The clinical manifestations of recurrent respiratory papillomatosis (RRP) can vary hugely from individual to individual. Whilst some affected children will outgrow the disease, a subset of patients will experience frequent recurrences and require multiple surgical procedures over the course of their lifetime, even as frequently as once a month. Several adjuvant therapies have been trialled to improve the clinical course of severe RRP, but none have achieved universal acceptance. Cidofovir and bevacizumab (Avastin) are the most commonly used adjuvants in the USA. The restricted availability and expense of these treatments limit their clinical utility in the NHS however. Gardasil is a quadrivalent vaccine against HPV types 6, 11, 16 and 18. By combining viral capsid proteins with adjuvants such as aluminium, a much higher antibody titre is achieved after vaccination than with a natural infection. It has therefore been hypothesised that administration of this vaccine to patients with RRP could help to achieve clearance of the disease, or at least extend periods of remission. In this paper, a retrospective chart review was conducted for 20 patients (12 male, median age 43) with established RRP who received Gardasil vaccination in addition to standard care at the Medical University of South Carolina. Eight patients (40%) experienced complete remission following vaccination. In the remainder, a significant increase in inter-surgical interval from 4.9 to 8.0 months was observed (p = 0.006). The absence of a control group and the variability in the natural course of RRP mean that the change in disease course following vaccination cannot conclusively be attributed to the effects of the vaccination alone. Nevertheless the results are certainly encouraging and merit further research, especially given the comparatively low cost and excellent side-effect profile of Gardasil vaccination relative to other adjuvant treatments for RRP.

The use of the quadrivalent human papilloma virus vaccine (Gardasil) as adjuvant therapy in the treatment of recurrent respiratory papilloma.
Young DL, Moore MM, Halstead LA.
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Christopher Burgess

Musgrove Park Hospital, Taunton, UK.

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