CASE REPORT
Condyloma of the neovaginal vault
successfully treated with topical
cidofovir therapy
Jose L. Cortez, MD, MS,a Danielle N. Turner, PhD,b John R. Durkin, MD, MBA,a and Mary E. Logue, MDa
Key words: condyloma acuminata; LGBTQ care; neovagina; topical cidofovir; transgender care.
INTRODUCTION
There is no consensus for treating condyloma
arising in the neovaginal vault in transgender women
following gender-affirming vaginoplasty. Prior re-
ports have documented successful treatment of
neovaginal condyloma with carbon dioxide (CO2)
laser, topical imiquimod, and topical trichloroacetic
acid (TCA). Additionally, topical cidofovir has been
cited in the literature as efficacious for the treatment
of external genital warts in cisgender patients. Here,
we discuss a case of condyloma of the neovaginal
vault arising de novo in a transgender woman who
was successfully treated with 1% topical cidofovir
with sustained clearance.
CASE REPORT
A 43-year-old transgender female with no prior
history of sexually transmitted infections (STIs)
presented with neovaginal lesions 18 months post-
penile inversion vaginoplasty. She initially presented
to her obstetrics and gynecology with worsening
vulvar irritation and pain that prevented her from
using her dilators and diagnosed with bacterial
vaginosis. During her speculum exam, her obstetrics
and gynecology biopsied lesions that were histolog-
ically consistent with condyloma acuminata; she was
then referred to Dermatology. Her external genitalia
was markedly inflamed and macerated with super-
ficial erosions and secondary white to gray exudate.
A speculum exam revealed several clusters of fleshy,
inflamed verrucous papules and plaques within the
posterior and lateral walls of the neovaginal vault.
From the Department of Dermatology, University of New Mexico,
Albuquerque, New Mexicoa; and University of New Mexico,
School of Medicine, Albuquerque, New Mexico.b
Funding sources: None.
Patient consent: Consent for the publication of all patient
photographs and medical information was provided by the
authors at the time of article submission to the journal stating
that all patients gave consent for their photographs and
medical information to be published in print and online and
with the understanding that this information may be publicly
available.
104
Abbreviations used:
CO2: carbon dioxide
STIs: sexually transmitted infections
TCA: trichloroacetic acid
The patient’s performing vaginoplasty surgeon was
consulted to discuss treatment options, given the
complexities around the anatomy and microbiome
of the neovagina. The decision was made to begin
daily application of compounded topical 1% cidofo-
vir cream (ChemistryRx). Of note, although TCA was
an initial treatment of choice, it was unable to be
obtained in a reasonable time due to supply chain
issues. Destructive modalities such as cryotherapy or
CO2 laser would carry a higher risk of damaging the
neovagina and are difficult to perform on the internal
vagina. Topical 5-fluorouracil and imiquimod could
both exacerbate the inflammation and erosion that
was already present. Additionally, imiquimod has a
higher risk of systemic absorption on mucosal
surfaces with unwanted side effects such as fevers,
chills and flu-like symptoms. As cidofovir is virucidal
and can be compounded to a lowest effective con-
centration to directly target the warts, it was felt this
option would be the optimal approach to spare
healthy tissue and minimize the risk of localized and/
or systemic side effects.
After the first 2 weeks of once daily application of
cidofovir 1% cream, patient reported a noticeable
decrease in her condyloma burden during manual
IRB approval status: Not applicable.
Correspondence to: Jose L. Cortez, MD, MS, UNM Department of
Dermatology, University of New Mexico, Albuquerque, NM
87131. E-mail: Jlcortez@salud.unm.edu.
JAAD Case Reports 2023;41:104-6.
