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Facts about anogenital wart/causes and treatment

This article focuses on anogenital wart(s); causes and treatments.

  • Anogenital wart is viral infection caused by human papiloma virus sub-types 6 or 11.
  • Other associated human papilloma virus are sub-types 16, 18, 31, 33, and 35 are also occasionally found in anogenital warts.
  • Sub-types 16, 18, 31, 33, and 35 associated with foci of high-grade squamous intraepithelial lesions (HSIL), particularly in persons who have HIV infection.
  • In addition to anogenital warts, HPV types 6 and 11 have been associated with conjunctival, nasal, oral, and laryngeal warts.
  • HPV is one of the most common sexually transmitted infections (STIs)
genital wart shown on a black male penis
genital wart shown on a black male penis

Anogenital wart(s) are usually asymptomatic, but depending on the size and anatomic location;

  • They can be painful or pruritic
  • They are usually flat, papular, or pedunculated growths on the genital mucosa
  • Anogenital warts occur commonly at certain anatomic sites, including around the vaginal introitus, under the foreskin of the uncircumcised penis, and on the shaft of the circumcised penis
  • Warts can also occur at multiple sites in the anogenital epithelium or within the anogenital tract (e.g., cervix, vagina, urethra, perineum, perianal skin, anus, and scrotum)
  • Intra-anal warts are observed predominantly in persons who have had receptive anal intercourse, but they also can occur in men and women who have not had a history of anal sexual contact

Diasgmostic criteria

Is usually made by visual inspection. It can be confirmed by biopsy, which is indicated if lesions are atypical (e.g., pigmented, indurated, affixed to underlying tissue, bleeding, or ulcerated lesions).

Indication for biopsy

  • If patient is immunocomproised eg HIV infected and diognosis is uncertain
  • When lesion do not respond to standard therapy and
  • When disease worsens during therapy
  • NB;HPV testing is not recommended for anogenital wart diagnosis, because test results are not confirmatory and do not guide genital wart management.

Treatment

The aim of treatment is removal of the wart and amelioration of symptoms, if present. The appearance of warts also can result in significant psychosocial distress, and removal can relieve cosmetic concerns. In most patients, treatment results in resolution of the wart(s). If left untreated, anogenital warts can resolve spontaneously, remain unchanged, or increase in size or number. Because warts might spontaneously resolve within 1 year, an acceptable alternative for some persons is to forego treatment and wait for spontaneous resolution. Available therapies for anogenital warts might reduce, but probably do not eradicate, HPV infectivity. Whether the reduction in HPV viral DNA resulting from treatment reduces future transmission remains unknown.

Recommended Regimens

Treatment of anogenital warts should be guided by;

  • Wart size
  • Number of warts
  • Anatomic site
  • Patient preference
  • Cost of treatment
  • Convenience
  • Adverse effects
  • Provider experience

Something to note;

  1. No evidence suggests that any one recommended treatment is superior to another and no single treatment is ideal for all patients or all wart
  2.  Treatment regimens are classified as either patient-applied or provider-administered modalities
  3. To ensure that patient-applied modalities are effective, instructions should be provided to patients while in the clinic, and all anogenital warts should be accessible and identified during the clinic visit
  4. Patient follow up should be done by healthcare provider so as to address any side effects due to medication and response to treatment

Recommended Regimens for External Anogenital Warts; eg penis, groin, scrotum, vulva, perineum and external anus.

Patient-Applied:

  • Imiquimod 3.75% or 5% cream
    OR
  • Podofilox 0.5% solution or gel
    OR
  • Sinecatechins 15% ointment

ProviderAdministered:

  • Cryotherapy with liquid nitrogen or cryoprobe
    OR
  • Surgical removal either by tangential scissor excision, tangential shave excision, curettage, laser, or electrosurgery
    OR
  • Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80%–90% solution

Many persons/patients with external anal warts also have intra-anal warts. Thus, persons with external anal warts might benefit from an inspection of the anal canal by digital examination, standard anoscopy, or high-resolution anoscopy.

