Investigating treatment alternatives for fingolimod in patients with multiple sclerosis developed refractory fingolimod-related genital Human Papilloma Virus (HPV) infection.

Introduction: Genital human papillomavirus (HPV) infection is a rare skin complication in patients with relapse-remitting multiples sclerosis (RRMS) treated with fingolimod. Herein, we aimed to report a case series of 23 MS patients who had to discontinue fingolimod due to persistent HPV infection.

Materials And Methods: This retrospective case series was conducted between September 2023 to September 2024 in six MS centers in Iran to identify the outcome of HPV infection who discontinued fingolimod.

Results: 23 patients with a mean age of 36.34 ± 6.90 -year-old. The majority of patients were female (78.3 %) with a mean disease duration of 3.83 ± 3.02 years, and a mean EDSS score of 1.26 ± 1.10 at the time of fingolimod initiation. Most patients (39.1%) were treatment naïve. They developed genital HPV infection after a mean 32.21± 25.15 months of using fingolimod. Most patients (78.3%) were affected by low risk HPV infection and received a mean 1.96± 1.43 cycles of cryotherapy. After a mean 14.30±11.05 months, all patients had to discontinue treatment, mainly switched to anti-CD20 agents (78.3%). The lesions were resolved after a mean 4.52± 3.11 months. In addition, except for two patients developing a rebound after fingolimod cessations, others were stable with no evidence of disease activity or progression over a one-year follow-up.

Conclusion: Our preliminary results revealed that anti-CD20s agents could be considered safe in patients treated with fingolimod who had to discontinue treatment due to persistent HPV infection. Larger studies are needed to warrant our data.