2352-5126
Ó 2023 by the American Academy of Dermatology, Inc. Published
by Elsevier Inc. This is an open access article under the CC BY
license (http://creativecommons.org/licenses/by/4.0/).
https://doi.org/10.1016/j.jdcr.2023.09.016
JAAD CASE REPORTS
VOLUME 41
Fig 1. Clinical presentation of condyloma of the neo-
vagina of a transgender woman. A, Pretreatment speculum
examination demonstrates pink papillomatous papules in
the neovaginal vault. B, Post-treatment speculum exami-
nation with complete resolution of pink papillomatous
papules in the neovaginal vault.
self-exams. She was unable to manually apply cream
to the posterior vault, so we started using her
smallest gauge dilator to successfully apply the
cream to this area. After a total of 6 weeks of
treatment, her follow-up speculum exam confirmed
no residual condyloma clinically (Fig 1). The only
side effect of her therapy was worsening of her initial
vaginitis which was treated with pulse dosing of
metronidazole 500 milligrams for 7 days followed by
fluconazole 150 milligrams on day 8, every 2 weeks,
as well as metronidazole 0.75% cream, miconazole
2% cream, and tacrolimus 0.1% ointment for twice
daily application to the external genitalia during
flares. As maintenance, zinc oxide 10% cream was
used as a skin protectant and 99% water based wipes
for hygiene. At this time, patient remains clinically
clear of condyloma.
DISCUSSION
Transgender individuals experience disparities in
care that can be detrimental to their overall physical
and psychosocial health. Higher rates of STIs,
violence, and mental health conditions have been
reported in this population.1 Dermatologists can play
an important role in the screening, prevention, and
treatment of STIs in transgender individuals.2 In
transgender women, diagnosis of condyloma can
be challenging and requires an understanding of
gender-affirming vaginoplasty and the sexual behav-
iors of these individuals.3 Additionally, there is a
paucity of information on how to treat condyloma in
transgender individuals which requires consider-
ation of the delicate nature of the skin used to create
the neovagina.
Cortez et al 105
Prior studies have documented the new onset of
condyloma in the transplanted neovaginal skin of
transgender women. Both Yang et al and Liguori
et al commented on the rarity of literature on
condyloma in transgender women and a lack of
consensus on treatment.4,5 Matsuki et al reported
successful clearance of condyloma in the neovagina
of a transgender woman with CO2 laser followed
by topical imiquimod for residual warts; this was
the first report to document the successful clearance
of condyloma with imiquimod.6 Fein et al subse-
quently reported successful treatment of biopsy-
proven neovaginal condyloma in a transgender
woman with TCA.7 Individuals in both reports had
sustained clearance.
The New England Journal of Medicine (NEJM)
published a case series of 3 cisgender male and
female patients with condyloma who were success-
fully treated with topical 1% cidofovir. All patients
were noted to have significant improvement after a
single week of therapy and remained free of recur-
rence at 6-12 month follow up.8 Subsequently, a
systematic review by Jung et al demonstrated that
efficacy of topical cidofovir as a therapeutic agent for
the treatment of external genital warts was compa-
rable to that of conventional therapies such as
imiquimod with no differences in recurrence of
warts or in severe adverse events.9 Therefore, these
studies suggested topical cidofovir could serve as a
treatment option for condyloma arising in the
neovaginal vault.
Herein, we described a case of condyloma in a
transgender woman with no history of condyloma
prior to vaginoplasty. To the best of our knowledge,
this individual represents the first case of successful
treatment with topical cidofovir of condyloma pre-
senting de novo in the neovagina of a transgender
woman. This case again underscores the important
role dermatologists play in screening, prevention,
and treatment of STIs in transgender individuals.2
Transgender women who present with new onset
condyloma should also be screened for other STIs.
Treatment of neovaginal condyloma should consider
the anatomy and delicate skin of the neovagina. Our
case also highlights the unique nature of the neo-
vaginal microbiome and the importance of success-
fully managing vaginitis to optimize dilation
exercises that are vital in maintaining the neovagina’s
postoperative patency. In summary, topical 1%
cidofovir cream can be considered as a viable,
alternative treatment to CO2 laser, imiquimod, and
TCA.
Conflicts of interest
None disclosed.
106 Cortez et al
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