Imiquimod ceram

  • It is topically active immune enhancer that stimulates production of interferon and other cytokines.
  • Imiquimod 5% cream should be applied once at bedtime, three times a week for up to 16 weeks.
  •  For imiquimod 3.75% cream should be applied once at bedtime, but is applied every night  for same period of 16 weeks

Side effects

Lacal inflammation reacton which include;

  • redness
  • irritation
  • induration(local harding of the skin)
  • ulceration/erosions of the skin
  • vesicle might occur with the use of imiquimod and
  • hypopigmentation has also been described.

In few cases treatment with imiquimod is associated with worsening of inflammatory or autoimmune skin disease such as psoriasis, vitiligo,and lichenoid dermatoses.

Podofilox (podophyllotoxin)

  • It is a patient-applied antimitotic drug that causes wart necrosis
  • How is applied; for podofilox solution  one should use use a cotton swab and for podofilox gel using a finger
  • It should be applied to anogenital warts twice a day for 3 days, followed by 4 days of no therapy and this cycle is repeated ,as necessary, up to 4 cycles
  • The total wart area treated should not exceed 10 cm2, and the total volume of podofilox should be limited to 0.5 mL per day
  • health-care provider should reasure client/patient that mild to moderate pain or local irritation might develop after treatment
  • Podofilox is contraindicated in pregnancy
  • NB;If possible, the health-care provider should apply the initial treatment to demonstrate proper application technique and identify which warts should be treated.

Sinecatechins 15% ointment

  1. It is a patient-applied, green-tea extract with an active product (catechins).
  2. Sinecatechins 15% ointment  is applied three times daily (0.5 cm strand of ointment to each wart) using a finger to ensure coverage with a thin layer of ointment until complete clearance of warts is achieved.
  3. This product should not be used for a period longer than 16 weeks
  4. The medication should not be washed off after use
  5. Genital, anal, and oral sexual contact should be avoided while the ointment is on the skin.

Common side effects of sinecatechins are;

  • Erythema,
  • Pruritus/burning,
  • local pain,
  • Ulceration/skin erosion
  •  Induration(local harding of the skin)
  • Local edema and
  • vesicular rash

 Special cases;

  1. The medication-(sinecatechins)is not recommended for persons with HIV infection, other immunocompromised conditions, or with genital herpes because the safety and efficacy of therapy has not been evaluated.
  2. The safety of sinecatechins during pregnancy is unknown.

Cryotherapy

  1. It is a provider-applied therapy that destroys warts by thermal-induced cytolysis by use of liquid nitrogen.
  2. Health-care providers must be trained on the proper use of this therapy because over- and under-treatment can result in complications or low efficacy.

Common side effects

  • Pain during and after application of the liquid nitrogen
  • Local necrosis
  • sometimes blistering

 NB; to reduce discomfort, a local anesthesia either topical or parenteral  might be used, to facilitate therapy if warts are present in many areas or if the area of warts is large.

Surgical therapy

  1. It has the advantage of eliminating most warts at a single visit, although recurrence can occur.
  2. After local anesthesia is applied, anogenital warts can be physically destroyed by electrocautery, in which case no additional hemostasis is required.
  3. Alternatively, the warts can be removed either by tangential excision with a pair of fine scissors or a scalpel, by carbon dioxide (CO2) laser, or by curettage.
  4. Hemostasis can be achieved with an electrocautery unit or, in cases of very minor bleeding, a chemical styptic (e.g., an aluminum chloride solution)
  5. Suturing is neither required nor indicated in most cases.
  6. In patients with large or extensive warts, surgical therapy, including CO2 laser, might be most beneficial; such therapy might also be useful for intraurethral warts, particularly for those persons who have not responded to other treatments.
  7. Treatment of anogenital and oral warts should be performed in an appropriately ventilated room using standard precautions and local exhaust ventilation.

