L. Cycle therapy of actinic
keratosis of the face and scalp with 5% topical imiquimod cream:
an open label trial. Journal of the American Academy of Dermatology 2002; 47: 5717.
21. Lebwohl M, Dinehart S, Whiting D et al. Imiquimod 5% cream for
the treatment of actinic keratosis: results from two phase III,
randomized, double-bind, parallel group, vehicle controlled trials.
Journal of the American Academy of Dermatology 2004; 50: 71421.
22. Tyring S, Conant M, Marini M et al. Imiquimod; an international
update on therapeutic uses in dermatology. The International
Society of Dermatology 2002; 41: 8106.

Rsum Limiquimod est un immunomodulateur avec des proprits antivirales et antitumorales. Lobjectif
de cette tude pilote tait dvaluer lefficacit dune crme 5% dimiquimod 5% cream (Aldara: 3M,
Saint Paul, MN) comme traitement topique des sarcodes du cheval. Quinze chevaux avec un total de 19
tumeurs ont t inclus, avec des sarcodes mixtes (7), fibroblastiques (5), plats (3), verruqueux (2), et
nodulaires (2). Les donnes tudies taient lanamnse, lexamen clinique, la localisation de la tumeur, la
taille, et des photographies digitales. Limiquimod tait appliqu par les propritaires trois fois par semaine
jusqu disparition complte de la tumeur ou pendant 32 semaines. Les tumeurs taient mesures et
photographies tous les mois. Le traitement tait considr efficace si la taille de la tumeur diminuait dau
moins 75% la fin de lessai. Quatre sarcodes sont sortis de lessai. Douze des quinze restants (80%) ont
264

2006 The Authors. Journal compilation 2006 European Society of Veterinary Dermatology.

Imiquimod 5% cream for equine sarcoid

diminu de plus de 75% et 9 (60%) ont totalement disparu entre 8 et 32 semaines. Les effets secondaires
les plus frquents taient une exudation, un rythme, des rosions, une dpigmentation et une alopcie
localiss la tumeur ou aux zones adjacentes. Ces rsultats suggrent que limiquimod par voie locale est
une option thrapeutique des sarcodes du cheval, bien que des tudes plus dtailles soient ncessaires
pour confirmer ces donnes.
Resumen Imiquimod es un modulador de la respuesta inmune con potente actividad antivrica y antitumoral. El objetivo de este estudio piloto fue evaluar la eficacia de una crema con un 5% de imiquimod
(Aldara: 3M, Saint Paul, MN) como tratamiento tpico para los sarcoides equinos. Quince caballos con
un total de 19 tumores fueron seleccionados, incluyendo los tipos mixto (7), fibroblstico (5), plano (3),
verrucoso (2) y nodular (2). La informacin clnica inicial incluy historia, examen fsico, localizacin de los
tumores, medidas y fotografa digital. La pomada de imiquimod se aplic por los propietarios tres veces en
semana hasta la curacin total del tumor o durante 32 semanas, lo que ocurriera antes. Los tumores fueron
medidos y fotografiados cada cuatro semanas. Un tratamiento efectivo se defini como aquel que produjo
una reduccin de un 75% o ms en el tamao del tumor al final del estudio. Cuatro de los sarcoides fueron
retirados del estudio. Doce de los restantes 15 (80%) presentaron una reduccin de ms de un 75% en el
tamao, y nueve (60%) resolvieron de forma completa entre las 8 y las 32 semanas. Los efectos adversos
mas comunes fueron exudacin, eritema, erosiones, depigmentacin y alopecia limitados al tumor y zonas
adjacentes. Los resultados sugieren que la pomada de imiquimod de aplicacin tpica es una opcin
terapetica para el tratamiento de los sarcoides equinos, aunque estudios ms detallados se requeriran
para confirmar estos hallazgos iniciales.
Zusammenfassung Imiquimod modifiziert die Immunantwort und besitzt starke antivirale und antitumorale
Aktivitt. Das Ziel dieser Pilotstudie war es, die Wirksamkeit einer 5%igen Imiquimod Crme (Aldara(tm):
3M, Saint Paul, MN) als topische Behandlung fr equine Sarkoide zu evaluieren. Fnfzehn Pferde mit
insgesamt 19 Tumoren wurden verwendet, diese setzten sich aus gemischten (7), fibroblastischen (5),
flachen (3), warzenartigen (2) und nodulren (2) Typen zusammen. Die Ausgangsdaten bestanden aus der
Anamnese, einer klinischen Untersuchung, der Lokalisation, Messung und digitalen Fotographie des Tumors.
Imiquimod wurde von den Besitzern drei mal wchentlich bis zum vlligen Verschwinden des Tumors oder
insgesamt fr 32 Wochen aufgetragen. Die Tumoren wurden alle vier Wochen gemessen und fotographiert.
Die Wirksamkeit der Behandlung wurde definiert mit einer 75% igen oder hheren Reduktion der Gre
des Tumors bei Studienende. Vier Sarkoide wurden aus der Studie genommen. Zwlf der brigen 15 (80%)
zeigten eine mehr als 75% ige Reduktion in Gre und 9 (60%) verschwanden zur Gnze nach 8 bis 32 Wochen.
Die hufigsten Nebenwirkungen wie Exudation, Erythem, Erosionen, Depigmentation und Alopezie waren
limitiert auf die Tumoren und angrenzenden Gebiete. Die Ergebnisse weisen darauf hin, dass topisches
Imiquimod eine therapeutische Option darstellt fr die Behandlung von equinen Sarkoiden, obwohl detailliertere Studien ntig sind, um diese anfnglichen Ergebnisse zu besttigen.

2006 The Authors. Journal compilation 2006 European Society of Veterinary Dermatology.

265