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Imiquimod cream is an immunomodulatory agent that has been approved by the US Food and Drug Administration for use in the treatment of anogenital warts (condylomata acuminata) due to its local immune effects in activating Toll-like receptors 7 and 8 on antigen-presenting cells, resulting in reduction of the viral load of human papillomavirus with subsequent wart regression. After its application, some side effects are commonly reported, including erythema, edema, scaling, erosion, and ulceration. While pigmentary changes, including vitiligo-like depigmentation, have been mentioned as a possible side effect, they have rarely been reported in the literature.

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Vitiligo-like lesions, although rare, are believed to be a prognostic factor in malignant melanoma. While a predictive role for such lesions was shown with immunomodulatory therapies, this relation was not demonstrated with temozolomide. We present 3 patients with metastatic malignant melanoma who developed vitiligo-like skin lesions accompanying good response to treatment and prolonged survival.

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A 25-year-old Caucasian female with multiple genital warts involving the vulvar area was treated with imiquimod 5% cream. During follow-up the patient developed areas of hypopigmentation at the site of application of imiquimod cream and areas of hypomelanosis around multiple preexisting nevi of the trunk. At 18 months follow-up genital depigmentation persisted and halo nevi of the trunk were still present.

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