New Tools for Old Problems: Answer my Question Pretty Please

The cutting edge of technology seems like a cool place. I, however, are nowhere near that. My soul is that of a cranky 60 year old who just gets used to his phone before a new update screws the whole thing up again. On the bright side, that cutting edge is where the AI will come to kill us all so at least I will be killed last. Take that techies. OK but what is this about? 

Antibiotic resistance is a growing problem, an old problem accelerating towards becoming a full fledged disaster. You may agree that the country is in a bit of a dumpster fire but it could be come a three dumpster fire. Yes, it is a three alarm fire I get it. It is a big, huge, gigantic, issue. I recommend "The Perfect Predator" by Steffanie Strathdee and Thomas Patterson for a small glimpse of what that could look like and just how screwed we might be. Another time or twelve I will talk about antibiotic stewardship but now, I want to talk about imiquimod.

Imiquimod was approved by the FDA in 1997 and has approved uses for superficial basal cell carcinoma, actinic keratoses, and external genital warts. Off label it is used for warts in general, molluscum, lentigo maligna, Bowen's disease, cutaneous manifestations of breast cancer, and many other conditions. It is, quoting StatPearls from the NIH "an immune response modifier... that induces the production of various cytokines... activates the adaptive immune response via binging to Toll-like receptor 7... induces apoptosis of skin cancer cells and has demonstrated anti-tumoral activity". 

To me, this seems awesome, kick the body's defenses into high gear to kill bad cells and viruses on the skin. Why can't we use this for cellulitis? I cannot seem to find any information on imiquimod being used for bacterial infections and only one case study of 4 patients treated for cutaneous fungal infections. Why? Please tell me. It seems to me that this would be a decent antibiotic alternative for skin infections. Tell me if my logic is flawed or the specific cytokines that imiquimod do not effect the immune response against bacteria because I can't find answers. Perhaps antibiotics just work better? How much better? If it is slightly better is it a good trade off to use a slightly less effective agent to stave off antibiotic resistance? Maybe I'm crazy. Ask my fiancé, she will tell you. Either way, educate my small mind. I want to know. 

References

Antibiotic resistance from the WHO website updated 2020.

Image of the histopathology of lentigo maligna melanoma from Tumoral Melanosis associated with Pembrolizumab Treated Metastatic Melanoma in Cureus by Bari & Cohen 2017.

Imiquimod from StatPearls by Nanda and Bermudez in the NIH National Library of Medicine updated 2022. 

Imiquimod: A Review off Off-Label Clinical Applications from the Journal of Drugs in Dermatology by Consuelo et al. in 2011.

Imiquimod - Its role in the treatment of cutaneous malignancies in the Indian Journal of Pharmacology by Bubna in 2015.

Topical Application of Imiquimod as a Treatment for Chromoblastomycosis from Clinical Infectious Diseases by da Gloria Teixeira de Sousa et al. in 2014.