Trichloroacetic acid (TCA) and bichloroacetic acid (BCA);

  1. They are provider-applied caustic agents that destroy warts by chemical coagulation of proteins.
  2. TCA solution has a low viscosity comparable with that of water and can spread rapidly and damage adjacent tissues if applied excessively.
  3. A small amount should be applied only to the warts and allowed to dry (i.e., develop white frost on tissue) before the patient sits or stands.
  4. If pain is intense or an excess amount of acid is applied, the area can be covered with sodium bicarbonate (i.e., baking soda), washed with liquid soap preparations, or be powdered with talc to neutralize the acid or remove unreacted acid.
  5. TCA/BCA treatment can be repeated weekly if necessary; Although these preparations are widely used, they have not been investigated thoroughly.

Alternative Regimens for External Genital Warts

Less data are available regarding the efficacy of alternative regimens for treating anogenital warts, which include;

  • podophyllin resin
  • intralesional interferon
  • photodynamic therapy
  • and topical cidofovir

Further, alternative regimens might be associated with more side effects.

Podopyllin resin application;

  1. It is no longer a recommended regimen because of the number of safer regimens available.
  2. Podophyllin resin 10%–25% in a compound tincture of benzoin might be considered for provider-administered treatment under conditions of strict adherence to recommendations.
  3. Podophyllin should be applied to each wart and then allowed to air-dry before the treated area comes into contact with clothing.
  4. Over-application or failure to air-dry can result in local irritation caused by spread of the compound to adjacent areas and possible systemic toxicity.
  5. The treatment can be repeated weekly, if necessary.

To avoid the possibility of complications associated with systemic absorption and toxicity

  • Application should be limited to <0.5 mL of podophyllin or an area of <10 cm2 of warts per session
  • The area to which treatment is administered should not contain any open lesions, wounds, or friable tissue;
  • The preparation should be thoroughly washed off 1–4 hours after application.

Podophyllin resin preparations differ in the concentration of active components and contaminants. Shelf-life and stability of podophyllin preparations are unknown. The safety of podophyllin during pregnancy has not been established.

Recommended Regimens for Urethral Meatus Warts

  • Cryotherapy with liquid nitrogen
    OR
  • Surgical removal

Recommended Regimens for Vaginal Warts

  • Cryotherapy with liquid nitrogen. (The use of a cryoprobe in the vagina is not recommended because of the risk for vaginal perforation and fistula formation).
    OR
  • Surgical removal
    OR
  • TCA or BCA 80%–90% solution

Recommended Regimens for Cervical Warts

  • Cryotherapy with liquid nitrogen
    OR
  • Surgical removal
    OR
  • TCA or BCA 80%–90% solution

Management of cervical warts should include consultation with a specialist.

For women who have exophytic cervical warts, a biopsy evaluation to exclude high-grade SIL is performed before treatment is initiated.

Recommended Regimens for Intra-anal Warts

  • Cryotherapy with liquid nitrogen
    OR
  • Surgical removal
    OR
  • TCA or BCA 80%–90% solution

Management of intra-anal warts should include consultation with a specialist.

Follow-Up

Most anogenital warts respond within 3 months of therapy.

Factors that might affect response to therapy include;

  • Immunosuppression
  • Treatment compliance

In general, warts located on moist surfaces or in intertriginous areas respond best to topical treatment. A new treatment modality should be selected when no substantial improvement is observed after a complete course of treatment or in the event of severe side effects. Treatment response and therapy-associated side effects should be evaluated throughout the course of therapy. Complications occur rarely when treatment is administered properly.  Rarely, treatment can result in chronic pain syndromes (e.g., vulvodynia and hyperesthesia of the treatment site) or, in the case of anal warts, painful defecation or fistulas.

