Hypertrophic Herpes Simplex in a 33-Year-Old Male with Human Immunodeficiency Virus Successfully Treated with Imiquimod Monotherapy

Abstract

Herpes simplex virus (HSV) typically manifests as grouped vesicles and erosions on mucosal surfaces or keratinized skin. In immunocompromised patients, however, HSV can present as ulcerative, hypertrophic, or verrucous lesions that mimic other infectious or malignant conditions. Treatment of atypical HSV can be challenging, particularly when antiviral resistance is suspected, and alternative agents are limited. We report the case of a 33-year-old Filipino man with advanced human immunodeficiency virus (HIV) presenting with a 2-month history of a painful, bleeding perianal ulcer that started as papules and vesicles before coalescing into an indurated plaque causing functional impairment. Histopathology showed full-thickness necrosis and viral cytopathic changes consistent with HSV infection. Topical imiquimod 5% cream was initiated, resulting in complete resolution after 2 months with residual scarring. Chronic perianal HSV in HIV poses significant diagnostic and therapeutic challenges, and topical imiquimod may be an effective alternative treatment, particularly in resource-limited settings where standard antiviral medications may be unavailable.