Counseling

Key Messages for Persons with Anogenital Warts

  • If left untreated, genital warts may go away, stay the same, or increase in size or number. The types of HPV that cause genital warts are different from the types that can cause cancer.
  • Women with genital warts do not need Pap tests more often than other women.
  • Time of HPV acquisition cannot be definitively determined. Genital warts can develop months or years after getting HPV. HPV types that cause genital warts can be passed on to another person even in the absence of visible signs of warts. Sex partners tend to share HPV, even though signs of HPV (e.g., warts) might occur in only one partner or in neither partner.
  • Although genital warts are common and benign, some persons might experience considerable psychosocial impact after receiving this diagnosis.
  • It is common for genital warts to recur after treatment, especially in the first 3 months.
  • Because genital warts can be sexually transmitted, patients with genital warts benefit from testing for other STDs. Sexual activity should be avoided with new partners until the warts are gone or removed. HPV might remain present and can still be transmitted to partners even after the warts are gone.
  • Condoms might lower the chances of transmitting genital warts if used consistently and correctly
  • A vaccine is available for males and females to prevent genital warts (Gardasil), but it will not treat existing HPV or genital warts. This vaccine is of beneficial in persons who have not yet been exposed to wart-causing types of HPV.

Management of Sex Partners.

Point to note;

  • Persons should inform current partner(s) about having genital warts because the types of HPV that cause warts can be passed on to partners.
  • Partners should receive counseling messages that partners might already have HPV despite no visible signs of warts.
  •  Physical examination  of the partner/patient to detect genital warts and tests for other STDs.
  • HPV testing of sex partners of persons with genital warts is not recommended.
  • No recommendations can be made regarding informing future sex partners about a diagnosis of genital warts because the duration of viral persistence after warts have resolved is unknown .

 Special Considerations;

1.Pregnancy

  1. Podofilox (podophyllotoxin), podophyllin, and sinecatechins are contraindicated in pregnancy.
  2. Imiquimod appears to pose low risk but should be avoided until more data are available.
  3. Anogenital warts can proliferate and become friable during pregnancy.
  4. Surgical excision and cryotherapy can be considered during pregnancy.
  5. Rarely, HPV types 6 and 11 can cause respiratory papillomatosis in infants and children, although the route of transmission (i.e., transplacental, perinatal, or postnatal) is not completely understood.

 Cesarean delivery is indicated for women with anogenital warts if;

  • The pelvic outlet is obstructed or
  • If vaginal delivery would result in excessive bleeding.

Pregnant women with anogenital warts should be counseled concerning the low risk for warts on the larynx of their infants or children (recurrent respiratory papillomatosis).

2 .HIV Infection and Other Causes of Immunosuppression

  • Patients with above conditions are more likely to develop anogenital wart than those who do not have HIV infection
  • The lesion are usually large or more numerous and respond poorly to therapy than those who are immunocompetent
  • Despite these factors, data do not support altered approaches to treatment for persons with HIV infection
  • Such person are likely to squamous cell carcinoma arising in or resembling anogenital warts, biopsy should be ordered to confirm diagnosis for suspicious cases

3.High-grade Squamous Intraepithelial Lesions (HSIL)

Biopsy of an atypical wart might reveal HSIL or cancer of the anogenital tract. In this instance, referral to a specialist for treatment is recommended.

Things People MISTAKE For Genital Warts

So if you are thinking about getting my report to treat your case, here are some things to check for first, so you can be sure you’re not wasting your time.

1. Fordyce spots- These are small, raised, pale red or white bumps that may appear on the labia, scrotum, shaft of the penis, or on the border of your lips.

2. Molluscum contagiosum – are cause by m. contagiosum virus. These bump appear alone or patch of 20 or more.

Extensive molluscum lesions on the flank of a young child; lesions are flesh- to pearly-colored with central dells
Extensive molluscum lesions on the flank of a young child; lesions are flesh- to pearly-colored with central dells

3. Male yeast infection – These are often itchy, red rashy areas that can look similar to pimples or just a dried out area of skin.

4. Pearly Penile Papules (PPP) – These are white little glans that develop around the rim of the penis head. They can form very quickly, leading some guys to think its an STD. About 30% of guys get these.

 

About Docbobhe 26 Articles
Am Robert Mathenge, a healthcare provider in Nakuru county. i love this profession as it gives me chance to serve my call, interacting with people from various social backgrounds makes me feel good.

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